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Understanding suicide

Statistics on suicide

  • Suicide is the ninth leading cause of death in Canada, accounting for 1.5% of all deaths (Statistics Canada, 2011).
  • More than 3,600 deaths per year were attributed to suicide in Canada between 2007 and 2011. This amounts to about 10 suicides per 100,000 people (Statistics Canada, 2011).
  • Suicide rates are higher for nearly every demographic group in rural areas compared with their urban counterparts (Hirsch, 2006).

Suicide and mental illness

  • More than 90% of people who die by suicide have a psychiatric disorder (Mann, 2002).
  • Lifetime mortality from suicide in discharged hospital populations is about 20% for people with bipolar disorder, 15% for unipolar depression, 10% for schizophrenia, 18% for alcohol use problems and 5–10% for borderline disorder and antisocial personality disorder (Mann, 2002).
  • Suicide is the most common cause of death for people with schizophrenia (Mann, 2002).

Suicide terminology

Using precise, specific terminology to discuss suicide with patients improves communication, assessment and clinical interventions (O'Carroll et al., 1996). It can also help to reduce patient distress and facilitate a stronger therapeutic alliance (Rudd, 2006).

We recommend using the following terms for communicating about and documenting suicidality, which were developed by the U.S. Centers for Disease Control and Prevention (Crosby et al., 2011).

Self-directed violence (analogous to self-injurious behaviour):

  • behaviour that is self-directed and deliberately results in injury or the potential for injury to oneself
  • categorized into non-suicidal, suicidal or undetermined, based on intent:
    • explicit intent: revealed or expressed without vagueness (e.g., "I want to kill myself.")
    • implicit intent: implied though not directly expressed (e.g., a desire to die, preparation for death, efforts to prevent discovery)

Non-suicidal self-directed violence:

  • behaviour that is self-directed and deliberately results in injury or the potential for injury to oneself
  • no evidence, either implicit or explicit, of suicidal intent

Suicidal self-directed violence:

  • behaviour that is self-directed and deliberately results in injury or the potential for injury to oneself
  • evidence, either implicit or explicit, of suicidal intent

Undetermined self-directed violence:

  • behaviour that is self-directed and deliberately results in injury or the potential for injury to oneself
  • suicidal intent is unclear based on available evidence

Suicide attempt:

  • non-fatal, self-directed, potentially injurious behaviour with intent to die as a result of the behaviour
  • may or may not result in injury

Interrupted self-directed violence – by self or by other:

  • by self ("aborted" suicidal behaviour): the person takes steps to injure the self but stops himself or herself before a fatal injury occurs.
  • by other: the person takes steps to injure the self but is stopped by another person before a fatal injury occurs. The interruption can occur at any point during the act, such as after the initial thought or after onset of the behaviour.

Other suicidal behaviour, including preparatory acts:

  • acts or preparation for making a suicide attempt, but before potential for harm has begun. This can include anything beyond a verbalization or a thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for death (e.g., writing a suicide note, giving things away) (Posner et al., 2007). 

Suicide:

  • death caused by self-directed injurious behaviour with intent to die as a result of the behaviour

Warning signs

Many people who are suicidal show warning signs before engaging in suicidal behaviour. People at acute risk for suicidal behaviour will most often:

  • threaten to hurt themselves, or talk of wanting to hurt or kill themselves
  • look for ways to die by suicide, for example, by seeking access to firearms or pills
  • talk or write about death, dying or suicide when they seem out of the ordinary.

Other warning signs include:

  • increased use of alcohol or other drugs
  • feeling no reason for living, no sense of purpose in life
  • anxiety, agitation, inability to sleep or sleeping all the time
  • feeling trapped, like there´s no way out
  • hopelessness
  • withdrawal from friends, family and society
  • rage, uncontrollable anger, seeking revenge
  • acting reckless or engaging in risky activities, seemingly without thinking
  • dramatic mood changes. 

These warning signs should alert the clinician to conduct a mental health evaluation as soon as possible and to put precautions in place immediately to ensure the safety and stability of the person.

Other behaviours that may be associated with increased short-term risk for suicide are making arrangements to divest responsibility for dependents (children, pets, elders) or making other preparations, such as updating wills, making financial arrangements for paying bills and saying goodbye to loved ones (U.S. Department of Veterans Affairs, 2007).

A mnemonic for remembering warning signs

The American Association of Suicidology (2006) has developed this easy-to-remember mnemonic for the warning signs of suicide:

IS PATH WARM:

Ideation

Substance abuse

Purposelessness

Anxiety

Trapped

Hopelessness

Withdrawal

Anger

Recklessness

Mood changes

Risk factors

Risk factors for suicide occur at the individual, relational, community and societal level. The risk factors listed below may or may not be direct causes of suicide (Crosby et al., 2011):

  • previous suicide attempt
  • history of mental disorders, particularly clinical depression
  • physical illness (serious medical condition or pain)
  • family history of suicide or suicide-related behaviour
  • family history of child maltreatment
  • history of alcohol and and other substance use problems
  • feelings of hopelessness
  • impulsive or aggressive tendencies
  • cultural and religious beliefs (e.g., belief that suicide is a noble resolution of a personal dilemma)
  • local epidemics of suicide
  • isolation, a feeling of being cut off from other people
  • barriers to accessing mental health treatment
  • loss (relational, social, work, financial)
  • easy access to lethal methods
  • unwillingness to seek help due to stigma of mental health and substance use issues or to suicidal thoughts.

Protective factors

Protective factors act as buffers to suicidal thoughts and behaviours. Although protective factors have not been studied as extensively as risk factors, they are equally important to identify (Centers for Disease Control and Prevention, 2013; DeHay et al., 2009). Protective factors include:

  • effective clinical care for mental, physical and substance use disorders
  • easy access to a variety of clinical interventions and support for seeking help
  • family and community support, feelings of connectedness
  • support through ongoing medical and mental health care relationships
  • skills in problem solving, coping with stress, resolving conflict and using nonviolent ways to handle disputes
  • cultural and religious beliefs that discourage suicide and support instincts for self preservation
  • responsibility to children or pets.

Theories of suicide

Interpersonal theory of suicide

The interpersonal theory of suicide is based on three distinct constructs that in combination can result in suicidal ideation and behaviour (Van Orden et al., 2010):

  • thwarted belongingness (e.g., "I am alone.")
    • unmet psychological need to belong
    • absence of reciprocally caring relationships
  • perceived burdensomeness (e.g., "I am a burden.")
    • belief that the self is so flawed as to be a liability to others
    • affectively laden cognitions of self-hatred
  • acquired capability
    • increased physical pain tolerance
    • reduced fear associated with suicidal behaviour
    • separate from the desire to engage in suicidal behaviour.

Suicidal ideation is caused by the simultaneous presence of thwarted belongingness and perceived burdensomeness. Only a small minority of individuals possess both the desire (thwarted belongingness and perceived burdensomeness) and capability for suicide.

Psychache theory of suicide

The theory of "psychache" posits that suicide is caused by hurt, anguish or psychological pain rooted in the blockage, thwarting or frustration of psychological needs the person believes to be vital to continued life (Schneidman, 1993). People have individual thresholds for enduring psychological pain. Suicide is a way to stop psychological pain when it becomes unbearable. Remediation of the suicidal state requires addressing the vital frustrated needs.

Stress-diathesis theory of suicide

According to the stress-diatheses theory, suicide occurs in the context of a psychosocial or biological vulnerability that is precipitated by stress (Mann, 2003; Mann et al., 1999). Stress may come in the form of a psychiatric disorder or psychosocial crisis; diathesis refers to the underlying psychosocial, genetic, neurological and biochemical vulnerabilities independent of the psychiatric disorder that predispose an individual to suicidal behaviour.

The risk for suicidal behaviour is determined by the relationship between a psychiatric disorder or psychosocial crisis (the stressor) and a diathesis as reflected by the tendency to experience more suicidal ideation, and to be more aggressive or impulsive, and therefore, to be more likely to act on suicidal thoughts.

References

American Association of Suicidology. (n.d.). Know the warning signs of suicide.

Centers for Disease Control and Prevention. (2013). Suicide: Risk and protective factors.

Crosby, A.E., Ortega, L. & Melanson, C. (2011). Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements. Atlanta, GA: Centers for Disease Control and Prevention.

DeHay, T., Litts, D.A., McFaul, M., Smith, C. & West, P. (2009). Suicide Prevention Toolkit for Rural Primary Care: A Primer for Primary Care Providers. Boulder, CO: Western Interstate Commission on Higher Education.

Hirsch, J.K. (2006). A review of literature on rural suicide: Risk and protective factors, incidence, and prevention. Crisis, 27, 189-199.

Mann, J.J. (2002). A current perspective of suicide and attempted suicide. Annals of Internal Medicine, 136, 302-311.

Mann, J.J. (2003). Neurobiology of suicidal behaviour. Nature Reviews: Neuroscience, 4, 819-828.

Mann, J.J., Waternaux, C., Haas, G.L. & Malone, K.M. (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156, 181-189.

O'Carroll, P.W., Berman, A.L., Maris, R.W., Moscicki, E.K., Tanney, B.L. & Silverman, M.M. (1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26, 237-252.

Rosenberg, M.L., Davidson, L.E., Smith, J.C., Berman, A.L., Buzbee, H., Gantner, G., . . . Murray, D. (1988). Operational criteria for the determination of suicide. Journal of Forensic Science, 33, 1445-1456.

Rudd, M.D. (2006). The Assessment and Management of Suicidality. Sarasota, FL: Professional Resource Press.

Schneidman, E.S. (1993). Suicide as psychache. Journal of Nervous and Mental Disease, 181, 145-147.

Statistics Canada. (2011). Leading causes of death, by sex (both sexes). [Table]. 

U.S. Department of Veterans Affairs. (2007). Suicide Risk Assessment Guide Reference Manual. Washington, DC: Author.

Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithewaite, S., Selbe, E.A. & Joiner, T.E. (2010). The interpersonal theory of suicide. Psychological Review, 117, 575-600.