Mental Health Matters: Is there more to the story of suicide rates?
March 26, 2015
Suicide makes the news more these days, with the widely publicized suicide of the great actor Philip Seymour Hoffman being a case in point.
Suicide is no longer considered a marker of moral degeneracy or a criminal act. Medicine's ability to keep people alive just a little bit longer during a terminal illness has opened a national dialogue about euthanasia and ending life during "end of life care."
Oregon has a law allowing terminally ill Oregon residents to obtain and use prescriptions from physicians for self-administered lethal injections. So does Washington state. These laws are a form of physician-assisted-suicide.
We now know more about the prevalence of suicide and other self-injurious behavior. There were 41,149 reported suicide deaths in 2013. There were also 494,169 people who visited hospitals for injuries due to self-harm.
“Suicide, we are learning, is largely an impulsive act, especially among young people, and therefore harder to predict. In many instances, half of the time by some accounts, the whole process from first suicidal thought to the final act takes no more than 10 minutes.”
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Other statistics from the Centers for Disease Control and Prevention indicate there is one suicide for every 25 attempts across all age groups, but there is one suicide for every four attempts among the elderly
A number of studies have elucidated a host of risk factors for suicide. Psychiatric disorders in general, but major depressive disorders in particular, constitute a major risk factor for suicide.
Overall, some 50 percent of all people who die by suicide suffer from major depression. Add the risk factor of alcohol abuse to depression, and the two ailments drive the suicide toll to 75 percent.
These numbers cause some to conclude that the best way to prevent suicide is through early detection and treatment of depression and alcoholism.
There are also increased suicide rates in vulnerable groups, including refugees, migrants, indigenous people and prisoners.
We now also know more about the potential warning signs of an impending suicide attempt. These include talk of wanting to die or killing oneself, feeling hopeless or seeing no reason to live, or feeling trapped and in unbearable pain.
Extreme mood swings, intense anger, wanting to seek revenge, and increased use of alcohol and drugs are other warning signs. Yet, other risk factors for suicide include a history of prior suicide attempts, a family history of suicide, stressful life events and access to lethal methods.
So, if we now know so much more about the myriad factors contributing to suicide, we should be seeing a significant decline in suicide rates.
Not so. Rates of suicide in the United States have hardly budged over the last 25 years, which means there is more to the story.
Two other critical issues frequently overlooked are the mechanics of suicide and the lethality index of suicide attempts.
About the former, it has become increasingly clear that attempted suicides are generally acute and short-lived affairs arising out of the heat of the moment rather than the culmination of established and worsening psychiatric problems.
Indeed, many people who commit suicide are not depressed at the time. In one study, some 60 percent of college students contemplating how to kill themselves tested negative for depression.
Moreover, only a small number of depressed people commit suicide, so encouraging all depressed people to seek professional help is not an efficient use of resources to prevent suicide.
Suicide, we are learning, is largely an impulsive act, especially among young people, and therefore harder to predict. In many instances, half of the time by some accounts, the whole process from first suicidal thought to the final act takes no more than 10 minutes.
In one study of people who survived a suicide attempt, of those who thought of killing themselves for an hour or so, 75 percent acted within the next 10 minutes once the decision was made.
If suicide is a sudden impulsive act, rather than the end point of a lengthy downhill process, then the conventional wisdom that people who plan a suicide will eventually find a way is wrong.
As to the first point, if you build a bridge barrier, the likelihood of jumping decreases. Similarly, if sedating medications are locked in a cabinet in another part of the house, you are less likely to overdose on them.
Says Dr. Miller at the Harvard Injury Control Research Center, some 90 percent of people who try suicide and live do not die by suicide.
The second point, more effective gun control, while a political quagmire, deserves careful consideration. Statistically, a gun in the home increases the probability of suicide for all age groups. If the gun is unloaded and locked away, the risk decreases, and if there is no gun, the risk decreases further.
People who try to die by suicide tend to choose the method most at hand, rather than the most effective method. With some methods the fatality rate is 2 or 3 percent. With a gun the fatality rate is 85-90 percent.
Dr. David Brent, an adolescent research psychiatrist at the University of Pittsburgh, finds that 40 percent of children under 16 who died by suicide did not have a definable psychiatric disorder, but a loaded gun in the house.
Says Dr. Brent, "if the kids are under 16, the availability of a gun is more important than a psychiatric disorder. They're not suicidal one minute, and then they are. Or they are mad and have a gun available."
Suicide means you don't get another chance. We know how to prevent suicide. Do we have the will to pursue effective suicide prevention strategies?
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. His column focuses on drugs, mental health and substance abuse in an effort to raise better awareness. He can be reached for comment at firstname.lastname@example.org.