Each year an estimated thirty thousand Americans commit suicide.

Several years ago, the Los Angeles Suicide Prevention Center profiled those individuals at greatest risk for suicide as elderly white males with either symptoms or a medical diagnosis of depression, who have made previous attemptsat suicide, who have recently experienced acute stressful life events, and who have few resources, friends, or relatives to draw on for support.

Studies have shown that the most common methods of committing suicide in theUnited States involve the use of firearms or explosives. The next most frequent methods are hanging, carbon monoxide, and jumping. In the case of men, thesecond most prevalent method involves hanging (including strangulation or suffocation); for women, it is poisoning by gas or liquids. A gun in the house,particularly a loaded gun, appears to increase the risk for completed suicide, even in those individuals without other obvious risk factors for suicide.Among those who attempt suicide, the two most common methods are overdose andwrist-cutting. Although some studies have shown conflicting results, there is strong evidence that a seasonal pattern exists in the rate of completed suicides, with peak rates occurring between the months of March and May, and thelowest rates occurring in December.

In 1980, the lowest rates of suicide were in the eastern states of New Jersey, Massachusetts, and Connecticut. The highest rates were found in the west, with Nevada leading the nation, followed in frequency by New Mexico, Arkansas,and Arizona.

Many studies have found that suicide is less common in rural areas than in urban ones. Several possible explanations for this finding have been proposed,including such possibilities as the stress associated with urban living beinggreater than in rural life, the tendency for many urban dwellers to live alone, and the tendency of the mentally ill to drift toward urban centers.

More than 2000 years ago the Greeks declared suicide against the law. Although the Romans condoned the act, they confiscated the property of persons who committed suicide. In the early common law of England, persons who committed suicide were punished by being buried in a highway with a stake through theirbodies, and by the confiscation of their property; the punishment of burial in the highway was finally repealed in 1823, and confiscation of property wasrepealed in 1870. In 1961, the British parliament removed the acts of suicideand attempted suicide from its list of crimes. In the United States, suicidehas never been considered to be a crime in most jurisdictions, although attempted suicide sometimes has been (with the law seldom invoked except to forcethe mentally ill into treatment).

As of 1997, forty-nine states had passed laws regulating assisted suicide, with forty-eight of them prohibiting the practice. Only Oregon permitted theirphysicians to help patients commit suicide. Even before Dr. Jack Kevorkian focused national attention on assisted suicide by assisting in the death of a patient in 1990, many terminally ill patients were dying with the quiet aid oftheir families and doctors in homes and hospitals throughout the United States. Physician-assisted suicide and a patient's right to die continue to be some of the most hotly debated medical ethics questions in this country, as proponents and opponents alike attempt to come to grips with such baffling issues as establishing a basis for distinguishing assisted suicide from euthanasia.

The suicide completion rate is about four times higher in males than females,while the rate of attempt is two to three times higher in females than males. Completed suicide may be greater among males because of the tendency of males to utilize methods of more potential lethality. The rate of suicide also varies according to victim's race. The highest rates are found for Native Americans and whites. The suicide rate among African American males increased dramatically in the 1980s, and by the late 1990s had approached 80% of the whitemale suicide rate. The suicide rate for fifteen- to twenty-four-year-old black males rose from 12.3 per 100,000 in 1980 to 20.1 per 100,000 in 1993.

Some researchers believe a rapid increase in suicides among young black malesis not due to racial factors, because the rate for black females has hardlychanged during the same period. One explanation is that young blacks inheritmany of the same problems that plague young whites as soon as they achieve greater economic parity with whites. Others attribute this rise to social illssuch as poverty and substance abuse.

The vast majority of both those who attempt suicide and those who complete suicide have evidence of at least one major psychiatric disorder. These disorders are most often affective disorders, causing changes in moods or emotions.Major depressive disorder is the single biggest risk factor for attempted orcompleted suicide, with the risk heightened even further by comorbid anxiety,substance abuse, or conduct disorder. Bipolar affective disorder also conveys increased risk for completed and attempted suicide.

The first suicide prevention center was founded in 1906 in New York as the result of a meeting between a minister and a suicidal young woman, who later died from her suicide attempt. Before her death, the woman reportedly told theminister that she might not have attempted to kill herself if she had been able to talk to someone like him. The suicide prevention movement remained small until the 1960s, by which time suicide had become a major social problem. Although statistics on the number of lives saved by suicide prevention centerswere initially hard to come by, studies did show that the typical caller toa suicidal hotline is a young or middle-aged female, while the typical suicide victim is an elderly white male. Subsequent studies have shown that the number of suicides by young white females tends to be lower in places where a suicide prevention center exists than elsewhere, though the number of lives saved nationwide each year by these centers is probably considerably less than 1000.

While it is not always possible to prevent suicide, many of the risk factorscan be reduced by proper and timely medical intervention. If the psychiatricdisorders responsible for the suicidal individual's clinical symptoms and impulsiveness are identified early enough and treated aggressively, and if the psychosocial stress factors are reduced (though therapy), most suicides can beprevented. Antidepressants, particularly the selective serotonin reuptake inhibitors, are effective in reducing the symptoms of many disorders that increase suicide risk, including impulsiveness and depression; and support groupscan help reduce the feeling of isolation common to persons at high risk.

Suicide in Children and Young Adults

The number of adolescents and young adults who commit suicide has soared since the 1950s, making suicide the third largest cause of death for those between fifteen and twenty-four. Suicide occurs at a rate of 10.8 per 100,000 among15-19 year olds in 1992. Suicide is much less common among 10-14 year olds,at 1.7 per 100,000, although the rate of suicide has increased dramatically since 1950 among all age groups. Suicide attempts are much more common, occurring in 2% of adolescent girls and 1% of adolescent boys per year. Significantsuicidal ideation (with a plan to commit suicide or intent to die) is more common, occurring in 5-10% of children and adolescent youth.

Suicidal ideation spans a continuum from non-specific thoughts, for example,"life is not worth living," to specific ideation. Community surveys indicatethat between 12 and 25% of primary and high school children experience some form of suicidal ideation, whereas 5-10% have suicidal ideation with a plan orintent to make a suicide attempt. Not surprisingly, specific ideation is more closely associated with risk for attempted suicide, and frequently occurs with other risk factors.

The most common precipitants for suicidal behavior among children and adolescents involve interpersonal conflict or loss, most frequently with parents orromantic attachment figures. Family discord, physical or sexual abuse, and anupcoming legal or disciplinary crisis are also commonly associated with completed and attempted suicide. Adolescents who complete suicide show relativelyhigh suicidal intent (i.e., wish to die), although many are intoxicated at the time of death. The most serious of those who attempt suicide leave suicidenotes, show evidence of planning, and use an irreversible method. Most adolescent suicide attempts, though, are of relatively low intent and lethality, and only a minority actually want to die. Usually, those who attempt suicide want to escape psychological pain or unbearable circumstances, gain attention,influence others, or communicate strong feelings, such as anger or love.

Family history and environment are also risk factors in themselves for suicide. The relatives of both those who attempt suicide and those who complete suicide exhibit high incidences of affective disorder, substance abuse, assaultive behavior, suicide, and suicide attempts. The tendency is for suicidal behavior to be passed on independently of the transmission of psychiatric disorders; it may also be closely related to the tendency for impulsive aggression.The family environments of those who attempt and complete suicide have been described as discordant, with high levels of exposure to family violence, including physical and sexual abuse. Both those who attempt and those who complete suicide have been exposed to suicidal behavior. Studies of friends and siblings of suicide victims, however, show they tend not to imitate the act, suggesting that increased risk is related more to distant exposure. For example,publicity in the media about fictional or true suicides have been shown consistently to increase the risk for suicide and suicidal behavior.

Repeated suicide attempts are common, but rates vary. Follow-up studies ranging from 1 to 12 years found a re-attempt rate among adolescents of between 6%and 15% per year, with the greatest risk occurring within the first three months after the initial attempt. Factors associated with a higher re-attempt rate included chronic and severe psychopathology (depression and substance abuse), hostility and aggression, non-compliance with treatment, poor level of social adaptation, family discord, abuse, or neglect, and parental psychopathology. The risk for completed suicide ranges from 0.7% per year among males and 0.1% per year among females seen in an emergency room for an overdose. Among psychiatric inpatients after a 10-15 year follow-up, the risks are higher,10% for males and 2.9% for females.

There is an average of seven years between the onset of a psychiatric disorder and completed suicide in adolescence, explaining in part why repeated suicide threats or attempts are common. Youths who attempt suicide frequently feelhopeless, are impulsive, and have poor problem-solving and social skills. Children with other illnesses may also face an increased risk of suicidal behavior. For example, children with epilepsy have a higher suicide rate, which may be related to the side effects of the drug phenobarbital.

Suicidal behavior is rare in prepubertal children, probably because of theirrelative inability to plan and execute a suicide attempt. Psychiatric risk factors, such as depression and substance abuse, become more frequent in adolescence, contributing to the increase in the frequency of suicidal behavior inolder children. The emergence of conflicts with parents and with boy/girlfriends and legal or disciplinary problems are frequently associated with suicidal behavior. Some view the transition from primary to middle school as particularly stressful, especially for girls. Finally, as parental monitoring and supervision decrease with increasing age, adolescents may be more likely to experience emotional difficulties without their parents' knowledge.

Note: In the treatment of a suicidal patient, the first step should be to assess the degree of suicidal risk and to determine the appropriate level of care. It is critical to obtain a no-suicide contract with the patient and family, in which the patient promises to refrain from self-destructive behavior andto notify the professional or caregiver if he or she does feel suicidal again. Treatment of a suicidal youngster should proceed on four levels: (1) removal of any firearms and dangerous medications from the home; (2) treatment ofthe underlying psychiatric disorders; (3) remediation of social and problem-solving skills; and (4) education of the family about psychiatric problems andsuicidal risk.

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