Suicide

Suicide CA Deming, Harvard University, Cambridge, MA, USA JJ Glenn, University of Virginia, Charlottesville, VA, USA MK Nock, Harvard University, Cambridge, MA, USA r 2016 Elsevier Inc. All rights reserved.

Glossary Emotional intelligence The ability to know/understand and manage one’s emotions. Non-suicidal self-injury Intentional self-harm performed without any intent to die. Protective factor Any event or characteristic that decreases the likelihood of a specific outcome in the face of risk. Psychache Severe psychological pain. Risk factor Any event or characteristic related to heightened likelihood of a specific outcome. (This article reviews both ‘vulnerability factors’ and ‘stressors’ as types of risk factors.) Stressors Proximal influences that may trigger specific negative outcomes among vulnerable people.

Epidemiology Suicide is a serious public health problem and a leading cause of death around the world. In fact, more deaths occur at one’s own hand than by all other forms of interpersonal violence, including war and homicide, combined (World Health Organization, 2009). Suicide is the 10th leading cause of death in the United States, accounting for over 41 000, or 1.6% of all, deaths (Centers for Disease Control and Prevention, 2013). Overall, the rate of suicide has remained relatively stable in recent history, with a similar prevalence in the 1950s to what we see today (National Center for Health Statistics, 2014). In terms of developmental trajectory, suicide death is rare in children but steadily increases in late adolescence and young adulthood (ages 15–19); the rate begins to level off around 25 years of age, with small peaks occurring in middle (50 years) and late (80 þ years) adulthood (Centers for Disease Control and Prevention, 2013). With regard to suicidal thoughts and behaviors, suicidal thinking is much more common than actual suicide attempt; roughly 10% of people have thoughts of suicide at some period in their lifetimes, and only a third of those with suicidal thoughts go on to attempt suicide (Nock et al., 2008). Among the methods used for suicide death in the United States, firearms are most common (51.5%), followed by suffocation (24.5%), poisoning (16.1%), and all other means (7.9%) (Centers for Disease Control and Prevention, 2013).

Defining Suicide Historically, researchers and clinicians have defined suicide and self-harm in vague and idiosyncratic ways (e.g., deliberate selfharm, self-mutilation, suicidality, and parasuicide). Recently,

Encyclopedia of Mental Health, Volume 4

Suicide Death by intentional self-harm. Suicide attempt Any nonfatal intentional self-harming behavior or action performed with some nonzero intention of dying. Suicide ideation Any thought of self-harm with at least some intention of dying. Suicide plan Any premeditated plot intended to aid in suicidal behaviour. Vulnerability factor Any distal influence that may lead people to be more susceptible to a specific outcome. Werther Effect Subsequent imitation or 'copycat' suicides following media report of a suicide death.

however, there has been a push for more precise and consistent terminology (Goldsmith et al., 2002; Silverman et al., 2007). A clear set of terms comprising the ‘suicidal’ continuum include: ‘suicide ideation’ (i.e., any thought of self-harm with some intention of dying), ‘suicide plan’ (i.e., any premeditated plot intended to aid in suicidal behavior), ‘suicide attempt’ (i.e., any nonfatal intentional self-harming behavior or action performed with some intention of dying), and ‘suicide’ (i.e., death by intentional self-harm). Importantly, suicidal self-injury is distinguished from non-suicidal self-injury (NSSI), defined as intentional self-harm performed without any intent to die. Appreciating these distinctions is important as each of these outcomes is associated with unique prevalence rates, risk and protective factors, as well as varying treatment and prevention strategies.

Models for Understanding Suicide Suicidal thoughts and behaviors are complex and determined by a wide range of factors. A number of proposed models have aimed to identify such factors and understand how they interact with one another. One of the earliest suicide theories holds that suicide is the result of ‘psychache’ (i.e., severe psychological pain, that is, a person’s report of subjective psychological, as opposed to physical, hurt) surpassing an individual’s threshold for pain (Shneidman, 1996). Another prominent model conceptualizes suicide as escape from self-awareness of one’s own failures (Baumeister, 1990). More recently, the ‘Interpersonal Theory of Suicide’ proposes that a few necessary components result in risk for suicide: ‘suicidal desire’ (brought about by feelings of thwarted belongingness and perceived burdensomeness) and ‘suicide capability’ (brought about by lessened fear of death and

doi:10.1016/B978-0-12-397045-9.00016-1

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Suicide Cavanagh et al., 2003). Contrary to widely held beliefs, depression is not the best predictor of suicide plans or attempts. Instead, depression is a strong predictor of suicide ideation, but disorders marked by lack of impulse control (e.g., substance use disorders and conduct disorder) and agitation/anxiety (e.g., posttraumatic stress disorder) best predict who, among ideators, will go on to make a suicide attempt (Nock et al., 2010). Further supporting this point, Thibodeau et al. (2013) show that anxiety disorders are uniquely related to suicide ideation and attempts, even after accounting for the effects of depression and a myriad of other disorders.

heightened tolerance for physical pain; Joiner, 2005; Van Orden et al., 2010). Overall, perhaps the most common and inclusive model guiding our understanding of suicide includes emphasis on both ‘risk factors’ for suicide (i.e., any event or characteristic related to heightened likelihood of suicidal outcomes) and ‘protective factors’ for suicide (i.e., any event or characteristic that decreases the likelihood of suicidal outcomes among those at risk). Because the term risk factor is fairly broad and the interaction between risk and protective factors can be complicated, it is useful to break this down further. To do this, and because many theoretical models draw a common overarching distinction between ‘vulnerability factors’ (i.e., distal influences that may lead people to be more susceptible to suicidal outcomes) and ‘stressors,’ also known as ‘stressful life events’ (i.e., proximal influences that may prompt vulnerable people to engage in suicidal outcomes), a vulnerability-stress model is used to guide this article (see Figure 1). The following sections review risk and protective factors for suicide using a vulnerability-stress model.

Previous self-injurious thoughts and behaviors A meta-analysis examining suicide in a group of depressed individuals found that having a history of previous suicide attempt increased the chances of future suicide by nearly five times (Hawton et al., 2013). Another recent study indicated that older adults with a history of self-harm (i.e., any intentional self-injury with or without intent to die) were 67 times more likely to die by suicide compared to older adults in the general population (Murphy et al., 2012). NSSI also is related to future suicide attempt among adolescents (Wilkinson et al., 2011; Asarnow et al., 2011; Guan et al., 2012; Klonsky et al., 2013) and adults (Klonsky et al., 2013). In fact, data suggest that NSSI may be a more robust predictor of suicide attempt than many other established risk factors (e.g., impulsivity, depression, anxiety, and borderline personality disorder); only suicide ideation shows a stronger relation (Klonsky et al., 2013). These recent findings mark NSSI as an important target for future research and clinical consideration when working with suicidal individuals.

Risk Factors for Suicide Identification and awareness of common risk factors for suicidal outcomes enable researchers and clinicians to better assess and treat those people most likely to engage in suicidal thinking and behaviors. As mentioned above, this article breaks down risk factors to include both vulnerability factors and stressors.

Vulnerability Factors

Psychological factors

Mental illness

General psychological factors may aid in explaining the associations between mental illness and suicidal outcomes. Working from the psychache model of suicide (Shneidman, 1996), it is possible that psychological pain, a common component of many forms of mental illness, may be an active ingredient leading to suicidal outcomes. Other psychological

The presence of mental illness is the most widely studied vulnerability factor. Data indicate that 66.0% of people with suicide ideation and 79.6% of suicide attempters report an earlier disorder, and roughly 90% of those who die by suicide had an existing disorder (Nock et al., 2010;

Protective factors Family support/children Social support/networks Religious affiliation/participation Psychological factors Mental health treatment

Protective factors

Vulnerability factors

Stressful life events

Family history Mental disorders Aggression/criminality Suicide attempt/death

Psychiatric factors Mental disorders Psychological factors Impulsive, aggressive traits Neurocognitive deficits

Early stressors Childhood abuse Household dysfunction Parental divorce

Suicidal behavior Suicide ideation Suicide plan Suicide attempt Suicide death

Negative life events Traumatic experiences Chronic illness/pain Recent stressors Situational factors

Figure 1 Vulnerability-stress model of suicidal behavior. Reprinted from Nock, M.K., Deming, C.A., Fullerton, C.S., et al., 2013. Suicide among soldiers: A review of psychosocial risk and protective factors. Psychiatry 76, 97–125, with permission of the Guilford Press.

Suicide

factors also may help to better explain why mental illness is related to suicide, including factors both subjectively reported (e.g., anhedonia, hopelessness about the future, aggressive personality, and impulsivity) and objectively measured (e.g., deficits in cognitive control, verbal fluency, decision-making, and problem-solving) (see Nock et al., 2013 for a review).

Family history In addition to mental illness and general psychological factors, other vulnerabilities for suicide include family history of mental illness. Data from the World Health Organization World Mental Health Survey (WMH) indicate that anxiety disorders and antisocial personality disorder in parents best predict the onset and persistence of suicide attempts among offspring with ideation, even after accounting for mental illness in offspring (Gureje et al., 2011). Relatedly, a recent meta-analysis revealed that family history of mental illness was related to an increased rate of suicide among depressed offspring (Hawton et al., 2013).

Stressful Life Events In addition to vulnerability factors, stressful life events – both acute and more chronic in nature – relate to suicidal outcomes. Acute stressors include various negative life events, occurring in both childhood and adulthood. Regarding adverse childhood experiences, WMH data suggest that physical and sexual abuse are consistently the strongest risk factors for a myriad of suicidal outcomes (Bruffaerts et al., 2010). Additionally, the likelihood of suicide ideation and suicide attempt becomes greater as the frequency of adverse childhood events increases (Bruffaerts et al., 2010). Further, and especially among youth, involvement in peer victimization/bullying is strongly tied to self-harm outcomes (Klomek et al., 2013). For adults, stressful events such as interpersonal and sexual violence (Stein et al., 2010) emerge as being especially important. Turning now to chronic stressors, these include: social disconnectedness (e.g., interpersonal conflict, poor social support, and loneliness among older adults; Fässberg et al., 2012) and physical conditions (e.g., epilepsy doubles the likelihood of suicide ideation; Scott et al., 2010).

Other Risk Factors Other known risk factors for suicide include basic demographic and situational factors. In terms of demographic factors, data indicate that being younger, single, White or Native American, and of lower education are all risk factors for suicide (Nock et al., 2008; Centers for Disease Control and Prevention, 2013). Further, in the United States, although being female is associated with a higher likelihood of suicide attempt, males are nearly four times more likely to die from suicide (Murphy et al., 2013). Suicide method choice may partially explain this difference: females tend to choose less lethal means (e.g., pills) and males choose more lethal means (e.g., firearms). Relatedly, easy access to lethal means is a risk factor for suicide and may help to explain the high prevalence of suicide among Army Soldiers (Nock et al., 2013).

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Other situational risk factors include: alcohol/drug misuse (e.g., current misuse of alcohol/drugs doubles the likelihood of suicide among depressed people; Hawton et al., 2013), calendar season (e.g., suicide rates peak in the spring; Christodoulou et al., 2012), belonging to a sexual minority group (Marshal et al., 2011), and environmental exposure to suicide of others (Swanson and Colman, 2013; Haw et al., 2013). Exposure to suicide through others can occur in multiple forms, including: personal acquaintance and media acquaintance with the suicide attempter/completer. The latter – termed the ‘Werther Effect’ (i.e., subsequent imitation or 'copycat' suicides following media reporting of suicide; Phillips, 1974) – has been given particular attention in the field of psychology. Over 50 research studies support this effect and indicate that description of the suicide method, use of dramatic images/language, and sensationalizing the death all relate to increased risk of suicide for vulnerable media consumers (American Foundation for Suicide Prevention et al., 2012). In fact, leading suicide experts, including the American Foundation for Suicide Prevention, collaborated to develop a set of ‘Recommendations for reporting on suicide’. For instance, instead of showing images of the suicide method, location of death, grieving family, or funeral – the media is encouraged to use images of the decedent’s workplace/school or a family photo.

Protective Factors for Suicide Similarly to risk factors, protective factors are of interest to researchers and clinicians as they aid in the assessment and treatment of suicide. Compared to risk factor research, protective factors for suicide receive relatively little emphasis and study. Protective factors against suicidal outcomes include: (1) social connectedness, (2) pregnancy and parenthood, (3) religiosity, and (4) general resilience. First, social connectedness to family and friends is protective against suicidal outcomes, especially among adolescents (Resnick et al., 1997) and older adults (Fässberg et al., 2012). In fact, connectedness is so integral to decreasing suicide risk that the Centers for Disease Control and Prevention (2008) have urged researchers to examine efforts in this area “to prevent suicidal behavior by building and strengthening connectedness or social bonds within and among persons, families, and communities” (p. 1). Second, pregnancy and parenthood are believed to be protective as pregnant women show lower rates of suicide attempt and completion compared to the general population of women (Lindahl et al., 2005), and being a parent (especially of young children) is related to lower rates of suicide death (Qin and Mortensen, 2003). On the flip side of parenthood as protective, the death of a child, especially by suicide, is related to an increased risk of suicide in parents (Qin and Mortensen, 2003). Third, religious beliefs and commitment may be protective against suicidal outcomes, perhaps due to lower levels of hostility and aggression, and having additional reasons for living (Gearing and Lizardi, 2009). Fourth, general resilience factors, such as enhanced personal agency, more positive attributional style (Johnson et al., 2011), and ‘emotional intelligence’ (i.e., ability to know/understand and manage one’s

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emotions; Cha and Nock, 2009), may be protective against suicide. For additional information on risk and protective factors relevant to suicide, please refer to the following articles concerning: child/adolescent suicide (Bursztein and Apter, 2008), general adult suicide (Beghi et al., 2013), older adult suicide (Van Orden and Conwell, 2011; Conwell et al., 2011), Army Soldier suicide (Nock et al., 2013), suicide among depressed people (Hawton et al., 2013), and suicide among non-suicidal self-injurers (Klonsky et al., 2013).

Assessment A number of measures have been developed to assess the presence of past and current suicidal thoughts, plans, and behaviors. Several measures rely on direct report by the individual (e.g., Beck Scale for Suicide Ideation; Beck and Steer, 1991), and others are administered by an interviewer (e.g., Suicide Intent Scale; Beck et al., 1974). Still other measures focus on either a specific demographic group (e.g., ideation in youth measured via the Suicidal Ideation Questionnaire; Reynolds, 1987) or a specific aspect of suicide (e.g., medical lethality of suicide attempts measured via the Lethality of Suicide Attempt Rating Scale; Smith et al., 1984). Nearly all suicide assessment tools rely on self-report, which presents an obstacle to accurate assessment, given: (1) people may lack self-knowledge and the ability to report what is in their minds (Nisbett and Wilson, 1977; Wilson, 2009); (2) even when people are aware of suicidal thoughts, they may be reticent to disclose such information (e.g., most hospital patients deny suicide ideation prior to completing suicide; Busch et al., 2003), and (3) suicidal thoughts are fleeting by nature and may be momentarily absent at the time of assessment (e.g., over 50% of suicidal thoughts last less than 30 min and nearly 90% of thoughts last less than 5 h; Nock et al., 2009). Based on the problems with self-report, it is not surprising that current measures have limited ability to predict future suicidal behavior (Brown, 2001). With regard to risk assessment, the field lacks a consistent and clear method. Most risk assessments rely on gathering information on: specific suicidal thoughts, risk factors, and protective factors (Menon, 2013; Bryan and Rudd, 2006). In the absence of empirically supported methods by which to synthesize data about known risk and protective factors, clinical judgment currently is utilized to determine an individual’s level of suicide risk (Nock et al., 2014). Researchers, however, have begun to collect and combine such data (e.g., Suicide Risk Formulation; Berman and Silverman, 2013), and new tools are being developed to address problems with selfreport. For instance, assessing a person’s implicit thoughts or attitudes toward suicide through the Implicit Association Task (e.g., Nock et al., 2010; Nock and Banaji, 2007) offers a promising new direction for prediction of future suicidal thoughts and behaviors.

Treatment Several interventions have shown some utility in decreasing suicidal outcomes, although no well-established treatments

currently exist. With or without established treatments, the unfortunate reality is that the majority of people experiencing suicidal thoughts and behaviors do not seek or receive treatment. The most common barriers to treatment include low perceived need for help and the want to handle the problem on one’s own (Bruffaerts et al., 2011).

Psychological Intervention Although evidence remains sparse, specific types of cognitive behavioral therapies appear to have the most empirical support for reducing suicidal thoughts and feelings. Dialectical behavior therapy (DBT; Linehan, 1993) – individual and group sessions designed to help people change problematic behaviors, regulate emotions more effectively, and improve interpersonal skills – has the strongest evidence. DBT has been shown to decrease suicidal thoughts (Pistorello et al., 2012) and attempts (Linehan et al., 2006). Cognitive therapy – designed specifically to identify problematic thoughts about suicide and develop adaptive coping strategies – also has shown some utility in decreasing suicidal behavior (Brown et al., 2005). Other psychological interventions with some support for decreasing suicidal thoughts and behaviors include psychodynamic therapy for adults (Guthrie et al., 2001), intensive family treatment for adolescents (Huey et al., 2004), collaborative client–patient management of suicidality (Jobes et al., 2005), and brief interventions in which therapists contact suicidal individuals through in-person visits, phone calls, or postcards (e.g., Hassanian-Moghaddam et al., 2011; Fleischmann et al., 2008). Interestingly, treatments for depression have not shown particular effectiveness in reducing suicide ideation (Cuijpers et al., 2013). In terms of prevention programs, those focused on restricting access to lethal means and educating medical professionals how to recognize and treat depression have been shown to decrease suicide death (Mann et al., 2005).

Pharmacological Intervention Currently, there are no well-established pharmacological treatments for suicidal behavior. Much of the attention and debate on pharmacological intervention for suicide has focused on antidepressant medications. In 2004, the US Food and Drug Administration released a black box warning alerting clinicians to closely monitor patients after prescribing antidepressants due to concerns about a potential link to the emergence of suicidal behavior in children, adolescents, and young adults (Hammad, 2004). Recent research, however, seems to suggest that antidepressants may decrease long-term suicide risk and be more helpful than harmful. For example, following a decrease in selective serotonin reuptake inhibitor prescriptions due to the black box warning, suicide rates among youth actually increased (Gibbons et al., 2007). Other research suggests that even if antidepressants temporarily increase suicidal behaviors (e.g., suicide ideation) in young people, the failure to treat depression poses a much larger suicide risk (Wijlaars et al., 2013). Further, a more recent study indicates that antidepressants may be effective in reducing suicide ideation in adults (Gibbons et al., 2012).

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Other medications used to reduce suicide risk include lithium and electroconvulsive therapy (Sakinofsky, 2007).

Conclusion Suicide is a serious and surprisingly prevalent public health problem in the United States and worldwide. Research in the area of suicide is growing at an exciting rate, and this article, although by no means all-inclusive, provides an overview of the many factors associated with suicide. Much more needs to be done, however, both to develop effective treatments for suicidal behavior and to implement better ways to identify and deliver services to at-risk individuals. Several future directions for the field include: (1) better understanding how known risk factors may relate to one another in amplifying suicide risk, (2) focusing on the identification of novel risk and protective factors, (3) improving our methods of assessment through the development of objective behavioral tasks (rather than self-report), and (4) using increased understanding of suicide risk and protective factors, as well as enhanced assessment techniques, to target, treat, and prevent future suicidal behavior among those who are most vulnerable.

See also: Adolescence. Age and Emotion. Alcohol Use Disorders. Anxiety, Panic, and Phobias. Borderline Personality Disorder. Bullying. Child Maltreatment. Childhood Stress. Chronic Illness and Mental Health. Cognitive-Behavioral Psychotherapy. Death and Dying. Depression. Dialectical Behavior Therapy. Disorders of Impulse Control. Disorders of Negative Affect. Emotional Intelligence. Learning from the Past to Understand the Origins of Acute and Chronic Pain. Lesbian, Gay, Bisexual, and Transgender Issues. Mental Health and Aging. Military Mental Health and Combat Deployments. Posttraumatic Stress Disorder. Religion, Spirituality, and Mental Health. Resilience. Self-Injury (NonSuicidal). Social Contagion. Social Support and Mental Health. Stress

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Suicide

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