AUTHORS: Shreedhar Paudel, MD, MPH and Carol Lim, MD, MPH
Definition
The Centers for Disease Control and Prevention (CDC) defines suicide and suicidal behavior as:
- Suicide: Death caused by self-directed injurious behavior with intent to die as a result of the behavior.
- Suicide attempt: A nonfatal, self-directed, potentially injurious behavior with intent to die as a result of the behavior. A suicide attempt may or may not result in injury.
- An estimated 1.2 million American people attempted suicide in 2020. There is about one death by suicide every 11 min.1
- Suicidal ideation: Thinking about, considering, or planning suicide.
- An estimated 12.2 million adults reported having suicidal thoughts in 2020.1
- An estimated 3.2 million American adults made a plan about how they would attempt suicide in 2020.1
- The percentage of adults having serious thoughts about suicide was highest among adults aged 18 to 25 (11.3%), followed by adults aged 26 to 49 (5.3%) and then by adults aged 50 or older (2.7%).2
Synonym
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Epidemiology & Demographics
- Suicide was the twelfth leading cause of death overall in the U.S. for all ages in 2020.
- There were 45,979 suicides in 2020 in the U.S.-a rate of 14 per 100,000, which is equal to 130 suicides per day, one death by suicide every 11 min.1
- CDC researchers reported that suicide rates in the U.S. rose nearly 36% between 2000 and 2018 and declined 5% between 2018 and 2020.1 Mental health conditions are one of several factors contributing to suicide. In addition, suicide rates have been increasing among both sexes, among all racial/ethnic groups except non-Hispanic Asian or Pacific Islanders, and in rural counties.
- Throughout the world, approximately 800,000 people die of suicide every year, accounting for 1.5% of all deaths.3
Data & Statistics1
Predominant Age1
- Suicide is the second-leading cause of death among individuals between the ages of 10 to 14 and 25 to 34, the third leading cause of death among individuals between the ages of 15 and 24, and the fourth leading cause of death among individuals between the ages of 35 and 44.
- People ages 85 and older have the highest rates of suicide (20.9 per 100,000).
Predominant Sex & Race1
- Women attempt suicide about two to three times as often as men.
- Males succeed at taking their own lives at nearly four times the rate of females and represent nearly 80% of all U.S. suicides.
- Suicide risk is higher among people who identify as LGBTQ+ (nearly four times higher than the rate among heterosexual counterparts).
- The suicide rate in men increased by 28% and the rate in women increased by 55% from 1999 to 2018.
- Firearms are the most common method of suicide among males (56.9%).
- Among males, the suicide rate was highest for those aged 75 and older (40.5 per 100,000).
- Among males, the most common methods of suicide were firearm (57.9%) followed by suffocation (26.7%).
- Among females, the suicide rate was the highest for those aged 45 to 64 (7.9 per 100,000).
- Among females, the most common methods of suicide were firearm (33%), suffocation (29.1%), and poisoning (28.6%).
- In 2020, the rates of suicide were highest for American Indian, non-Hispanic males (37.4 per 100,000), and White, non-Hispanic males (27.0 per 100,000).
Risk Factors (CDC) (Table E1)
- Family history of suicide
- Family history of child maltreatment
- Previous suicide attempt(s)
- History of mental disorders, particularly clinical depression
- History of alcohol and substance abuse
- Feelings of hopelessness
- Impulsive or aggressive tendencies
- Cultural and religious beliefs (e.g., belief that suicide is 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, or financial)
- Physical illness
- Easy access to lethal methods4
- Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts
- Rates are higher in developing countries
- Rates vary by occupation, ethnicity, and employment status
TABLE E1 Suicide and Risk Factors: A Summary
| Primary Diagnosis | Demographics | Personality Factors | Comorbidities | Social Factors | Other Factors |
|---|---|---|---|---|---|
| Bipolar | Male | Borderline | Substance abuse | Divorced | Means available |
| Schizophrenia | Older age | Narcissistic | Panic disorder | Widower | History of child abuse |
| Major depressive disorder | White race | Antisocial | Anxiety | Lives alone | Few reasons to live |
| Dysthymia | LGBT | Conduct disorder | Medical diagnoses | Isolated | Many adverse events |
| Adjustment disorder | History of attempt | Impulsive | Money worries | Change in grades | |
| Conduct disorder | Family history | Other losses | Change in friends | ||
| Psychosis | Suicidal ideas | No religion | Giving things away | ||
| Hopeless | Guns in the home | ||||
| Helpless |
From Sadock BJ et al: Kaplan & Sadock’s comprehensive textbook of psychiatry, ed 9, Philadelphia, 2009, Wolters Kluwer Health/Lippincott Williams & Wilkins.
Marital Status
Suicide rates are highest among the divorced, separated, and widowed and lowest among the married.
Substance Use
CDC data from 16 National Violent Death Reporting System states in 2010: 33.4% of suicide decedents tested positive for alcohol, 23.8% for antidepressants, and 20% for opiates including heroin and prescription painkillers.5
Financial Impact of Suicides
- Suicide results in an estimated $70 billion per year in combined medical and work lost costs to society.6
- The average suicide costs $1,164,499 (the estimate is based on 2010 CDC data and refers to people aged 10 and above).
Survivors
- A survivor of suicide is a family member or friend of a person who died by suicide.
- Surviving the loss of loved one to suicide is a risk factor for suicide.
- Surviving family members and close friends are deeply impacted by each suicide and experience a range of complex grief reactions including guilt, anger, abandonment, denial, helplessness, and shock.
No exact figure exists, but it is estimated that about 50% of people are exposed to suicide in their lifetime.7
Protective Factors (CDC)
- Effective clinical care for mental, physical, and substance abuse disorders
- Easy access to a variety of clinical interventions and support for help seeking
- Family and community support (connectedness)
- Support from ongoing medical and mental health care relationships
- Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
- Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
Suicidal Behavior
- All suicidal behavior should be taken seriously, as a failed attempt may lead to a completed suicide in the future.
- Nearly half of suicides are preceded by an attempt that does not end in death.
- Those with a history of attempts are 23 times more likely to eventually end their own lives than those without.
- A suicidal gesture does not have death as a goal, but can serve as a dramatic way of alerting others to some type of ongoing distress.
- Risky behaviors such as speeding or disregarding traffic laws, or abusing drugs, are considered parasuicide when the person shows total disregard for whether the actions might result in his or her death.
- Unsuccessful suicide attempts may also result from miscalculations in the plan. These people are at high risk for attempting suicide again.
Evaluation
- Directly inquire into the presence of suicidal ideation. Box E1 describes suggestions for dialog when approaching a patient about suicide. One-half to two thirds of individuals who died by suicide committed suicide within 1 mo of being evaluated by a health care professional.8
- Box E2 describes a brief screening suicide risk template. Key components of the suicide evaluation are summarized in Table E2.
- Emergency evaluation9: See www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/emergencydepartment/pdfs/bssa_155388.pdf.
- Explicit suicidal intent, hopelessness, and a well-formulated plan indicate high risk. Clinicians can use the mnemonic SAL: Is the method specific? Is it available? Is it lethal? Remember to inquire about gun availability.
- The concurrence of multiple psychiatric problems, substance abuse, and multiple physical problems increases the risk.
- Covert suicidal ideation occurs in patients primarily with multiple vague physical complaints, depression, anxiety, or substance abuse.
- Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.
BOX E1 Approaching a Patient About Suicide-Mastering the Dialog
From Warshaw G et al: Ham’s primary care geriatrics, ed 7, Philadelphia, 2022, Elsevier.
BOX E2 Brief Screening Suicide Risk Template
From Cameron P et al. Textbook of adult emergency medicine, ed 5, 2019, Elsevier, Australia.
Acute Psychopharmacologic Interventions
- Benzodiazepines may be useful in reducing extreme anxiety and dysphoria in an acutely suicidal patient; however, these agents should not be prescribed until the means of the suicidal attempt are known (not a benzodiazepine overdose) and patient is medically stable (i.e., respiratory system, vital signs, cognitive functioning are stable).
- Antipsychotics (typicals or atypicals) can be used if psychosis is present (e.g., voices telling patient to hurt self) and to manage acute agitation.
- If indicated, mood stabilizers and antidepressants can be started in the acute setting but may have up to a 2-wk latency period. However, awareness of increased risk of suicidal thoughts/behavior with these medications in some populations is required.
Therapy
- Long-term: Psychotherapy aimed at factors that underlie the decision to pursue suicide or at the risk factors contributing to suicidal behavior. Remember that the basic suffering reflected in suicidality with its hopelessness and despair is often fueled by disconnectedness and loss of attachments.
- Both cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) show modest benefit in reducing suicide ideation compared with treatment as usual (TAU).10
- Substance abuse treatment (e.g., Alcoholics Anonymous, Narcotics Anonymous) when substance use disorder is present.
- Therapy should be aimed at the underlying condition (e.g., antidepressants for depression, anxiolytics or antidepressants for anxiety, substance abuse treatment, or psychotherapy for chronic low self-esteem, hopelessness).
- Lithium and clozapine can be effective medications to prevent suicidal thoughts and behaviors in bipolar disorder and schizophrenia, respectively.11
- In the elderly, loneliness and medical disability are major reasons for suicide and therefore major targets for intervention.
- Involvement of family members, spouse, loved one, caregivers if possible for therapy and management.
- Suicide prevention strategies are summarized in Box E3.
Adapted and used with permission from Crisis 32(2):106-109, 2011. © 2011 Hogrefe Publishing www.hogrefe.com https://doi.org/10.1027/0227-5910/a000053.