• In Harm’s Way: Suicide in America
  (National Institutes of Mental Health)
  
  
• When Someone Takes His Own Life (Normal Vincent Peale)
  
  
• CISM Information Pamphlet 
  (International Critical Incident Stress Foundation)
  
  
• International CISM Hotline Information   
  (International Critical Incident Stress Foundation)

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In Harm's Way: Suicide in America

Suicide is a tragic and potentially preventable public health problem. In 1997, suicide was the 8th leading cause of death in the U.S.¹ Specifically, 10.6 out of every 100,000 persons died by suicide. The total number of suicides was approximately 31,000, or 1.3 percent of all deaths. Approximately 500,000 people received emergency room treatment as a result of attempted suicide in 1996. Taken together, the numbers of suicide deaths and attempts show the need for carefully designed prevention efforts.

Suicidal behavior is complex. Some risk factors vary with age, gender and ethnic group and may even change over time. The risk factors for suicide frequently occur in combination. Research has shown that more than 90 percent of people who kill themselves have depression or another diagnosable mental or substance abuse disorder.³ In addition, research indicates that alterations in neurotransmitters such as serotonin are associated with the risk for suicide.⁴ Diminished levels of this brain chemical have been found in patients with depression, impulsive disorders, a history of violent suicide attempts, and also in postmortem brains of suicide victims.

Adverse life events in combination with other risk factors such as depression may lead to suicide. However, suicide and suicidal behavior are not normal responses to stress. Many people have one or more risk factors and are not suicidal. Other risk factors include: prior suicide attempt; family history of mental disorder or substance abuse; family history of suicide; family violence, including physical or sexual abuse; firearms in the home; incarceration; and exposure to the suicidal behavior of others, including family members, peers, and even in the media.⁵

Gender Differences

More than 4 times as many men than women die by suicide;¹ however, women report attempting suicide about 2 to 3 times as often as men.⁶ Suicide by firearm is the most common method for both men and women, accounting for 58 percent of all suicides in 1997. Seventy-two percent of all suicides were committed by white men, and 79 percent of all firearm suicides were committed by white men. The highest suicide rate was for white men over 85 years of age-65 per 100,000 persons.

Children, Adolescents, and Young Adults

Over the last several decades, the suicide rate in young people has increased dramatically.⁷ In 1997, suicide was the 3rd leading cause of death in 15 to 24 year olds-11.4 of every 100,000 persons-following unintentional injuries and homicide.¹ Suicide also was the 3rd leading cause in 10 to 14 year olds, with 303 deaths among 19,097,000 children in this age group. For adolescents aged 15 to 19, there were 1,802 suicide deaths among 19,146,000 adolescents. The gender ratio in this age group was about 4:1 (males: females). Among young people 20 to 24 years of age, there were 2,384 suicide deaths among 17,488,000 people in this age group. The gender ratio in this age range was about 6:1 (males: females).⁸

Attempted Suicides

There may be as many as 8 attempted suicides to 1 completion;⁹ the ratio is higher in women and youth and lower in men and the elderly. Risk factors for attempted suicide in adults include depression, alcohol abuse, cocaine use, and separation or divorce.^10,11 Risk factors for attempted suicide in youth include depression, alcohol or other drug use disorder, physical or sexual abuse, and aggressive or disruptive behaviors.^12-14 The majority of suicide attempts are expressions of extreme distress and not just harmless bids for attention. A suicidal person should not be left alone and needs immediate mental health treatment.

Prevention

All suicide prevention programs need to be scientifically evaluated to demonstrate whether or not they work. Preventive interventions for suicide must also be complex and intensive if they are to have lasting effects. Most school-based, information-only, prevention programs focused solely on suicide have not been evaluated to see if they are effective, and research suggests that such programs may actually increase distress in the young people who are most vulnerable.¹⁵ School and community prevention programs designed to address suicide and suicidal behavior as part of a broader focus on mental health, coping skills in response to stress, substance abuse, aggressive behaviors, etc., are more likely to be successful in the long run.

Recognition and appropriate treatment of mental and substance abuse disorders also hold great suicide prevention value. For example, because most elderly suicide victims-70 percent-have visited their primary care physician in the month prior to their suicides,¹⁶ improving the recognition and treatment of depression in medical settings is a promising way to prevent suicide in older adults. Toward this goal, NIMH-funded researchers are currently investigating the effectiveness of a depression education intervention delivered to primary care physicians and their elderly patients.

If someone is suicidal, he or she must not be left alone. You may need to take emergency steps to get help, such as calling 911. It is also important to limit the person's access to firearms, large amounts of medication, or other lethal means of committing suicide.

For More Information

All material in this fact sheet is in the public domain and may be copied or reproduced without permission from the Institute. Citation of the source is appreciated.

References

¹Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. National Vital Statistics Report, 47(19). DHHS Publication No. 99-1120. Hyattsville, MD: National Center for Health Statistics, 1999. http://www.cdc.gov/nchs/data/nvs47_19.pdf

²McCraig LF, Stussman BJ. National Hospital Ambulatory Care Survey: 1996. Emergency department summary. Advance Data from Vital and Health Statistics, no. 293. Hyattsville, MD: National Center for Health Statistics, 1997. http://www.cdc.gov/nchs/data/ad293.pdf

³Conwell Y, Brent D. Suicide and aging I: patterns of psychiatric diagnosis. International Psychogeriatrics, 1995; 7(2): 149-64.

⁴Mann JJ, Oquendo M, Underwood MD, et al. The neurobiology of suicide risk: a review for the clinician. Journal of Clinical Psychiatry, 1999; 60(Suppl 2): 7-11; discussion 18-20, 113-6.

⁵Blumenthal SJ. Suicide: a guide to risk factors, assessment, and treatment of suicidal patients. Medical Clinics of North America, 1988; 72(4): 937-71.

⁶Weissman MM, Bland RC, Canino GJ, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 1999; 29(1): 9-17.

⁷National Center for Injury Prevention and Control. Fact book for the year 2000: suicide and suicide behavior. http://www.cdc.gov/ncipc/pub-res/FactBook/suicide.htm

⁸National Center for Injury Prevention and Control. Suicide deaths and rates per 100,000: United States 1994-1997. http://www.cdc.gov/ncipc/data/us9794/Suic.htm

⁹Moscicki EK. Epidemiology of suicide. In: Jacobs D, ed. The Harvard Medical School guide to suicide assessment and intervention. San Francisco, CA: Jossey-Bass, 1999, 40-71.

¹⁰Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 1999; 56(7): 617-26.

¹¹Petronis KR, Samuels JF, Moscicki EK, et al. An epidemiologic investigation of potential risk factors for suicide attempts. Social Psychiatry and Psychiatric Epidemiology, 1990; 25(4): 193-9.

¹²Gould MS, King R, Greenwald S, et al. Psychopathology associated with suicidal ideation and attempts among children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37(9): 915-23.

¹³Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse and psychiatric disorder in young adulthood, II: psychiatric outcomes of childhood sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(10): 1365-74.

¹⁴Kaplan SJ, Pelcovitz D, Salzinger S, et al. Adolescent physical abuse and suicide attempts. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(6): 799-808.

¹⁵Vieland V, Whittle B, Garland A, et al. The impact of curriculum-based suicide prevention programs for teenagers: an 18-month follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 1991; 30(5): 811-5.

¹⁶Conwell, Y. Suicide in elderly patients. In: Schneider LS, Reynolds CF III, Lebowitz, BD, Friedhoff AJ, eds. Diagnosis and treatment of depression in late life. Washington, DC: American Psychiatric Press, 1994; 397-418.

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When Someone Takes His Own Life

by Norman Vincent Peale

In many ways, this seems to be the most tragic form of death. Often the stigma of suicide is what rests most heavily on those left behind...The Bible warns us not to judge, if we ourselves hope to escape judgment. And I believe that this is the one area that Biblical command especially should be heeded. For how do we know how many valiant battles such a person may have fought and won before he loses that one particular battle? And is it fair that all the good acts and impulses of such a person should be forgotten or blotted out by his final tragic act?

I think our reaction should be one of love and pity, not of condemnation. Perhaps the person was not thinking clearly in his final moments; perhaps he was so driven by emotional whirlwinds that he was incapable of thinking at all. This is terribly sad. But surely it is understandable. All of us have moments when we lose control of ourselves, flashes of temper, or irritation, or selfishness that we later regret. Each one of us, probably, has a final breaking point - or would have if our faith did not sustain us. Life puts far more pressure on some of us than it does on others. Some people have more stamina than others...

My heart goes out to those who are left behind, because I know they suffer terribly...The immediate family of the victim is left wide open to tidal waves of guilt: "What did I fail to do that I should have done? What did I do that was wrong?" To such grieving persons I can only say, "Lift up your heads and your hearts. Surely you did your best. And surely the loved one who is gone did his best, for as long as he could. Remember, now, that his battles and torments are over. Do not judge him, and do not presume to fathom the mind of God where this one of His children is concerned."

A few years ago, when a young man died by his own hand, a service for him was conducted by his pastor, the Reverend West Stephens. What he said that day expresses far more eloquently than I can, the message that I’m trying to convey. Here are some of his words:

"Our friend died on his own battlefield. He was killed in action fighting a civil war. He fought against adversaries that were as real to him as his casket is real to us. They were powerful adversaries. They took toll of his energies and endurance. They exhausted the last vestiges of his courage and his strength. At last these adversaries overwhelmed him. And it appeared that he had lost the war. But did he? I see a host of victories that he has won!

"For one thing - he has won our admiration - because even if he lost the war, we give him credit for his bravery on the battlefield. And we give him credit for the courage and pride and hope that he used as his weapons as long as he could. We shall remember not his death, but his daily victories gained through his kindnesses and thoughtfulness, through his love for his family and friends...for all things beautiful, lovely, and honorable. We shall remember not his last day of defeat, but we shall remember the many days that he was victorious over overwhelming odds. We shall remember not the years we thought he had left, but the intensity with which he lived the years that he had. Only God knows what this child of His suffered in the silent skirmishes that took place in his soul. But our consolation is that God does know, and understands."