Suicide
The World Health Organization (WHO) estimated that the 2016 suicide rate was 10.6 suicides per 100,000 persons, with 80% of suicides occurring in low- and middle-income countries. Across the six WHO regions, the incidence of suicide differed by a factor of 4 between the region with the highest rate (Europe) and the region with the lowest rate (the Eastern Mediterranean, including the Middle East). Explanations for this variation include differences in the classification of suicide, sociocultural attitudes toward suicide, access to lethal means of dying by suicide, and the adequacy of treatment for mental disorders. Worldwide, suicide rates vary according to age and sex, with the highest rates among older people and with higher rates among men (15.6 suicides per 100,000) than among women (7.0 per 100,000).
Suicide rates have been declining over recent decades in most of these regions, with an estimated 18% reduction from 2000 to 2016. The exception is the Americas; in the United States, rates have increased by 1.5% annually since 2000,3and rates among men 45 to 64 years of age increased from 21 suicides per 100,000 in 1999 to 30 per 100,000 in 2017.
Ecologic studies, which can explain time trends within countries, suggest a contribution of restrictive alcohol policies in lowering suicide rates.5 Changes in suicide rates have also been attributed to restriction of common means of suicide, such as detoxification of domestic gas (i.e., the reduction and eventual elimination of the carbon monoxide content of gas owing to a switch to natural gas) in the United Kingdom, starting in the 1960s,6 decreased availability of alcoholic spirits in Russia,7 and state restrictions of firearms in the United States.
As extrapolated from household surveys, for each suicide death, there are 20 suicide attempts (defined as self-injurious behavior associated with an intent to die), amounting annually to 16 million attempts and approximately 160 million persons who express suicidal thoughts.9 The epidemiology of self-harm, defined as any type of self-injurious behavior, including suicide attempts and nonsuicidal self-injury, is different from the epidemiology of suicide, with the highest rates of self-harm among women and young people. Among persons who attempt suicide, 1.6% die by suicide within the next 12 months, and 3.9% die by suicide within the next 5 years.
Psychological Models of Suicide
A stress-diathesis psychological model explains suicide risk as a combination of stressors in vul-nerable persons. Individual vulnerability is con-sidered to express itself in suicidal ideation un-der stress and is magnified by impulsivity and aggression, which increase the likelihood of act-ing on suicidal ideas.
This model has been augmented by an interpersonal psychological model, in which the sense of burdening others and not being accepted in social groups interacts with the feeling of hopelessness that these per-ceptions will not change. Another aspect of psychological models is the premise that sui-cidal persons have a reduced fear of death and increased pain tolerance as a result of habitua-tion by previous acts of self-harm.
Impulsivity is a component of most psycho-logical models of suicide. This trait is partly fa-milial32 and has a disproportionate inf luence on suicide risk among young people.33 Perfection-ism may be another contributory personality trait, leading to isolation out of fear of being stigmatized for an interpersonal crisis. A perfec-tionist trait also impedes psychological recovery from self-harm or suicidal ideation.34 Rigidit y, inf lexibility, and rumination impair problem-solving with respect to common stressors, includ-ing trying to find solutions to financial prob-lems, unemployment, criminal justice involvement, interpersonal conf licts, and family strife
Familial, Genetic, and Other Biologic Factors
A family history of suicide is a risk factor for suicide,19 with some evidence suggesting that a mother’s suicidal behavior has a greater inf luence than a father’s suicidal behavior.
the effect of parental suicide is greater on younger children than on adolescents; that is, the younger children are when they experience suicidal behavior in their parents, the higher their lifetime risk of suicide.
This familial risk is partially explained by parental mood disorder, traits of impulsivity and aggressiveness, or neuro-cognitive disorders, all of which are heritable
However, studies have not been able to differen-tiate between behavioral imitation of a family member’s suicide and a genetic propensity for suicide as explanatory factors. Twin studies have yielded estimates of the genetic contribution to the risk of suicidal behavior that range from 30 to 50%
Despite the apparent heritability of suicidal behavior, risk genes have not been iden-tified.3Some unreplicated studies have suggested that genetic promoters of inf lammation overlap suicide risk and that suicide risk is mediated by immunologic responses to acute infection, but these observations are speculative
Imaging and postmortem studies have shown changes in serotonergic pathways that are cor-related with suicide, but these associations have not been validated. One hypothesis is that changes in the medial prefrontal cortex lead to an overvaluing of social signs of rejection, defi-cits in emotional responses, and poor decision making.
One study showed that persons who experienced adversity in early life have an over-active hypothalamic–pituitary–adrenal axis in re-sponse to stress, which increases anxiety and acts as a mediator of suicidal behavior
Psychological Treatments
Studies of psychological treatments for suicide prevention have mainly addressed how suicidal ideas and thoughts develop and their conversion into plans for self-harm; alternatively, they have focused on mental states associated with sui-cide, such as depressive and anxiety symptoms. A meta-analysis that included various psycho-logical treatments showed that at the end of the treatment period, interventions that directly ad-dressed suicidal thoughts and behaviors and provided strategies for coping with them had better outcomes than treatment for anxiety and depression, but these differences were dimin-ished after 1 year.
Trials of cognitive behav-ioral therapy have shown a reduction in suicidal thoughts,69 presumed to be mediated by reduc-ing hopelessness. Mindfulness-based cognitive therapy, which combines cognitive behavioral techniques with meditation and deep breathing, has improved mood stability and problem solv-ing in suicidal persons.
Dialectical behavioral therapy, a form of cognitive therapy involving both individual and group-based treatment that focuses on keeping people in therapy and help-ing them learn to manage emotions and learn mindfulness skills, has reduced self-harm in 12 trials but with small effect sizes.
A study of family therapy as compared with usual treat-ment for adolescents who had harmed them-selves showed no reduction in suicides with family therapy
Another study showed that In-ternet-administered self-help treatments may of-fer approaches for hard-to-reach groups, such as persons who have had negative health care expe-riences or persons with financial or time con-straints that impede access to care,73 but these findings were not replicated in a similar trial.
References
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Age-standardized suicide rates (per 100 000 population), both sexes, 2016. Geneva: World Health Organization, 2018 (https://www .who .int/ gho/ mental_health/suicide_rates/ en/ )
States, 1999–2016 and circum-stances contributing to suicide — 27 states, 2015. MMWR Morb Mortal Wkly Rep 2018; 67: 617-24.4. Centers for Disease Control and Pre-vention. Multiple cause of death, 1999-2017.
CDC Wonder Online Database (https://wonder .cdc .gov/ mcd .html).5. Xuan Z, Naimi TS, Kaplan MS, et al. Alcohol policies and suicide: a review of the literature. Alcohol Clin Exp Res 2016;40: 2043-55.6. Kreitman N. The coal gas story: United Kingdom suicide rates, 1960-71. Br J Prev Soc Med 1976; 30: 86-93.7.
Razvodovsky YE. Beverage-specific alcohol sale and suicide in Russia. Crisis 2009; 30: 186-91.8. Kaufman EJ, Morrison CN, Branas CC, Wiebe DJ. State firearm laws and in-terstate firearm deaths from homicide and suicide in the United States: a cross-sectional analysis of data by county. JAMA Intern Med 2018; 178: 692-700.9.
Preventing suicide: a global impera-tive. Geneva: World Health Organization, 2014.10.
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Fazel S, Wolf A, Larsson H, Mallett S, Fanshawe TR. The prediction of suicide in severe mental illness: development and validation of a clinical prediction rule (OxMIS). T
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Chan MK, Bhatti H, Meader N, et al. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry 2016; 209: 277-83.49.
Bolton JM, Gunnell D, Turecki G. Sui-cide risk assessment and intervention in people with mental illness. BMJ 2015;351:h4978.50.
Fazel S, Wolf A. Suicide risk assess-ment tools do not perform worse than clinical judgement. Br J Psychiatry 2017; 211: 183.51. Pease JL, Forster JE, Davidson CL, Holliman BD, Genco E, Brenner LA. How Veterans Health Administration suicide prevention coordinators assess suicide risk. Clin Psychol Psychother 2017;24:401-10.52.
Berman NC, Stark A, Cooperman A, Wilhelm S, Cohen IG. Effect of patient and therapist factors on suicide risk as-sessment. Death Stud 2015;39:433-41
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