Suicidal behavior is a global cause of death and disability. Many become depressed and cannot handle it. The do not know where to turn. They are afraid to tell others. Worldwide, suicide is the fifteenth leading cause of death, accounting for 1.4% of all deaths (WHO 2014). In total, more than 800,000 people die by suicide each year. The annual global age-standardized death rate for 2012 is estimated to be 11.4 per 100,000, and the World Health Organization (WHO) projects this rate to remain steady through 2030 (WHO 2013, 2014). In addition to suicide deaths, suicidal thoughts and nonfatal suicide attempts also warrant attention. Globally, lifetime prevalence rates are approximately 9.2% for suicidal ideation and 2.7% for suicide attempt (Nock et al. 2008a).
Suicide attempts are strongly predictive of suicide deaths; can result in negative consequences such as injury, hospitalization, and loss of liberty; and exert a financial burden of billions of dollars on society (CDC 2010a; Nock et al. 2008a,b; WHO 2014). Taken together, suicide and suicidal behavior comprise the nineteenth leading cause of global disease burden (i.e., years lost to disability, ill-health, and early death), and the sixth and ninth leading cause of global disease burden among men and women 15 to 44 years of age, respectively (WHO 2008). By any measure, there is urgency to better understand and prevent suicide and suicidal behavior. s mental disorders, numerous clinical and psychological variables have been demonstrated to influence suicide risk.
Suicide mortality and morbidity are a major cost not only to the health sector but also to society in general. These cost include: premature loss of life, the provision of medical, surgical, mental health and rehabilitative services to those making non-fatal suicide attempts, bereavement and other psychological impacts on family and others closely involved with individuals making fatal and non-fatal suicide attempts, loss of productivity for those involved in the suicidal behaviors and those affected by it. Accurate cost evaluations are not available, as they would require long-term follow up. However, in general terms suicide and suicide attempts including self-inflicted injuries are estimated to cost billions of dollars each year.
A recent paper on the psychology of suicide by O’Connor & Nock (2014; see panel 2) –lists more than 30 psychological risk and protective factors. Here, we focus on three psychological variables often considered to be particularly important predictors of suicidal thoughts and attempts: depression (measured as a continuous variable rather than a discrete mental disorder), hopelessness, and impulsivity. Indeed, there is evidence that each of these variables exhibits statistically reliable relationships to measures of suicidality and suicide risk. However, the literature for each of these variables has important nuances. Depression appears to be one of the strongest predictors of suicidal ideation but does not appear to distinguish those who have attempted suicide from those who have experienced suicidal ideation without attempts (May & Klonsky 2016).
Hopelessness is well known for demonstrating prospective prediction of suicide and suicide attempts in very-long-term studies; however, the magnitude of prediction in this research is actually quite small, similar to a correlation of about 0.2 (Beck et al. 1989). In addition, like depression, hopelessness is elevated in those who have experienced suicidal ideation but is not higher in attempters compared to ideators (May & Klonsky 2016).
Evidence-based clinical intervention
Suicidal thoughts and behaviors remain difficult to treat. Unfortunately, no gold-standard, highly effective treatments exist. However, some treatments have better evidence than others for reducing suicidal thoughts and behaviors, and we summarize these below. We specifically focus on clinical interventions that target individuals at risk for suicide and that seek to reduce suicidal thoughts and behaviors; we address community-level suicide prevention efforts separately in a subsequent section.
Many different theories of suicide have been proposed over the last century. These include biological (e.g., Oquendo et al., 2014) and sociological approaches (e.g., Durkheim, 1897), and psychological theories that conceptualize suicide as a phenomenon related to the following: psychache (Shneidman, 1993); escape from aversive self-awareness (Baumeister, 1990); hopelessness (e.g., Beck, Steer, Kovacs, & Garrison, 1985); emotion dysregulation (Linehan, 1993); perceived burdensomeness, thwarted belongingness, and capability for suicide (Joiner, 2005; Van Orden et al., 2010); defeat, entrapment, and low social support (Williams, 2001); various diathesis-stress models (e.g., Mann, Waternaux, Haas, & Malone, 1999; O’Connor, 2011; Wenzel & Beck, 2008); and ideation to action frameworks (see Nock, Kessler, & Franklin, 2016 for a discussion), among several others. Each of these approaches is actively researched, with several relevant publications each year.
The trend for attempted suicide rates seem to be the reverse of completed suicide rates. The highest attempted suicide rate among females occurred in the 15-19 age category, at 265.3 per 100,000; the second highest attempted suicide rate was for the subsequent 20- 24 age category, at 202.9 per 100,000. There were very few hospital admissions for attempted suicides among elderly females. Hospitalization for suicide attempts among males in Manitoba also followed the female trend. That is, the rates of hospitalization for suicide attempts were skewed towards young adults. The highest rate occurred in the 20-24 age group, with a rate of 134.5 per 100,000. The second highest was among the 25-29 age category, with a rate of 119.8 per 100,000.
Suicides by those under age 11 are rare. Suicide rates start to increase in adolescence, and continue to rise up to and including the 24-35 year age group. Suicide is the second leading cause of death among 15 – to- 24 year olds. Suicides among the youth and young adult age group have increased over the last forty years, while the overall rate has remained relatively steady (Allebeck et al. 1996). Onset of mental illness and the stressors related to the transition from adolescence to adulthood have been identified as possible factors contributing to youth suicide (Beautrais et al. 1996; Tousignant et al. 1993). Late Middle-aged and Elderly Persons Suicide rates decrease until approximately age 60-64 years. Following this they begin to demonstrate a slight increase. Suicides among older age groups can be expected to rise given that they constitute the fastest growing segment of the population (De Leo et al, 1999). Some factors attributed to high rates of suicides among the elderly are poor health and chronic pain, unemployment, depression, isolation and loss. (Canadian National Task Force, 1994 ) Losses inherent to mid and older adult life have been identified as one of the most serious risk factors for suicidal behavior in adults. Losses may include marital breakups, death, retirement, loss of autonomy and physical disability (De Leo et al, 1999).
Summary of the Incidence of Suicide
Completed suicides by males outnumber those of females. The number of females who make a suicide attempt exceeds that of males. Suicide rates peak in young adulthood and old age. Slight fluctuations in the number of suicides could have a pronounced effect on rates. Winnipeg data is limited at the time this report was prepared however more complete data is pending. Data provided does not illustrate the impact suicide has on the Aboriginal and the 1st Nations community. This is due to the lack of reliable and consistent collection of race data in Manitoba as it pertains to suicide and injury.
Schizophrenia is a part of suicide. Suicide is the major cause of death among individuals with schizophrenia, with as many as 1 out of 4 persons with schizophrenia dying from suicide. (Conwell, 1998) Individuals with schizophrenia who commit suicide tend to do so during times when symptoms of psychosis are not acute or during remission (Roy 1986). An unrecognized affective disorder is strongly correlated with suicide in people with schizophrenia. (Roy, 1986)
An estimated 6.5% of individuals with borderline personality disorder and 5% of those with antisocial personality disorder commit suicide (The Update of the National Task Force on Suicide, 1994). Certain personality traits have been identified as important correlates of increased risk of suicide including obsessive-compulsive traits, perfectionism, and cognitive rigidity. (Beck et, al 1985) Individual personality factors cannot be considered alone but must be evaluated within the context of other risk factors. A ten-year longitudinal study concluded that measurement of an individual’s hopelessness is a strong predictor for future suicidal behaviors. (Beck et al, 1985) Other personality characteristics that are associated with suicidal behaviors are high levels of anxiety, low self-esteem, high impulsivity, poor problem-solving skills and irrationality (Lester, 1992).
As you can see, protective factors are those dynamics that lessen, compensate or protect individuals from exposure and impact to risk factors. Research into protective factors, well-being, optimism, connectedness and resilience as related to suicide is limited. The literature indicates the value of considering evidence from the study of other potentially relevant areas and associations between protective factors and proxy measures for suicide such as depression. The following are some of the factors that have been suggested as protecting against suicide: good problem solving skills, helping seeking behaviors, family and community social supports (e.g. marriage), and connectedness (e.g. to family, peer group, school or community), secure social identity, cultural, religious and personal beliefs that discourage suicidal behavior and, skills in managing conflicts and disputes.