Understanding Suicide

1. Suicide Facts
2. Risk Factors
3. Warning Signs of Suicide
4. What To Do if a Friend or Relative is Suicidal
5. Suicide Among Youth and Young Adults
6. Suicide Among the Elderly
7. Survivors of Suicide
8. Intentional Injury
9. Depression
   1. Warning Signs of Depression
   2. Depression and Children/Adolescents
   3. Depression Later in Life
   4. The Links Between Depression and Suicide
10. Suicide and Firearms

A. Suicide Facts

• Suicide takes the lives of more than 30,000 Americans every year.
• Every 18 minutes another life is lost to suicide.
• Every day 80 Americans take their own lives and over 1,900 Americans visit emergency departments for self-inflicted injury.
• Suicide is now the 11th leading cause of death among Americans.
• For every two victims of homicide in the U.S. there are three persons who take their own lives.
• There are now twice as many deaths due to suicide as to HIV/AIDS.
• Since 1950, the incidence of suicide among adolescents and young adults has nearly tripled.
• In the month prior to their suicide, 75% of elderly persons had visited a physician.
• Over half of all suicides occur in adult men, aged 25-65.
• Many who attempt suicide never seek mental health care.
• Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death.
• Males are four times more likely to die from suicide than are females.
• More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease, combined.

Source: National Strategy for Suicide Prevention, www.mentalhealth.org/suicide

B. Risk Factors for Suicide

• Major mental health problems
• Trauma, including rape, and sexual assault
• Substance abuse problems
• Loss of family member or friend (especially by suicide)
• Gender identity issues
• Poor family stability

Source: National Mental Health Association, www.nmha.org

C. Warning signs of suicide

No suicide attempt should be dismissed or treated lightly!

• Verbal threats such as "You’d be better off without me" or "Maybe I won’t be around anymore..."
• Expressions of hopelessness and/or helplessness
• Previous suicide attempts
• Daring and risk-taking behavior
• Personality changes (e.g. withdrawal, aggression, moodiness)
• Depression
• Giving away prized possessions
• Lack of interest in the future
• Increase in drug or alcohol intake
• Recent severe loss or threat of such a loss

Source: National Mental Health Association, www.nmha.org

D. What to do if a friend or relative is suicidal

• Trust your instincts and believe that the person may attempt suicide.
• Talk with the person about your concerns and show that you care and want to help.
• Ask the person direct questions. The more detailed their plan, the greater the immediate risk.
• Remember that the most important thing is to listen.
• Get professional help - even if the person resists.
• Do not leave the person alone.
• Do not swear to secrecy.
• Do not act shocked or judge the person.
• Do not counsel the person.

Source: National Mental Health Association, www.nmha.org

In An Acute Crisis

• In an acute crisis, take your friend or loved one to an emergency room or walk-in clinic at a psychiatric hospital. Do not leave them alone until help is available.
• Remove from the vicinity any firearms, drugs or sharp objects that could be used in a suicide attempt.
• Hospitalization may be indicated and may be necessary at least until the crisis abates.
• If a psychiatric facility is unavailable, go to your nearest hospital or clinic.
• If the above options are unavailable, call your local emergency number.

Source: American Foundation for Suicide Prevention; www.afsp.org

E. Suicide Among Youth and Young adults

• Suicide ranks as the third leading cause of death for young people (ages 15 to 24); only accidents and homicides occur more frequently.
• Approximately 11 young people between the ages of 15-24 die every day by suicide.
• Within every 2 hours and 15 minutes a person under the age of 25 completes suicide.
• Suicide rates, for 15 –24 year olds, have more than doubled since the 1950’s, and remained largely stable at these higher levels between the late 1970’s and the mid 1990’s. They have declined 25.6% since 1995.
• In the past 60 years, the suicide rate has quadrupled for males 15 to 24 years old, and has doubled for females of the same age.
• The male to female ratio of completed suicides was 5: 1 among 15 to 19 year olds and 6.9: 1 among 20 to 24 yea olds.
• Firearms remain the most commonly used suicide method among youth, regardless of race or gender, nearly accounting for almost 3 of 5 (57%0 completed suicides.
• Research has shown that the access to and availability of firearms is a significant factor in the increase of youth suicide. Guns in the home are deadly to its occupants.
• Among 15-19 year old black males, rates (since 1980) have increased 80% (2001 data). The rates for black males ages 15-19 is currently 7.3 per 100,000. For the age group 20 to 24, the rate is 19.4.
• For every suicide completed by youth, it is estimated that 100 to 200 attempts are made. In grades 9 through 12, 8.8% of students attempted suicide in the previous 12 months (6.2% male and 12.2% female). These numbers decrease from grades 9 (10.7%) to 12 (5.5%). A prior suicide attempt is an important risk factor for an eventual completion.
• GLBT youth are at an increased risk for suicide and GLBT youth who have been the victims of harassment or violence are at the highest risk.

Sources:
American Association of Suicidology, www.suicidology.org
National Vital Statistics Reports, National Center for Health Statistics; www.cdc.gov/nchs
National Mental Health Association; www.nmha.org

Massachusetts Statistics for Suicidal Thinking and Behavior Among High School Students (2003)

• 28% of students reported feeling sad or hopeless for two weeks or more in the past year.
• 16.3% of students have seriously considered suicide in the past year.
• 12.5% of students made a suicide plan.
• 8.4% of students attempted suicide.
• 2.8% of students received medical attention for a suicide attempt.
• Sexual minority youth attempted suicide 5 times more often than other youth and made a suicide attempt with injury 7 times more often.

Source: 2003 Massachusetts Youth Risk Behavior Survey Results; Massachusetts Department of Education May 2004; www.doe.mass.edu/hssss/program/youthrisk

Facing the Danger of Teen Suicide

Sometimes teens feel so depressed that they consider ending their lives. Nationwide, each year almost 5,000 young people, ages 15 to 24, kill themselves. The rate of suicide for this age group has nearly tripled since 1960, making it the third leading cause of death in adolescents and the second leading cause of death among college age youth.

Studies show that suicide attempts among young people may be based on long standing problems triggered by a specific event. Suicidal adolescents may view a temporary situation as a permanent condition. Feelings of anger and resentment combined with exaggerated guilt can lead to impulsive, self-destructive acts.

Source: National Mental Health Association, www.nmha.org

Recognizing the Warning Signs

Four out of five teens who attempt suicide have given clear warnings. Pay attention to these warning signs:

• Suicide threats, direct and indirect
• Obsession with death
• Poems, essays and drawings that refer to death
• Dramatic change in personality or appearance
• Irrational, bizarre behavior
• Overwhelming sense of guilt, shame or reflection
• Changed eating or sleeping patterns
• Severe drop in school performance
• Giving away belongings

Helping Suicidal Teens

• Offer help and listen. Encourage depressed teens to talk about their feelings. Listen, don’t lecture.
• Trust your instincts. If it seems that the situation may be serious, seek prompt help. Break a confidence, if necessary, in order to save a life.
• Pay attention to talk about suicide. Ask direct questions and don’t be afraid of frank discussions. Silence is deadly!
• Seek professional help. It is essential to seek expert advice from a mental health professional that has experience helping depressed teens. Also, alert key adults in the teen’s life - family, friends and teacher

Source: National Mental Health Association, www.nmha.org

What Parents Can Do

• Talk with your child and let him or her know you care and want to help. Don’t assume that a teen’s moodiness is “just a phase”.
• Have your teen screened for depression. You can get information from a school counselor or pediatrician.
• Get professional help early. The sooner teen depression is treated, the better.
• Lock up medications that may be deadly-or don’t keep them around at all.
• Remove all firearms, including hunting rifles, from the home.
• Make sure your child’s treatment is up-to-date and that his or her therapist is aware of the most effective approaches.
• Address the dangers of alcohol and illegal drugs, explaining to teens that they are especially vulnerable to drug use/experimentation.

What School Personnel Can Do

• Know the warning signs!
• Know the school's responsibilities. Schools have been held liable in the courts for not warning parents in a timely fashion or adequately supervising the suicidal student.
• Encourage students to confide in someone. Let students know that someone is there to help, that there is someone who cares at school. Encourage them to come to someone at school if they or someone they know is considering suicide.
• Refer student immediately. Do not "send" a student to the school psychologist or counselor. Make sure student is escorted to a member of the school’s crisis team. If a team has not been identified, notify the principal, psychologist, counselor, nurse or social worker
• Organize/join the school crisis team.
• Advocate for the child. Sometimes administrators may minimize risk factors and warning signs in a particular student. Advocate for the child until staff is certain the child is safe.

Source: National Association of School Psychologists, www.nasponline.org

Suicide Among Children

• Suicide rates for those between the ages of 10 and 14 increased 99% between 1980 and 1997. This age group has shown a small decline in the past two years. For 2001, the rate is 1.5 per 100,000.
• In the 10 to 14 age group, white youths (ranked 3rd leading cause of death) were far more likely to complete suicide than black youths (ranked 7TH leading cause of death). White males between 10 and 14 years of age were three times more likely to complete suicide than females of the same age.
• In 2001, there were 272 suicides in the U.S. among children ages 10 to 14.

Source: American Association of Suicidolgy; www.suicidolgy.org
National Vital Statistics Reports, National Center for Health Statistics; www.cdc.gov/nchs

Suicide Among College Students

• Suicide is the 3rd leading cause of death in college-age students (20 to 24 years old).
• It is estimated that there are more than 1,000 suicides on college campuses per year.
• One in 12 college students have made a suicide plan.
• Two groups of students might be at higher risk for suicide:
  • Students with a pre-existing (before college) mental health condition, and
  • Students who develop a mental health condition while in college. Within these groups, students who are male, Asian and Hispanic, under the age of 21 are more likely to experience suicide ideation and attempts.
• Reasons attributed to the appearance or increase of symptoms/disorders:
  • New and unfamiliar environment
  • Academic and social pressures
  • Feelings of failure or decreased performance
  • Alienation
  • Family history of mental illness
  • Lack of adequate coping skills
  • Difficulties adjusting to new demands and different work loads
• Risk factors for suicide in college students include depression, sadness, hopelessness and stress.
• As with the general population, depression plays a large role in suicide. Ten percent of college students have been diagnosed with depression. The vast majority of young adults aged 18 and older who are diagnosed with depression do not receive appropriate treatment or even any treatment at all.

Source: American Association of Suicidology; www.suicidolgy.org “Safeguarding your students Against Suicide-Expanding the Safety Net: Proceedings from an Expert panel on Vulnerability, Depressive Symptoms, and Suicidal Behavior on College Campuses, a report by NMHA and The Jed Foundation (2002).

F. Suicide among the Elderly

• The elderly make up 13% of the population; they account for almost 25% of all suicides.
• There is one elderly suicide every 83 minutes. There are about 18 elderly suicides each day, resulting in 5,393 suicides among those 65 and older.
• Elderly white men are at the highest risk with a rate of approximately 34 suicides per 100,000 each year.
• 83% of elderly suicides are male; the number of male suicides in late life is 7 times greater than for female suicides.
• The rate of suicide for women declines after age 60 (after peaking in middle adulthood, ages 40-54).
• Although older adults attempt suicide less often than those in other age groups, they have a higher completion rate. For all ages combined, there is an estimated 1 suicide for every 25 attempts. Among the young (ages 15-24 years) there is an estimated 1 suicide for every 100-200 attempts. Over the age of 65, there is 1 suicide for every 4 attempts.
• Firearms are the most common means used for completing suicide among the elderly. Men (79%) use firearms more than twice as often as women (39%).
• Alcohol or substance abuse plays a diminishing role in later life suicides.
• One of the leading causes of suicide among the elderly is depression, often undiagnosed and/or untreated.

Source: American Association of Suicidolog y; www.suicidology.org
National Vital Statistics Reports; National Center for Health Statistics; www.cdc.gov/nchs
Institute on Aging; www.gioa.org

G. Survivors of Suicide

• Each year over 30,000 people in the United States die by suicide. The devastated family and friends they leave behind are known as “survivors”. There are millions of survivors who are trying to cope with this loss.
• Survivors often experience a wide range of grief reactions, including some or all of the following: shock, symptoms of depression, anger towards the deceased, relief, guilt.
• 90 percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death. Suicide is almost always complicated, resulting from a combination of painful suffering, desperate hopelessness and underlying psychiatric illness.

Coping With Suicide Loss

• Some survivors struggle with what to tell other people. Although you should make whatever decision feels right to you, most survivors have found it best to simply acknowledge that their loved one died by suicide.
• You may find that it helps to reach out to family and friends. Because some people may not know what to say, you may need to take the initiative to talk about the suicide, share your feelings and ask for their help.
• Maintaining contact with other people is especially important during the stress-filled months after a loved one’s suicide.
• Keep in mind that each person grieves in his or her own way.
• Each person also grieves at his or her own pace; there is no set rhythm or timeline for healing.
• Anniversaries, birthdays, and holidays may be especially difficult, so you might want to think about whether you want to continue old traditions or create some new one.
• Children experience many of the feelings of adult grief, and are particularly vulnerable to feeling abandoned and guilty. Reassure them that the death was not their fault. Listen to their questions and try to offer honest, straightforward, age-appropriate answers.
• Eventually starting to enjoy life is not a betrayal of your loved one, but rather a sign that you have begun to heal.

Source: American Foundation for Suicide Prevention; www.afsp.org/survivor

H. Intentional Injuries

There are two basic types of intentional injury, self-injury and injuries with suicidal intent. Self-injury (also called self-mutilation) includes behaviors that are deliberate and cause immediate physical harm to the subject. For example: cutting, burning, interfering with wound healing, hair pulling, scratching and self-hitting are all examples of self-injuries that are considered pathological and warrant intervention. Some self-injuries, if not carried to extremes, are socially sanctioned such as body art and body piercing and are not considered pathological. Other self-injurious behavior such as smoking, drinking, drug use, failure to exercise, etc. although deleterious in the long run, usually do not cause immediate self-harm.

Prevalence

Unfortunately, questions about self-injury behaviors that are lacking in suicidal intent are not asked on the Youth Risk Behavior Survey, a valuable source of information on risk behaviors in Massachusetts’ young people. However, data from the MA Division of Health Care, Finance and Policy*, reveals that in Massachusetts, in 1999 and 2000, there were more admissions to hospitals due to self-injuries (3,694) than there were due to assaults (1382). The methods of self-injury were: poisoning (78%); cutting/piercing (14%); Other (6%); and suffocation (2%). For females, but not for males, self-injury also accounted for more emergency department treatments than assaults (7,626 vs. 4,107). The majority of these admissions were of young women aged 10-24 years.

The 2003 Massachusetts Youth Risk Behavior Survey reported that 29% of the 5,000 students participating admitted to feeling so sad or hopeless for two or more weeks in the past 12 months that they stopped doing some usual activities. Twenty percent reported suicidal thoughts and 10% reported making an actual suicide attempt. Six percent said the attempt required medical treatment.

Suicidal intent and self-injury

The behaviors of cutting, burning, interference with wound healing, self-hitting and hair pulling are coping behaviors that help the subject release pent up emotions such as anxiety, fear or anger. As maladaptive as the behavior seems it is an effective coping mechanism that may become habitual. It is most often practiced in secret when alone and can stimulate tremendous shame and guilt if it becomes repetitive. The subject does not intend to die by their acts.

Suicidal behavior is an even more maladaptive attempt at coping behavior since it may result in either death or serious injury. Suicide is less about seeking death than it is about seeking relief and release from overpowering feelings of helplessness and hopelessness. It feels to the subject like the only solution and is a last resort.

* Data reported here does not distinguish between self-injury with or without suicidal intent

Although a fairly clear distinction may be drawn between self-injury behavior and suicidal behavior, subjects who engage in self-injury, if found out, may experience ostracism from their social peers due to the difficulty others have in understanding and accepting such behavior. If the shame and isolation from peers is felt strongly, the subject may become suicidal.

What schools can do

• Provide all school nurses, health teachers, counselors, coaches, classroom teachers and administrators with training on intentional injury.
• Contact the local mental health system to learn about services available for students and how to access them.
• Incorporate age-appropriate information on intentional injury into comprehensive health education programs and school-based health center admission policies and procedures.
• Set up on-site counseling groups for students who practice self-injurious behaviors.
• Post counseling and other information resources widely.
• Advertise responsible health websites for students to visit anonymously.

I. Depression

Warning signs of major depression or mental illness among all age groups

Changes in feelings such as fear and anger are a normal part of life. Personal situations, such as a divorce, loss of a job, or strained relationships with family or friends can cause emotional stress, thus making a person feel sad or blue. These are not unusual reactions.

Certain thoughts and feelings associated with some experiences, however, may be warnings of more serious problems and the need for mental health intervention. It is not always easy to spot these warning signs, or figure out what they mean—qualified mental health professionals should be consulted in order to make an accurate diagnosis.

The following feelings and experiences may be warning signs of major depression or mental illness:

• Finding little or no pleasure in life
• Feeling worthless or extremely guilty
• Crying a lot for no particular reason
• Withdrawing from other people
• Experiencing severe anxiety, panic or fear
• Having very low energy
• Losing interest in hobbies and pleasurable activities
• Having too much energy, having trouble concentrating or following through on plans
• Experiencing racing thoughts or agitation
• Hearing voices or seeing images that other people do not experience
• Believing that others are plotting against you
• Wanting to harm yourself or someone else

Source: The National Mental Health Awareness Campaign, www.nostigma.org

Depression and Children/Adolescents

Depression is a mental health problem that affects people of all ages, including children. Depression is more than just “feeling blue” or having a bad day, and it is different from the feelings of grief or sorrow that might follow a major loss, such as a death in the family. It is not a personal weakness or a character flaw. Children with clinical depression cannot simply “snap out of it.” As many as 1 in every 33 children—and 1 in 8 adolescents—may have depression.

No one thing causes depression. Biological, environmental, and psychological factors occurring individually or in combination seem to contribute to the onset of the disorder. Children who develop depression are likely to have a family history of the disorder. Children who have a chronic illness or who experience abuse, neglect, or other trauma are also at a higher risk for depression. Depression in children often co-occurs with other mental disorders such as anxiety disorders or disruptive behavior disorders. Adolescents who are depressed are also at risk for substance abuse.

Consequences of depression can include social isolation, academic underachievement, and strained family interactions. Depression in children is also associated with an increased risk for suicidal behaviors. Once a young person has experienced an episode of depression, he or she is at an increased risk for developing another episode of depression within the next 5 years. Children who experience a depressive episode are 5 times more likely to have depression as an adult, and depression in childhood may predict a more severe depressive illness in adulthood. Teens need adult guidance more than ever to understand all the emotional and physical changes they are experiencing. When teens’ moods disrupt their ability to function on a day-to day basis, it may indicate a serious emotional or mental disorder that needs attention.

Source: US Center for Mental Health Services, www.mentalhealth.org

Depression in Later Life

Depression affects more than 19 million Americans every year, regardless of age, race, or gender. While depression is not a normal part of the aging process, there is a strong likelihood of it occurring when other physical health conditions are present. For example, nearly a quarter of the 600,000 people who experience a stroke in a given year will experience clinical depression. Unfortunately, symptoms of depression are often overlooked and untreated when they coincide with other medical illnesses or life events that commonly occur as people age (e.g., loss of loved ones). However, clinical depression is never a “normal” response; it is a serious medical illness that should be treated at any age.

Prevalence

• More than two million of the 34 million Americans age 65 and older suffer from some form of depression.

Co-occurring Illnesses

• Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimer’s disease, Parkinson’s disease, heart disease, cancer and arthritis.

Widowhood

• One-third of widows/widowers meet criteria for depression in the first month after the death of their spouse, and half of these individuals remain clinically depressed after one year.

Healthcare Costs

• Older patients with symptoms of depression have roughly 50% higher healthcare costs than non-depressed seniors.

Suicide

• Depression is a significant predictor of suicide in elderly Americans.
• Comprising only 13% of the U.S. population, individuals aged 65 and older account for 25% of all suicide deaths, with white males being particularly vulnerable.
• Suicide among white males aged 85 and older (65.3 deaths per 100,000 persons) is nearly six times the suicide rate (10.8 per 100,000) in the U.S.

Treatment

• More than 55% of older persons treated for mental health services received care from primary care physicians. Less than 3% aged 65 and older received treatment from mental health professionals.
• Primary care physicians accurately recognize less than one half of patients with depression, resulting in potentially decreased function and increased length of hospitalization.
• Fortunately, clinical depression is a very treatable illness. More than 80% of all people with depression can be successfully treated with medication, psychotherapy or a combination of both.

Source: National Institute of Mental Health, www.nimh.gov

Older Adult Attitudes toward Depression

According to a National Mental Health Association survey on attitudes and beliefs about clinical depression:

• Approximately 68% of adults aged 65 and over know little or almost nothing about depression.
• Only 38% of adults aged 65 and over believe that depression is a “health” problem.
• If suffering from depression, older adults are more likely than any other group to “handle it themselves.” Only 42% would seek help from a health professional.
• Signs of depression are mentioned more frequently by people under age 64 than people aged 65 and over. These include “a change in eating habits” (29% vs. 15%), “a change in sleeping habits” (33% vs. 16%) and “sadness” (28% vs. 15%).
• About 58% of people aged 65 and older believe that it is “normal” for people to get depressed as they grow older.

Source: National Institute of Mental Health, www.nimh.nih.gov/depression/genpop/gen_fact.htm

The Links Between Depression and Suicide

• Major depression is the psychiatric diagnosis most commonly associated with suicide.
• About 2/3 of people who complete suicide are depressed at the time of their deaths.
• One out of every sixteen people who are diagnosed with depression eventually go on to end their lives through suicide.
• About 7 out of every 100 men and 1 out of every 100 women who have been diagnosed with depression in their lifetime will go on to complete suicide.
• The risk of suicide in people with major depression is about 20 times that of the general population.
• People who have had multiple episodes of depression are at greater risk for suicide than those that have had one episode.
• People who have a dependence on alcohol and drugs in addition to being depressed are at greater risk for suicide.
• People who are depressed and exhibit the following symptoms are at particular risk for suicide:
  1. Extreme hopelessness
  2. A lack of interest in activities that were previously pleasurable
  3. Heightened anxiety and/or panic attacks
  4. Global insomnia
  5. Talk about suicide or a prior history of attempts/acts
  6. Irritability and agitation

Source: American Association of Suicidology; www.suicidology.org

J. Suicide and Firearms

There is a strong correlation between suicide and gun violence. In fact, 60% of suicide deaths involve a firearm.

The facts:

• Contrary to public belief, most gun deaths are suicides, not homicides. In 1999 out of 28,874 people killed by firearms, 16,599 were suicides. (Centers for Disease Control)
• The risk of suicide of a household member is increased nearly five times in homes with guns. (Kellerman, 1992, New England Journal of Medicine)
• Firearms are now the most common method of suicide for women, a change from 1970 when poisonings was the leading method for women. (National Center for Health Statistics)
• Firearms are used in two of three youth suicides. Unlike any other attempted method, use of firearms is most likely to be fatal. (National Center for Health Statistics)
• 72.9% of suicides committed by older adults involved a firearm. (National Center for Health Statistics)
• The Surgeon General’s National Strategy for Suicide Prevention identifies easy access to guns as a risk factor for suicide. Professionals need to ask families about the presence of firearms in their homes. Delaying access to lethal means can provide a valuable opportunity for an adult in crisis or an impulsive young person to seek help.

Source: Join Together: Gun Violence: Making Connections with Suicide, Domestic Violence and Substance Abuse, www.jointogether.org

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