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Nonsuicidal self-injuryis an act of self-harm that is not intended to result in death. Such acts
include inflicting scratches on the arms, burning oneself with a cigarette, and overdosing on
vitamins. Nonsuicidal self-injury may be a way to reduce tension or may be a plea for help
from people who still wish to live. These acts should not be dismissed lightly.
Information about the frequency of suicide comes mainly from death certificates and inquest
reports and probably underestimates the true rate. Even so, suicidal behavior is an all-too-
common health problem. Suicidal behavior occurs in people of all ages and of both sexes.
In the United States, in 2014 there were 42,773completed suicides. There is one death by
suicide in the United States every 12.3 minutes. As a leading cause of death, suicide ranks as
follows:
3rd among young people aged 10 to 24
2nd among people aged 25 to 34
4th among those aged 35 to 64
10th overall
The suicide rate is highest in people aged 45 to 64.
In all age groups, men who commit suicide outnumber women 4 to 1. The reasons are
unclear, but the following may be involved:
When men have problems, they are less likely to seek help—from friends and/or
health care practitioners.
Alcohol abuse and drug abuse, which appear to contribute to suicidal behavior, are
more common among men.
Men are more aggressive and use more lethal means when they attempt suicide.
Each year, about 1 million people attempt suicide. The number of attempts is about 15 to 20
times higher than the number of completed suicides. Many people make repeated attempts.
However, only 5 to 10% of people who make an attempt eventually die by suicide. Attempted
suicide is particularly common among adolescent girls. Girls aged 15 to 19 attempt suicide
100 times more often than boys in the same age group. Across all age groups, women attempt
suicide two or three times as often as men, but men are four times more likely to die in their
attempts. Older people attempt suicide 4 times for every completed suicide.
People who have been separated, divorced, or widowed are more likely to complete suicide.
Rates of attempted and completed suicide are higher among those who live alone. Having a
family member who has attempted or completed suicide may increase the risk as well. Whites
are more likely to complete suicide than other ethnic groups. Black women attempt suicide
nearly as often as white women but are less likely to die in their attempts.
Suicide is less common among people who are in a secure relationship than among single
people and among practicing members of most religious groups. However, people of all
races, creeds, incomes, and educational levels die by suicide. There is no typical suicide
profile.
Causes
About one in six people who kill themselves leaves a suicide note, which sometimes provides
clues as to why. Suicidal behaviors usually result from the interaction of several factors. The
most common is
Depression
Depression is involved in over 50% of attempted suicides. Marital problems, recent arrest or
trouble with the law, unhappy or ended love affairs, disputes with parents (among
adolescents), or the recent loss of a loved one (particularly among older people) may trigger
the depression. Often, one factor, such as a disruption of an important relationship, is the last
straw in a series of upsetting circumstances. However, depression can occur "out of the blue"
particularly if there is a family history of a mood disorder or suicide. The risk of suicide is
higher if people with depression also have significant anxiety.
People with certain general medical disorders may become depressed and attempt or
complete suicide. Most disorders associated with increased suicide rates either directly affect
the nervous system and brain (such as AIDS, multiple sclerosis, or temporal lobe epilepsy) or
involve treatments that can cause depression (such as certain drugs used to treat high blood
pressure).
In older people, about 20% of suicides may at least partly be a response to serious chronic
and painful physical disorders. People who have traumatic childhood experiences, including
abuse, are more likely to attempt suicide, perhaps because they are at higher risk of becoming
depressed.
Depression may be intensified by the use of alcohol, which, in turn, makes suicidal behavior
more likely. Alcohol also reduces self-control. About 30% of people who attempt suicide
drink alcohol before the attempt. Because alcoholism, particularly binge drinking, often
causes deep feelings of remorse during dry periods, alcoholics are suicide-prone even when
sober.
Other mental health disorders besides depression also put people at risk of suicide. People
with schizophrenia or other psychotic disorders may have delusions (fixed false beliefs) that
they find impossible to cope with, or they may hear voices (auditory hallucinations)
commanding them to kill themselves. People with borderline personality disorder or
antisocial personality disorder, especially those with a history of violent behavior, are also at
higher risk of suicide.
RISK FACTORS FOR SUICIDE
White
Male
Painful or disabling illness
Living alone
Debt or poverty
Unemployment
Bereavement or loss
Humiliation or disgrace
Depression, especially when accompanied by psychosis or anxiety
Most other serious mental health disorders
Persistent sadness even when other symptoms of depression are lessening
A history of drug or alcohol abuse
A history of prior suicide attempts
A history of suicide or mental health disorders in family members
Traumatic childhood experiences, including physical or sexual abuse
Preoccupation with and talk about suicide
Well-defined plans for suicide
Because of public health warnings about the possible association between taking
antidepressants and an increased risk of suicide, doctors started prescribing antidepressants
about 30% less often for children and young people. However, during this same time, suicide
rates among young people temporarily increased by 14%. Thus, it is possible that by
discouraging drug treatment of depression, these warnings resulted in more, not fewer, deaths
by suicide.
When people with depression are given antidepressants, doctors take certain precautions to
reduce the risk of suicidal behavior:
Giving people antidepressants in amounts that would not cause death
Scheduling more frequent visits when treatment is first started
Clearly warning people and their family members and significant others to be alert for
worsening symptoms or suicidal ideation
Instructing people and their family members and significant others to immediately
call the doctor who prescribed the antidepressant or to seek care elsewhere if
symptoms worsen or suicidal thoughts occur
Suicide attempts most often involve drug overdose and self-poisoning. Violent methods, such
as shooting and hanging, are uncommon among suicide attempts because they usually result
in death. For completed suicides, men most commonly use firearms (56%), followed by
hanging, poisoning, jumping from a height, and cutting. Women most commonly use
poisoning (37%), followed by firearms, hanging, jumping from a height, and drowning.
A doctor may hospitalize people who have threatened or attempted suicide. Even if they do
not agree to hospitalization, most states allow a doctor to hospitalize people against their
wishes if the doctor believes that they are at high risk of harming themselves or other people.
After the initial evaluation, people who have attempted suicide are referred to a psychiatrist,
who tries to identify problems that contributed to the attempt and plan appropriate treatment.
Because depression increases the risk of suicidal behavior, doctors carefully monitor people
with depression for suicidal behavior and thoughts.
Impact of Suicide
Death by suicide has a marked emotional effect on all involved. Family, friends, and doctors
may feel guilt, shame, and remorse at not having prevented the suicide. They may also feel
anger toward the person. Eventually, they may realize that they could not have prevented the
suicide.
Sometimes a grief counselor or a self-help group can help family and friends deal with their
feelings of guilt and sorrow. The primary care doctor or local mental health services (for
example, at the county or state level) can often help locate these resources. In addition,
national organizations, such as the American Foundation for Suicide Prevention, maintain
directories of local support groups. Resources are also available on the Internet.
The effect of attempted suicide is similar. However, family members and friends have the
opportunity to resolve their feelings by responding appropriately to the person's cry for help.
Physician Aid in Dying (formerly, Assisted Suicide)
Physician aid in dying refers to the assistance given by physicians to people who wish to end
their lives. It is very controversial because it reverses the doctor's usual goal, which is to
preserve life. Physician aid in dying is illegal in all states except Oregon, Washington,
Montana, Vermont, and California. In the rest of the United States, doctors can provide
treatment intended to minimize physical and emotional suffering, but they cannot
intentionally hasten death.