Suicide
Intentional act of causing one's own death / From Wikipedia, the free encyclopedia
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Suicide is the act of intentionally causing one's own death.[9] Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders, attention deficit hyperactivity disorder, cognitive disengagement syndrome), physical disorders (such as chronic fatigue syndrome), and substance abuse (including alcoholism and the use of and withdrawal from benzodiazepines) are risk factors.[2][3][5][10] Some suicides are impulsive acts due to stress (such as from financial or academic difficulties), relationship problems (such as breakups or divorces), or harassment and bullying.[2][11][12] Those who have previously attempted suicide are at a higher risk for future attempts.[2] Effective suicide prevention efforts include limiting access to methods of suicide such as firearms, drugs, and poisons; treating mental disorders and substance abuse; careful media reporting about suicide; improving economic conditions;[2][13] and dialectical behaviour therapy (DBT).[14] Although crisis hotlines are common resources, their effectiveness has not been well studied.[15][16]
Suicide | |
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Le Suicidé by Édouard Manet | |
Specialty | Psychiatry, clinical psychology, clinical social work |
Usual onset | 15–30 and 70+ years old[1] |
Risk factors | Depression, bipolar disorder, autism, schizophrenia, personality disorders, anxiety disorders, alcoholism, substance abuse[2][3][4][5] |
Prevention | Limiting access to methods of suicide, treating mental disorders and substance misuse, careful media reporting about suicide, improving social and economic conditions[2] |
Frequency | 12 per 100,000 per year[6] |
Deaths | 793,000 / 1.5% of deaths (2016)[7][8] |
The most commonly adopted method of suicide varies from country to country and is partly related to the availability of effective means.[17] Common methods of suicide include hanging, pesticide poisoning, and firearms.[2][18] Suicides resulted in 828,000 deaths globally in 2015, an increase from 712,000 deaths in 1990.[19][20][inconsistent] This makes suicide the 10th leading cause of death worldwide.[3][6]
Approximately 1.5% of all deaths worldwide are by suicide.[8] In a given year, this is roughly 12 per 100,000 people.[6] Rates of suicide are generally higher among men than women, ranging from 1.5 times higher in the developing world to 3.5 times higher in the developed world.[1] Suicide is generally most common among those over the age of 70; however, in certain countries, those aged between 15 and 30 are at the highest risk.[1] Europe had the highest rates of suicide by region in 2015.[21] There are an estimated 10 to 20 million non-fatal attempted suicides every year.[22] Non-fatal suicide attempts may lead to injury and long-term disabilities.[23] In the Western world, attempts are more common among young people and women.[23]
Views on suicide have been influenced by broad existential themes such as religion, honor, and the meaning of life.[24][25] The Abrahamic religions traditionally consider suicide as an offense towards God due to belief in the sanctity of life.[26] During the samurai era in Japan, a form of suicide known as seppuku (腹切り, harakiri) was respected as a means of making up for failure or as a form of protest.[27] Similarly, a ritual fast unto death, known as Vatakkiruttal (Tamil: வடக்கிருத்தல், Vaṭakkiruttal, 'fasting facing north'), was a Tamil ritual suicide in ancient India during the Sangam age.[28] Suicide and attempted suicide, while previously illegal, are no longer so in most Western countries.[29] It remains a criminal offense in some countries.[30] In the 20th and 21st centuries, suicide has been used on rare occasions as a form of protest; it may also be committed while or after murdering others, such as suicide attacks which have been used as both a military and terrorist tactic.[31] Suicide is often seen as a major catastrophe causing significant grief to the deceased's relatives, friends and community members, and it is viewed negatively almost everywhere around the world.[32][33][34]
Suicide, derived from Latin suicidium, is "the act of taking one's own life".[9][35] Attempted suicide or non-fatal suicidal behavior amounts to self-injury with at least some desire to end one's life that does not result in death.[36][37] Assisted suicide occurs when one individual helps another bring about their own death indirectly via providing either advice or the means to the end.[38] This is in contrast to euthanasia, where another person takes a more active role in bringing about a person's death.[38]
Suicidal ideation is thoughts of ending one's life but not taking any active efforts to do so.[36] It may or may not involve exact planning or intent.[37] Suicidality is defined as "the risk of suicide, usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan."[39]
In a murder–suicide (or homicide–suicide), the individual aims at taking the lives of others at the same time. A special case of this is extended suicide, where the murder is motivated by seeing the murdered persons as an extension of their self.[40] Suicide in which the reason is that the person feels that they are not part of society is known as egoistic suicide.[41]
In 2011, in an article calling for changing the language used around suicide entitled "Suicide and language: Why we shouldn't use the ‘C’ word," the Centre for Suicide Prevention in Canada found that the normal verb in scholarly research and journalism for the act of suicide was commit, and argued for destigmatizing terminology related to suicide.[42][43] The American Psychological Association lists "committed suicide" as a term to avoid because it "frame[s] suicide as a crime".[44] Some advocacy groups recommend using the terms took his/her own life, died by suicide, or killed him/herself instead of committed suicide.[45][46][47] The Associated Press Stylebook recommends avoiding "committed suicide" except in direct quotes from authorities.[48] The Guardian and Observer style guides deprecate the use of "committed",[49] as does CNN.[50] Opponents of commit argue that it implies that suicide is criminal, sinful, or morally wrong.[51]
Precipitating circumstances in the US, 2017[52] | ||||
---|---|---|---|---|
Categories | Percentage | |||
Diagnosed mental problem | 50% | |||
Recent or upcoming crisis | 31% | |||
Intimate partner problem | 27% | |||
Physical health problem | 21% | |||
Alcohol problem | 18% | |||
Substance abuse (excluding alcohol) | 18% | |||
Argument | 16% | |||
Family problem | 10% | |||
Job problem | 10% | |||
Financial problem | 9% | |||
Legal problem | 8% | |||
Death of loved one | 7% | |||
Suicide is multi-factorial. Multiple precipitating circumstances and risk factors can apply to the same person. |
Factors that affect the risk of suicide include mental disorders, drug misuse, psychological states, cultural, family and social situations, genetics, experiences of trauma or loss, and nihilism.[53][54][16] Mental disorders and substance misuse frequently co-exist.[55] Other risk factors include having previously attempted suicide,[23] the ready availability of a means to take one's life, a family history of suicide, or the presence of traumatic brain injury.[56] For example, suicide rates have been found to be greater in households with firearms than those without them.[57]
Socio-economic problems such as unemployment, poverty, homelessness, and discrimination may trigger suicidal thoughts.[58][59] Suicide might be rarer in societies with high social cohesion and moral objections against suicide.[37] About 15–40% of people leave a suicide note.[60] War veterans have a higher risk of suicide due in part to higher rates of mental illness, such as post-traumatic stress disorder, and physical health problems related to war.[61] Genetics appears to account for between 38% and 55% of suicidal behaviors.[62] Suicides may also occur as a local cluster of cases.[63]
Most research does not distinguish between risk factors that lead to thinking about suicide and risk factors that lead to suicide attempts.[64][65] Risks for suicide attempt rather than just thoughts of suicide include a high pain tolerance and a reduced fear of death.[66]
Mental illness
Mental illness is present at the time of suicide 27% to more than 90% of the time.[67][23][68][69] Of those who have been hospitalized for suicidal behavior, the lifetime risk of suicide is 8.6%.[23][70] Comparatively, non-suicidal people hospitalized for affective disorders have a 4% lifetime risk of suicide.[70] Half of all people who die by suicide may have major depressive disorder; having this or one of the other mood disorders such as bipolar disorder increases the risk of suicide 20-fold.[71] Other conditions implicated include schizophrenia (14%), personality disorders (8%),[72][73] obsessive–compulsive disorder,[74] and post-traumatic stress disorder.[23] Those with autism also attempt and consider suicide more frequently.[75]
Others estimate that about half of people who die by suicide could be diagnosed with a personality disorder, with borderline personality disorder being the most common.[76] About 5% of people with schizophrenia die of suicide.[77] Eating disorders are another high risk condition.[78] Around 22% to 50% of people suffering with gender dysphoria have attempted suicide, however this greatly varies by region.[79][80][81][82][83]
Among approximately 80% of suicides, the individual has seen a physician within the year before their death,[84] including 45% within the prior month.[85] Approximately 25–40% of those who died by suicide had contact with mental health services in the prior year.[67][84] Antidepressants of the SSRI class appear to increase the frequency of suicide among children and young persons.[86] An unwillingness to get help for mental health problems also increases the risk.[63]
Substance misuse
Substance misuse is the second most common risk factor for suicide after major depression and bipolar disorder.[87] Both chronic substance misuse as well as acute intoxication are associated.[55][88] When combined with personal grief, such as bereavement, the risk is further increased.[88] Substance misuse is also associated with mental health disorders.[55]
Most people are under the influence of sedative-hypnotic drugs (such as alcohol or benzodiazepines) when they die by suicide,[89] with alcoholism present in between 15% and 61% of cases.[55] Use of prescribed benzodiazepines is associated with an increased rate of suicide and attempted suicide. The pro-suicidal effects of benzodiazepines are suspected to be due to a psychiatric disturbance caused by side effects, such as disinhibition, or withdrawal symptoms.[10] Countries that have higher rates of alcohol use and a greater density of bars generally also have higher rates of suicide.[90] About 2.2–3.4% of those who have been treated for alcoholism at some point in their life die by suicide.[90] Alcoholics who attempt suicide are usually male, older, and have tried to take their own lives in the past.[55] Between 3 and 35% of deaths among those who use heroin are due to suicide (approximately fourteenfold greater than those who do not use).[91] In adolescents who misuse alcohol, neurological and psychological dysfunctions may contribute to the increased risk of suicide.[92]
The misuse of cocaine and methamphetamine has a high correlation with suicide.[55][93] In those who use cocaine, the risk is greatest during the withdrawal phase.[94] Those who used inhalants are also at significant risk with around 20% attempting suicide at some point and more than 65% considering it.[55] Smoking cigarettes is associated with risk of suicide.[95] There is little evidence as to why this association exists; however, it has been hypothesized that those who are predisposed to smoking are also predisposed to suicide, that smoking causes health problems which subsequently make people want to end their life, and that smoking affects brain chemistry causing a propensity for suicide.[95] Cannabis, however, does not appear to independently increase the risk.[55]
Previous attempts
A previous history of suicide attempts is the most accurate predictor of suicide.[23] Approximately 20% of suicides have had a previous attempt, and of those who have attempted suicide, 1% die by suicide within a year[23] and more than 5% die by suicide within 10 years.[78]
Self-harm
Non-suicidal self-harm is common with 18% of people engaging in self-harm over the course of their life.[96]: 1 Acts of self-harm are not usually suicide attempts and most who self-harm are not at high risk of suicide.[97] Some who self-harm, however, do still end their life by suicide, and risk for self-harm and suicide may overlap.[97] Individuals who have been identified as self-harming after being admitted to hospital are 68% (38–105%) more likely to die by suicide.[98]: 279
Psychosocial factors
A number of psychological factors increase the risk of suicide including: hopelessness, loss of pleasure in life, depression, anxiousness, agitation, rigid thinking, rumination, thought suppression, and poor coping skills.[71][99][100] A poor ability to solve problems, the loss of abilities one used to have, and poor impulse control also play a role.[71][101] In older adults, the perception of being a burden to others is important.[102] Those who have never married are also at greater risk.[23] Recent life stresses, such as a loss of a family member or friend or the loss of a job, might be a contributing factor.[71][63]
Certain personality factors, especially high levels of neuroticism and introvertedness, have been associated with suicide. This might lead to people who are isolated and sensitive to distress to be more likely to attempt suicide.[99] On the other hand, optimism has been shown to have a protective effect.[99] Other psychological risk factors include having few reasons for living and feeling trapped in a stressful situation.[99] Changes to the stress response system in the brain might be altered during suicidal states.[37] Specifically, changes in the polyamine system[103] and hypothalamic–pituitary–adrenal axis.[104]
Social isolation and the lack of social support has been associated with an increased risk of suicide.[99] Poverty is also a factor,[105] with heightened relative poverty compared to those around a person increasing suicide risk.[106] Over 200,000 farmers in India have died by suicide since 1997, partly due to issues of debt.[107] In China, suicide is three times as likely in rural regions as urban ones, partly, it is believed, due to financial difficulties in this area of the country.[108]
The time of year may also affect suicide rates. There appears to be a decrease around Christmas,[109] but an increase in rates during spring and summer, which might be related to exposure to sunshine.[37] Another study found that the risk may be greater for males on their birthday.[110]
Being religious may reduce one's risk of suicide while beliefs that suicide is noble may increase it.[111][63][112] This has been attributed to the negative stance many religions take against suicide and to the greater connectedness religion may give.[111] Muslims, among religious people, appear to have a lower rate of suicide; however, the data supporting this is not strong.[30] There does not appear to be a difference in rates of attempted suicide.[30] Young women in the Middle East may have higher rates.[113]
Medical conditions
There is an association between suicidality and physical health problems such as[78] chronic pain,[114] traumatic brain injury,[115] cancer,[116] chronic fatigue syndrome,[117] kidney failure (requiring hemodialysis), HIV, and systemic lupus erythematosus.[78] The diagnosis of cancer approximately doubles the subsequent frequency of suicide.[116] The prevalence of increased suicidality persisted after adjusting for depressive illness and alcohol abuse. Among people with more than one medical condition the frequency was particularly high. In Japan, health problems are listed as the primary justification for suicide.[118]
Sleep disturbances, such as insomnia[119] and sleep apnea, are risk factors for depression and suicide. In some instances, the sleep disturbances may be a risk factor independent of depression.[120] A number of other medical conditions may present with symptoms similar to mood disorders, including hypothyroidism, Alzheimer's, brain tumors, systemic lupus erythematosus, and adverse effects from a number of medications (such as beta blockers and steroids).[23]
Occupational factors
Certain occupations carry an elevated risk of self-harm and suicide, such as military careers. Research in several countries has found that the rate of suicide among former armed forces personnel in particular,[121][122][123][124] and young veterans especially,[125][126][121] is markedly higher than that found in the general population.
Media
The media, including the Internet, plays an important role.[53][99] Certain depictions of suicide may increase its occurrence, with high-volume, prominent, repetitive coverage glorifying or romanticizing suicide having the most impact.[127] When detailed descriptions of how to kill oneself by a specific means are portrayed, this method of suicide can be imitated in vulnerable people.[17] This phenomenon has been observed in several cases after press coverage.[128][129] In a bid to reduce the adverse effect of media portrayals concerning suicide report, one of the effective methods is to educate journalists on how to report suicide news in a manner that might reduce that possibility of imitation and encourage those at risk to seek for help. When journalists follow certain reporting guidelines the risk of suicides can be decreased.[127] Getting buy-in from the media industry, however, can be difficult, especially in the long term.[127]
This trigger of suicide contagion or copycat suicide is known as the "Werther effect", named after the protagonist in Goethe's The Sorrows of Young Werther who killed himself and then was emulated by many admirers of the book.[130] This risk is greater in adolescents who may romanticize death.[131] It appears that while news media has a significant effect, that of the entertainment media is equivocal.[132][133] It is unclear if searching for information about suicide on the Internet relates to the risk of suicide.[134] The opposite of the Werther effect is the proposed "Papageno effect", in which coverage of effective coping mechanisms may have a protective effect. The term is based upon a character in Mozart's opera The Magic Flute—fearing the loss of a loved one, he had planned to kill himself until his friends helped him out.[130] As a consequence, fictional portrayals of suicide, showing alternative consequences or negative consequences, might have a preventive effect,[135] for instance fiction might normalize mental health problems and encourage help-seeking.[136]
Other factors
Trauma is a risk factor for suicidality in both children[137] and adults.[99] Some may take their own lives to escape bullying or prejudice.[138] A history of childhood sexual abuse[139] and time spent in foster care are also risk factors.[140] Sexual abuse is believed to contribute to approximately 20% of the overall risk.[62] Significant adversity early in life has a negative effect on problem-solving skills and memory, both of which are implicated in suicidality.[37] According to a 2022 study, adverse childhood experiences maybe “associated with a two-fold higher odds” of anxiety disorders, depression and suicidality.”[141]
Problem gambling is associated with increased suicidal ideation and attempts compared to the general population.[142] Between 12 and 24% of pathological gamblers attempt suicide.[143] The rate of suicide among their spouses is three times greater than that of the general population.[143] Other factors that increase the risk in problem gamblers include concomitant mental illness, alcohol, and drug misuse.[144]
Genetics might influence rates of suicide. A family history of suicide, especially in the mother, affects children more than adolescents or adults.[99] Adoption studies have shown that this is the case for biological relatives, but not adopted relatives. This makes familial risk factors unlikely to be due to imitation.[37] Once mental disorders are accounted for, the estimated heritability rate is 36% for suicidal ideation and 17% for suicide attempts.[37] An evolutionary explanation for suicide is that it may improve inclusive fitness. This may occur if the person dying by suicide cannot have more children and takes resources away from relatives by staying alive. An objection is that deaths by healthy adolescents likely does not increase inclusive fitness. Adaptation to a very different ancestral environment may be maladaptive in the current one.[101][145]
Infection by the parasite Toxoplasma gondii, more commonly known as toxoplasmosis, has been linked with suicide risk. One explanation states that this is caused by altered neurotransmitter activity due to the immunological response.[37]
There appears to be a link between air pollution and depression and suicide. There may be an association between long-term PM2.5 exposure and depression, and a possible association between short-term PM10 exposure and suicide.[146]
Rational
Rational suicide is the reasoned taking of one's own life.[147] However, some consider suicide as never being rational.[147]
Euthanasia and assisted suicide are accepted practices in a number of countries among those who have a poor quality of life without the possibility of getting better.[148][149] They are supported by the legal arguments for a right to die.[149]
The act of taking one's life for the benefit of others is known as altruistic suicide.[150] An example of this is an elder ending his or her life to leave greater amounts of food for the younger people in the community.[150] Suicide in some Inuit cultures has been seen as an act of respect, courage, or wisdom.[151]
A suicide attack is a political or religious action where an attacker carries out violence against others which they understand will result in their own death.[152] Some suicide bombers are motivated by a desire to obtain martyrdoms or are religiously motivated.[61] Kamikaze missions were carried out as a duty to a higher cause or moral obligation.[151] Murder–suicide is an act of homicide followed within a week by suicide of the person who carried out the act.[153]
Mass suicides are often performed under social pressure where members give up autonomy to a leader (see Notable cases below).[154] Mass suicides can take place with as few as two people, often referred to as a suicide pact.[155] In extenuating situations where continuing to live would be intolerable, some people use suicide as a means of escape.[156][157] Some inmates in Nazi concentration camps are known to have killed themselves during the Holocaust by deliberately touching the electrified fences.[158]
The leading method of suicide varies among countries. The leading methods in different regions include hanging, pesticide poisoning, and firearms.[18] These differences are believed to be in part due to availability of the different methods.[17] A review of 56 countries found that hanging was the most common method in most of the countries,[18] accounting for 53% of male suicides and 39% of female suicides.[161]
Worldwide, 30% of suicides are estimated to occur from pesticide poisoning, most of which occur in the developing world.[2] The use of this method varies markedly from 4% in Europe to more than 50% in the Pacific region.[162] It is also common in Latin America due to the ease of access within the farming populations.[17] In many countries, drug overdoses account for approximately 60% of suicides among women and 30% among men.[163] Many are unplanned and occur during an acute period of ambivalence.[17] The death rate varies by method: firearms 80–90%, drowning 65–80%, hanging 60–85%, jumping 35–60%, charcoal burning 40–50%, pesticides 60–75%, and medication overdose 1.5–4.0%.[17] The most common attempted methods of suicide differ from the most common methods of completion; up to 85% of attempts are via drug overdose in the developed world.[78]
In China, the consumption of pesticides is the most common method.[164] In Japan, self-disembowelment known as seppuku (harakiri) still occurs;[164] however, hanging and jumping are the most common.[165] Jumping to one's death is common in both Hong Kong and Singapore at 50% and 80% respectively.[17] In Switzerland, firearms are the most frequent suicide method in young males, although this method has decreased since guns have become less common.[166][167] In the United States, 50% of suicides involve the use of firearms, with this method being somewhat more common in men (56%) than women (31%).[168] The next most common cause was hanging in males (28%) and self-poisoning in females (31%).[168] Together, hanging and poisoning constituted about 42% of U.S. suicides (as of 2017[update]).[168]
There is no known unifying underlying pathophysiology for suicide;[23] it is believed to result from an interplay of behavioral, socio-economic and psychological factors.[17]
Low levels of brain-derived neurotrophic factor (BDNF) are both directly associated with suicide[169] and indirectly associated through its role in major depression, post-traumatic stress disorder, schizophrenia and obsessive–compulsive disorder.[170] Post-mortem studies have found reduced levels of BDNF in the hippocampus and prefrontal cortex, in those with and without psychiatric conditions.[171] Serotonin, a brain neurotransmitter, is believed to be low in those who die by suicide.[172] This is partly based on evidence of increased levels of 5-HT2A receptors found after death.[173] Other evidence includes reduced levels of a breakdown product of serotonin, 5-hydroxyindoleacetic acid, in the cerebral spinal fluid.[174] However, direct evidence is hard to obtain.[173] Epigenetics, the study of changes in genetic expression in response to environmental factors which do not alter the underlying DNA, is also believed to play a role in determining suicide risk.[175]