What is the American Foundation for Suicide Prevention?

Introduction

The American Foundation for Suicide Prevention (AFSP) is a voluntary health organisation based in New York City, with a public policy office based in Washington, D.C.

The organisation’s stated mission is to “save lives and bring hope to those affected by suicide.”

Refer to Suicide Awareness.

Brief History

Founded in 1987 as the American Suicide Foundation by Herbert Hendin M.D., AFSP is the world’s largest private funder of suicide prevention research. The founding families, alarmed by a combination of increases in death by suicide in the previous four decades and with their personal experience with loved ones dying by suicide, decided to the create AFSP in order to establish a private source of support for suicide research, education, and prevention efforts that could be sustained into the future. According to a Charity Navigator rating published in September 2018, more than 83% of the organisation’s finances went towards programme expenses (based on financial data from fiscal year 2017), receiving a perfect rating for accountability and transparency. AFSP also partners with Aetna (a US managed health care company that sells traditional and consumer directed health care insurance and related services).

For 2018, AFSP received $37 million in financial contributions from 700,000 new and returning donors.

Programmes

Programmes designed to educate the larger public about suicide and prevention best practices, such as Talk Saves Lives: An Introduction to Suicide Prevention, are offered by AFSP under the umbrella of prevention education and provide a general understanding of suicide, including its scope and what can be done to prevent it.

International Survivors of Suicide Loss Day (also known as “Survivor Day”) is one of the most prominent postvention programmes or events organised by AFSP. Originally introduced as “National Survivors of Suicide Loss Day” in 1999, when United States Senator Harry Reid – himself a survivor of suicide loss – formally introduced a resolution to the Senate, the day is officially observed annually on the Saturday before American Thanksgiving.

The Interactive Screening Programme, or ISP, is an online tool offered by AFSP first piloted at Emory University, and has since been implemented in colleges, police departments, workplaces and the NFL Players Union. Francis Levesque created this in Sept-Îles in 1973 in meeting all members of the association.

Criticism

In August 2016, AFSP formed a partnership with the National Shooting Sports Foundation, a gun industry trade association, to educate the firearm-owning community on suicide prevention through outreach at firearm retailers and shooting ranges. In December 2017, The New York Times released an opinion piece written by Erin Dunkerly, a volunteer whose father died by suicide using a firearm. The piece cites that there is a high risk of suicide from keeping firearms in the home, but claims that local AFSP staff told volunteers not to discuss the topic of gun control. The piece goes on to say that AFSP excluded from its walks violence prevention groups that promoted gun control, and that AFSP excludes the Brady Campaign to Prevent Gun Violence from donating or participating. According to a post published on digital health community The Mighty, similar accounts of gun safety groups have been reported in Wisconsin by Khary Penebaker, San Diego by Wendy Wheatcroft, and in Maine by Judi Richardson.

What is the Samaritans (UK)?

Introduction

Samaritans is a registered charity aimed at providing emotional support to anyone in emotional distress, struggling to cope, or at risk of suicide throughout Great Britain and Ireland, often through their telephone helpline.

Its name derives from the biblical Parable of the Good Samaritan although the organisation itself is non-religious. Its international network exists under the name Befrienders Worldwide, which is part of the Volunteer Emotional Support Helplines (VESH) with Lifeline International and the International Federation of Telephone Emergency Services (IFOTES).

Brief History

Samaritans was founded in 1953 by Chad Varah, a vicar in the Church of England Diocese of London. His inspiration came from an experience he had had some years earlier as a young curate in the Diocese of Lincoln. He had taken a funeral for a fourteen-year old girl who had killed herself because she feared she had contracted an STD. In reality, she was menstruating. Varah placed an advertisement in a newspaper encouraging people to volunteer at his church, listening to people contemplating suicide.

The movement grew rapidly: within ten years there were 40 branches and now there are 201 branches across the UK and Ireland helping many, deliberately organised without regard to national boundaries on the basis that a service which is not political or religious should not recognise sectarian or political divisions. Samaritans offers support through over 21,200 trained volunteers (2015) and is entirely dependent on voluntary support. The name was not originally chosen by Chad Varah: it was part of a headline to an article in the Daily Mirror newspaper on 07 December 1953 about Varah’s work.

In 2004, Samaritans announced that volunteer numbers had reached a thirty-year low, and launched a campaign to recruit more young people (specifically targeted at ages 18-24) to become volunteers. The campaign was fronted by Phil Selway, drummer with the band Radiohead, himself a Samaritans volunteer.

Chad Varah Breaks with Samaritans

In 2004, Varah announced that he had become disillusioned with Samaritans. He said, “It’s no longer what I founded. I founded an organisation to offer help to suicidal or equally desperate people. The last elected chairman re-branded the organisation. It was no longer to be an emergency service, it was to be emotional support”. One in five calls to Samaritans are from someone with suicidal feelings. Samaritans’ vision is that fewer people will die by suicide.

Services

The core of Samaritans’ work is a telephone helpline, operating 24 hours a day, 365 days a year. Samaritans was the first 24-hour telephone helpline to be set up in the UK. In addition, the organisation offers a drop-in service for face-to-face discussion, undertakes outreach at festivals and other outdoor events, trains prisoners as “Listeners” to provide support within prisons, and undertakes research into suicide and emotional health issues.

Since 1994, Samaritans has also offered confidential email support. Initially operating from one branch, the service is now provided by 198 branches and co-ordinated from the organisation’s head office. In 2011, Samaritans received over 206,000 emails, including many from outside the UK, and aims to answer each one within 24 hours. In 2009, Ofcom introduced the first harmonised European numbers for harmonised services of social value, allocating 116 123 to Samaritans. This number is free to call from mobiles and landlines. From 22 September 2015, Samaritans has promoted 116123 as their main number, replacing the premium rate 0845 number previously advertised.

In 2014, Samaritans received 5,100,000 calls for help by phone, email, text, letter, minicom, Typetalk, face-to-face at a branch, through their work in prisons, and at local and national festivals and other events.

Samaritans volunteers are given rigorous training, and as such they are non-judgmental, empathic and congruent. By listening and asking open questions, the Samaritans volunteers help people explore their feelings and work out their own way forward.

Samaritans does not denounce suicide, and it is not necessary to be suicidal to contact Samaritans. In 2014, nearly 80% of the people calling Samaritans did not express suicidal feelings. Samaritans believes that offering people the opportunity to be listened to in confidence, and accepted without prejudice, can alleviate despair and make emotional health a mainstream issue.

Media Guidelines

In 2013, following extensive consultation with journalists and editors throughout the industry, Samaritans produced a set of guidelines outlining best practice when reporting suicide. Since its publication, the organisation has received many awards in recognition of its work influencing the way in which suicide is reported.

Samaritans Radar

On 29 October 2014, Samaritans launched the Samaritans Radar app, which Twitter users could activate to analyse tweets posted by people they followed; it sent an email alert to the user if it detected signs of distress in a tweet. However, because Twitter users were not notified that their account was being monitored in this way, concerns were raised that the service could be abused by stalkers and internet trolls, who would instantly be made aware that an intended victim was potentially feeling vulnerable.

Following concerns, the service was suspended on 07 November 2014, nine days after launch. Joe Ferns, policy director for Samaritans, said in a statement: “We have made the decision to suspend the application at this time for further consideration”. He added: “We are very aware that the range of information and opinion, which is circulating about Samaritans Radar, has created concern and worry for some people and would like to apologise to anyone who has inadvertently been caused any distress. This was not our intention”. The app was later withdrawn completely.

Confidentiality

Samaritans have a strict code of caller confidentiality, even after the death of a caller. Unless the caller gives consent to pass on information, confidentiality will be broken only in rare circumstances, such as when Samaritans receives bomb or terrorism warnings, to call an ambulance because a caller appears to be incapable of making rational decisions for themselves, or when the caller is threatening volunteers or deliberately preventing the service being delivered to other callers.

In November 2011, the Board of Trustees UK agreed a motion breaking with confidentiality in the Republic of Ireland by agreeing, “To provide confidential support to children but report to the Health Service Executive any contacts (from either adults or children) where it appears a child is experiencing specific situations such as those that can cause them serious harm from themselves or others.” In 2011, Facebook collaborated with Samaritans to offer help to people in distress. This led to ‘cold case’ calling, which some believed was an infringement on people’s privacy. An Irish journalist wrote of her experience of receiving such a communication.

International Reach

Through its email service, Samaritans’ work has extended well beyond the UK and Ireland, as messages are received from all around the world.

Samaritans’ international reach is through Befrienders Worldwide, an organisation of over 400 centres in 38 countries offering similar activities. Samaritans took on and renamed the Befrienders International network in 2003, a year after it collapsed. Some members of Befrienders Worldwide also use the name Samaritans; this includes centres in the United States, India, Hong Kong, Serbia and Zimbabwe, among others.

The Volunteer Emotional Support Helplines (VESH) combines Samaritans (through Befrienders Worldwide) with the other two largest international services (IFOTES & Lifeline), and plans a combined international network of helplines. In their roles as emotional support service networks, they have all agreed to develop a more effective and robust international interface.

See also:

  • The Samaritans Hong Kong (Multilingual Service).
  • The Samaritan Befrienders Hong Kong.
  • Samaritans of Singapore.
  • Samaritans USA:
    • This was formed in 2005 when Samaritans of Boston (established 1974) joined forces with their Framingham branch.
    • Samaritans is also a certified member of Contact USA (a Lifeline International member).
    • There are Samaritans offices in other regions of Massachusetts and the US operating independently with a common mission and philosophy.

Similar Charities

A number of other helplines exist that offer a similar service to Samaritans. These are often aimed at a specific sector/group of people.

  • One example is Nightline:
    • A student-run listening and information services, based at universities across the country, offer a night time support service for students.
    • Each service is run specifically for students at a particular university/geographical area, and most Nightlines are members of the Nightline Association, a registered charity in England, Wales, and Scotland.
  • The NSPCC’s ChildLine service is similar to Samaritans in some ways:
    • NSPCC (National Society for the Prevention of Cruelty to Children) offers support for children only, but Samaritans supports both children and adults alike.
    • The NSPCC does not usually support adults.
  • Another example is Aware:
    • A national voluntary organisation, based in Ireland, which provides supports to individuals who experience depression with their families and friends.
    • It provides a Helpline service, as well as nationwide Support Groups and monthly lectures, which seek to educate and increase awareness of depression.

32 Pills: My Sister’s Suicide (2017)

Introduction

She’s beautiful, artistic, loved and can’t stand to be alive. 32 PILLS traces the fascinating life and mental illness of my sister, New York artist and photographer Ruth Litoff, and my struggle to come to terms with her tragic suicide.

Outline

After struggling with mental illness for most of her life, New York artist Ruth Litoff committed suicide at age 42 in 2008 by overdosing on prescription pills. Six years later, her younger sister, Hope Litoff, decides to film herself while she empties a packed-to-the-brim storage unit filled with Ruth’s belongings, driven by the need to understand Ruth’s illness and desire to end her life – but as she pores through the items her sister left behind, she must exorcise the demons that threaten her sobriety.

Read the rest of the HBO synopsis here.

Cast

  • Ruth Litoff as self.
  • Hope Litoff as Self.

Production & Filming Details

  • Director(s):
    • Hope Litoff.
  • Producer(s):
    • Dan Cogan … executive producer.
    • Steven H. Cohen … co-executive producer.
    • Paula M. Froehle … co-executive producer.
    • Lise King … social impact producer.
    • Beth Levison … producer.
    • Sheila Nevins … executive producer.
    • Regina K. Scully … executive producer (as Regina Kulik Scully).
  • Writer(s):
  • Music:
    • Todd Griffin.
  • Cinematography:
    • Daniel B. Gold.
  • Editor(s):
    • Toby Shimin.
  • Production:
    • HBO Documentary Films.
  • Distributor(s):
    • Home Box Office (HBO) (2016) (USA) (TV).
  • Release Date: 01 May 2017 (Canada, Hot Docs International Documentary Festival).
  • Running Time: 89 minutes.
  • Rating: TV-MA.
  • Country: US.
  • Language: English.

What is the National Suicide Prevention Lifeline?

Introduction

The National Suicide Prevention Lifeline is a United States-based suicide prevention network of over 160 crisis centres that provides 24/7 service via a toll-free hotline with the number 1-800-273-8255 (TALK).

It is available to anyone in suicidal crisis or emotional distress. The caller is routed to their nearest crisis centre to receive immediate counselling and local mental health referrals. The lifeline supports people who call for themselves or someone they care about. In July 2020, the US Federal Communication Commission (FCC) finalised an order to direct telecommunication carriers to implement 9-8-8 as the new toll-free nationwide telephone number for the hotline by 16 July 2022.

Logo of the National Suicide Prevention Lifeline.

Brief History

The National Suicide Prevention Lifeline grant is one component of the National Suicide Prevention Initiative (NSPI), a multi-project effort to reduce suicide, led by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Centre for Mental Health Services.

In July 2004, SAMHSA released a notice of funding availability (NOFA) as part of its National Suicide Prevention Initiative (NSPI). In keeping with SAMHSA’s duty to advance the goals of the National Strategy for Suicide Prevention, the NOFA called for proposals from non-profit organisations to expand, enhance, and sustain a network of certified crisis centres providing suicide prevention and intervention services to those in need using a toll-free number and website.

In September 2004, the Mental Health Association of New York City (MHA-NYC) was selected to administer the federally funded network of crisis centres named the National Suicide Prevention Lifeline.

In December 2004, the National Suicide Prevention Lifeline was founded by the Substance Abuse and Mental Health Services Administration, a division of the Department of Health and Human Services.

Google, Bing, Yahoo and Ask.com all place the phone number and website details of the National Suicide Prevention Lifeline as the reserved first result for when one enters keywords related to suicide, such as “How to tie a noose” and “I want to die.”

In April 2017, Logic, an American musician and rapper released a song featuring Alessia Cara and Khalid for his third album Everybody titled “1-800-273-8255”, the number used for The National Suicide Prevention Hotline. On the day of the song release, the lifeline received one of its highest daily call volumes. It was made to bring awareness to the hotline and to the problems associated with suicide. After being featured on the 2017 MTV Video Music Awards, it increased the calls to the hotline by 50% that night. On the day of the song release, “Lifeline’s Facebook page saw 3 times its usual traffic” and Lifeline’s “website saw a 17% increase in users in May 2017 over the previous month.” Many of the callers to several crisis centres have mentioned Logic’s song, and a third of those callers were struggling with suicidal thoughts. The song was performed at the 60th Annual Grammy Awards as a tribute to Linkin Park vocalist Chester Bennington, who committed suicide in the previous year.

The National Suicide Hotline Improvement Act of 2018 required the Federal Communications Commission and other agencies to consider a three-digit number for the hotline. On 15 August 2019, FCC staff recommended that the Commission designate the number 988 for the hotline. On 12 December 2019, the Commission approved a proposed rule starting the process for public commenting and final rule making. The rule was adopted on 16 July 2020 in final form in a 5-0 vote by the FCC. The rule requires telecommunication carriers to implement the telephone number 988 to route calls to the existing service number by 16 July 2022. This provides sufficient time to expand staff and training to handle the anticipated call volume. As 988 is already assigned as a central office prefix in many area codes, the dialling procedures for these areas must prescribe ten-digit dialling, or the central office prefix 988 must be retired. Where necessary, ten-digit dialling will become mandatory on 24 October 2021.

On 17 October 2020, the National Suicide Hotline Designation Act (S.2661) was signed into law to support the implementation of the hotline. Disability advocates, calling for equity, petitioned the FCC to implement text-to-988 service for hard-of-hearing and speech-disabled people. The following month, on 20 November 2020, T-Mobile became the first wireless carrier to implement the 9-8-8 number for voice calls.

The Canadian Radio-television and Telecommunications Commission has recommended using a three-digit number, most likely 988, for a similar program in Canada. Should 988 be used, it would require the last four areas without ten-digit dialling currently in place or with a planned overlay, those being area codes 506, 709, 807 and 867, to convert to ten-digit dialling to implement, as 988 is an active prefix in all areas above.

Veterans Hotline

In June 2007, the Department of Veterans Affairs (VA) partnered with SAMHSA and the National Suicide Prevention Lifeline to provide a veterans hotline to help veterans in emotional crisis. Callers who identify themselves as a US military veteran are routed to a special veterans hotline. This service caters to VA-specific mental health care needs, and helps connect vets to the VA Healthcare system. In addition to the hotline, the veterans hotline also offers text messaging support by texting to 838255, as well as an online chat service for those who want to use the hotline.

What is World Suicide Prevention Day?

Introduction

World Suicide Prevention Day (WSPD) is an awareness day observed on 10 September every year, in order to provide worldwide commitment and action to prevent suicides, with various activities around the world since 2003.

The International Association for Suicide Prevention (IASP) collaborates with the World Health Organisation (WHO) and the World Federation for Mental Health (WFMH) to host World Suicide Prevention Day. In 2011 an estimated 40 countries held awareness events to mark the occasion. According to WHO’s Mental Health Atlas released in 2014, no low-income country reported having a national suicide prevention strategy, while less than 100% of lower-middle income countries, and almost a third of upper-middle and high-income countries had.

On its first event in 2003, the 1999 WHO’s global suicide prevention initiative is mentioned with regards to the main strategy for its implementation, requiring:

  • “The organisation of global, regional and national multi-sectoral activities to increase awareness about suicidal behaviours and how to effectively prevent them.”
  • “The strengthening of countries’ capabilities to develop and evaluate national policies and plans for suicide prevention.”

As of recent WHO releases, challenges represented by social stigma, the taboo to openly discuss suicide, and low availability of data are still to date obstacles leading to poor data quality for both suicide and suicide attempts: “given the sensitivity of suicide – and the illegality of suicidal behaviour in some countries – it is likely that under-reporting and misclassification are greater problems for suicide than for most other causes of death.”

Suicide has a number of complex and interrelated and underlying contributing factors … that can contribute to the feelings of pain and hopelessness. Having access to means to kill oneself – most typically firearms, medicines and poisons – is also a risk factor. Campaign release.

Background

Refer to Suicide Prevention, Suicidal Ideation, Suicide Awareness, and Epidemiology of Suicide.

An estimated one million people per year die by suicide or about one person in 10,000 (1.4% of all deaths), or “a death every 40 seconds or about 3,000 every day”. As of 2004 the number of people who die by suicide is expected to reach 1.5 million per year by 2020.

On average, three male suicides are reported for every female one, consistently across different age groups and in almost every country in the world. “Conversely, rates of suicide attempts tend to be 2-3 times higher in women than in men, although the gender gap has narrowed in recent years.” More people die from suicide than from murder and war; it is the 13th leading cause of death worldwide. According to WHO there are twenty people who have a suicide attempt for every one that is fatal, at a rate approximately one every three seconds. Suicide is the “most common cause of death for people aged 15 – 24.”

According to WHO, suicide accounts for nearly half of all violent deaths in the world. Brian Mishara, IASP president, noted that, “more people kill themselves than die in all wars, terrorist acts and interpersonal violence combined.” As of 2008, the WHO refers the widest number of suicides occur in the age group 15-29, while the lowest in the 80+ although representing as well the one with the highest rate (per 100,000) of all age groups, with 27.8 suicides and 60.1 for females and males respectively. In 2015 the reported global age-standardized rate is 10.7 per 100,000.

Social norms play a significant role in the development of suicidal behaviours. Late 19th century’s sociological studies recorded first ever observations on suicide: with statistics of the time at hand, sociologists mentioned the effects of industrialisation as in relations between new urbanised communities and vulnerability to self-destructive behaviour, suggesting social pressures have effects on suicide. Today, differences in suicidal behaviour among different countries can be significant.

Themes

  • 2003 – “Suicide Can Be Prevented!”.
  • 2004 – “Saving Lives, Restoring Hope”.
  • 2005 – “Prevention of Suicide is Everybody’s Business”.
  • 2006 – “With Understanding New Hope”.
  • 2007 – “Suicide prevention across the Life Span”.
  • 2008 – “Think Globally, Plan Nationally, Act Locally”.
  • 2009 – “Suicide Prevention in Different Cultures”.
  • 2010 – “Families, Community Systems and Suicide”.
  • 2011 – “Preventing Suicide in Multicultural Societies”.
  • 2012 – “Suicide Prevention across the Globe: Strengthening Protective Factors and Instilling Hope”.
  • 2013 – “Stigma: A Major Barrier to Suicide Prevention”.
  • 2014 – “Light a candle near a Window”.
  • 2015 – “Preventing Suicide: Reaching Out and Saving Lives”.
  • 2016 – “Connect, Communicate, Care”.
  • 2017 – “Take a Minute, Change a Life”.
  • 2018 – “Working Together to Prevent Suicide”.
  • 2019 – “Working Together to Prevent Suicide”.
  • 2020 – “Working Together to Prevent Suicide”.

Suicide Prevention Priorities

Suicide prevention’s priorities, as declared on the 2012 World Suicide Prevention Day event, are stated below:

  • We need to continue to research suicide and non-fatal suicidal behaviour, addressing both risk and protective factors.
  • We need to develop and implement awareness campaigns, with the aim of increasing awareness of suicidal behaviours in the community, incorporating evidence on both risk and protective factors.
  • We need to target our efforts not only to reduce risk factors but also to strengthen protective factor, especially in childhood and adolescence.
  • We need to train health care professionals to better understand evidence-based risk and protective factors associated with suicidal behaviour.
  • We need to combine primary, secondary and tertiary prevention.
  • We need to increase use of and adherence to treatments shown to be effective in treating diverse conditions; and to prioritise research into effectiveness of treatments aimed at reducing self-harm and suicide risk.
  • We need to increase the availability of mental health resources and to reduce barriers to accessing care.
  • We need to disseminate research evidence about suicide prevention to policy makers at international, national and local levels.
  • We need to reduce stigma and promote mental health literacy among the general population and health care professionals.
  • We need to reach people who don’t seek help, and hence don’t receive treatment when they are in need of it.
  • We need to ensure sustained funding for suicide research and prevention.
  • We need to influence governments to develop suicide prevention strategies for all countries and to support the implementation of those strategies that have been demonstrated to save lives.

Factors

Below are two quotes on the subject of suicide:

“The main suicide triggers are poverty, unemployment, the loss of a loved one, arguments and legal or work-related problems [..] Suicide results from many complex sociocultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis (e.g. loss of a loved one, unemployment, sexual orientation, difficulties with developing one’s identity, disassociation from one’s community or other social/belief group, and honour). [..] In richer countries, three times as many men die of suicide than women do, but in low- and middle-income countries the male-to-female ratio is much lower at 1.5 men to each woman. [..] In the United States, males are four times more likely to die from suicide than are females. However, females are more likely to attempt suicide than are males. [..] The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die [..] in men than women.”

“In much of the world, suicide is stigmatized and condemned for religious or cultural reasons. In some countries, suicidal behavior is a criminal offence punishable by law. Suicide is therefore often a secretive act surrounded by taboo, and may be unrecognized, misclassified or deliberately hidden in official records of death. [..] Stigma, particularly surrounding mental disorders and suicide, means many people thinking of taking their own life or who have attempted suicide are not seeking help and are therefore not getting the help they need. The prevention of suicide has not been adequately addressed due to a lack of awareness of suicide as a major public health problem and the taboo in many societies to openly discuss it. [..] Raising community awareness and breaking down the taboo is important for countries to make progress in preventing suicide.”

Physical and especially mental health disabling issues such as depression, are among the most common of the long list of complex and interrelated factors, ranging from financial problems to the experience of abuse, aggression, exploitation and mistreatment, that can contribute to the feelings of pain and hopelessness underling suicide. Usually substances and alcohol abuse also play a role. Prevention strategies generally emphasize public awareness towards social stigma and suicidal behaviours.

Country-Based Information

In 1999, death by self-inflicted injuries was the fourth leading cause of death among aged 15-44, in the world. In a 2002 study it was reported the countries with the lowest rates tend to be in Latin America, “Muslim countries and a few Asian countries”, and noted a lack of information from most African countries. Data quality is to date a concern for suicide prevention policies. Incidence of suicide tends to be under-reported and misclassified due to both cultural and social pressures, and possibly completely unreported in some areas. Since data might be skewed, comparing suicide rates between nations can result in statistically unsound conclusions about suicidal behaviour in different countries. Nevertheless, the statistics are commonly used to directly influence decisions about public policy and public health strategies.

Of the 34 member countries of the OECD, a group of mostly high-income countries that uses market economy to improve the Human Development Index, South Korea had the highest suicide rate in 2009. In 2011 South Korea’s Ministry of Health and Welfare enacted legislation coinciding with WSPD to address the high rate.

In 2008 it was reported that young people 15-34 years old in China were more likely to die by suicide than by any other mean, especially young Chinese women in rural places because of “arguments about marriage”. By 2011 however, suicide rate for the same age group had been declining significantly according to official releases, mainly by late China’s urbanisation and migration from rural areas to more urbanised: since the 1990s indeed, overall national Chinese suicide rate dropped by 68%.

According to WHO, in 2009 the four countries with the highest rates of suicide were all in Eastern Europe; Slovenia had the fourth highest rate preceded by Russia, Latvia, and Belarus. This stays within findings from the start of the WSPD event in 2003 when the highest rates were also found in Eastern European countries. As of 2015 the highest suicide rates are still in Eastern Europe, Korea and the Siberian area bordering China, in Sri Lanka and the Guianas, Belgium and few Sub-Saharan countries.

According to WHO’s Mental health Atlas released in 2014, no low-income country reported having a national suicide prevention strategy, while less than 10% of lower-middle income countries, and almost a third of upper-middle and high-income countries had. Focus of the WSPD is the fundamental problem of suicide, considered a major public health issue in high-income and an emerging problem in low and middle-income countries. Among high-income countries (besides South Korea) highest rates in 2015 are found across some Eastern European countries, Belgium and France, Japan, Croatia and Austria, Uruguay and Finland.

Socioeconomic status plays an important role in suicidal behaviour, and wealth is a constant with regards to Male-Female suicide rate ratios, being that excess male mortality by suicide is generally limited or non-existent in low- and middle-income societies, whereas it is never absent in high-income countries.

Suicidal behaviour is also subject of study for economists since about the 1970s: although national costs of suicide and suicide attempts (up to 20 for every one completed suicide) are very high, suicide prevention is hampered by scarce resources for lack of interest by mental health advocates and legislators; and moreover, personal interests even financial are studied with regards to suicide attempts for example, in which insights are given that often “individuals contemplating suicide do not just choose between life and death … the resulting formula contains a somewhat paradoxical conclusion: attempting suicide can be a rational choice, but only if there is a high likelihood it will cause the attempter’s life to significantly improve.” In the United States alone, yearly costs of suicide and suicide attempts are comprised in 50-100 billion dollars.

The United Nations issued “National Policy for Suicide Prevention” in the 1990s, which some countries also use as a basis for their assisted suicide policies. Nevertheless, the UN noted that suicide bombers’ deaths are seen as secondary to their goal of killing other people or specific targets and the bombers are not otherwise typical of people committing suicide.

According to a 2006 WHO press release, one-third of worldwide suicides were committed with pesticides, “some of which were forbidden by United Nations (UN) conventions.” WHO urged the highly populated Asian countries to restrict pesticides that are commonly used in failed attempts, especially organophosphate-based pesticides that are banned by international conventions but still made in and exported by some Asian countries. WHO reports an increase in pesticide suicides in other Asian countries as well as Central and South America. It is estimated that such painful failed attempts could be reduced by legalising controlled voluntary euthanasia options, as implemented in Switzerland.

As of 2017, it is estimated that around 30% of global suicides are still due to pesticide self-poisoning, most of which occur in rural agricultural areas in low- and middle-income countries (consisting in about 80% world population). In high-income countries consisting of the remaining 20% world population most common methods are firearms, hanging and other self-poisoning.

Gender and Suicide

European and American societies report a higher male mortality by suicide than any other, while various Asian a much lower. According to most recent data provided by WHO, about 40,000 females of the global three hundred thousand female suicides and 150,000 males of the global half million male suicides, deliberately take their own life every year in Europe and the Americas (consisting of about 30% of the world’s population). As of 2015, apart from a few South and East Asian countries home to twenty percent of world population, Morocco, Lesotho, and two Caribbean countries, because of changing gender roles suicide rates are globally higher among men than women.

Even though women are more prone to suicidal thoughts than men, rates of suicide are higher among men. On average, there are about three male suicides for every female one – though in parts of Asia, the ratio is much narrower.

The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die, when suicidal, in men than women.

There are many potential reasons for different suicide rates in men and women: gender equality issues, differences in socially acceptable methods of dealing with stress and conflict for men and women, availability of and preference for different means of suicide, availability and patterns of alcohol consumption, and differences in care-seeking rates for mental disorders between men and women. The very wide range in the sex ratios for suicide suggests that the relative importance of these different reasons varies greatly by country and region.

In western countries men are about 300% or thrice as likely to die by suicide than females, while a few countries (counting over a hundred million residents overall) exceed the 600% figure. Most considerable difference in male–female suicide ratios is noted in countries of the former Soviet Bloc and in some of Latin America.

Globally, in 2015 women had higher suicide rates in eight countries. In China (almost a fifth of world population) women were up to 30% more likely than men to commit suicide and up to 60% in some other South Asian countries: overall South Asian (including South-Eastern Asia, a third of world population) age-adjusted ratio however, was around global average of 1.7:1 (men being around 70% more likely than women to die by suicide).

Some suicide reduction strategies do not recognize the separate needs of males and females. Researchers have recommended aggressive long-term treatments and follow up for males that show indications of suicidal thoughts. Studies have also found that because young females are at a higher risk of attempting suicide, policies tailored towards this demographic are most effective at reducing overall rates.

Shifting cultural attitudes about gender roles and social norms, and especially ideas about masculinity, may also contribute to closing the gender gap: social status and working roles are assumed to be crucial for men’s identity.

What is the Assessment of Suicide Risk?

Introduction

Suicide risk assessment is a process of estimating the likelihood for a person to attempt or die by suicide.

The goal of a thorough risk assessment is to learn about the circumstances of an individual person with regard to suicide, including warning signs, risk factors, and protective factors. Risk for suicide is re-evaluated throughout the course of care to assess the patient’s response to personal situational changes and clinical interventions. Accurate and defensible risk assessment requires a clinician to integrate a clinical judgment with the latest evidence-based practice, although accurate prediction of low base rate events, such as suicide, is inherently difficult and prone to false positives.

The assessment process is ethically complex: the concept of “imminent suicide” (implying the foreseeability of an inherently unpredictable act) is a legal construct in a clinical guise, which can be used to justify the rationing of emergency psychiatric resources or intrusion into patients’ civil liberties. Some experts recommend abandoning suicide risk assessment as it is so inaccurate. In addition suicide risk assessment is often conflated with assessment of self-harm which has little overlap with completed suicide. Instead, it is suggested that the emotional state which has caused the suicidal thoughts, feelings or behaviour should be the focus of assessment with a view to helping the patient rather than reducing the anxiety of clinician who overestimates the risk of suicide and are fearful of litigation. Given the difficulty of suicide prediction, researchers have attempted to improve the state of the art in both suicide and suicidal behaviour prediction using natural language processing and machine learning applied to electronic health records.

Refer to Suicidal Ideation, Suicide Awareness, Suicide Prevention, and Suicide Prevention Contract.

In Practice

There are risks and disadvantages to both over-estimation and under-estimation of suicide risk. Over-sensitivity to risk can have undesirable consequences, including inappropriate deprivation of patients’ rights and squandering of scarce clinical resources. On the other hand, underestimating suicidality as a result of a dismissive attitude or lack of clinical skill jeopardises patient safety and risks clinician liability. Some people may worry that asking about suicidal intentions will make suicide more likely. In reality, regarding that the enquiries are made sympathetically, it does not. Key areas to be assessed include the person’s predisposition to suicidal behaviour; identifiable precipitant or stressors such as job loss, recent death of a loved one and change of residence; the patient’s symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behaviour; impulsivity and self-control; and protective factors.

Suicide risk assessment should distinguish between acute and chronic risk. Acute risk might be raised because of recent changes in the person’s circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. Bryan and Rudd (2006) suggest a model in which risk is categorized into one of four categories: Baseline, Acute, Chronic high risk, and Chronic high risk with acute exacerbation. Risk level can be described semantically (in words) e.g. as Non-existent, Mild, Moderate, Severe, or Extreme, and the clinical response can be determined accordingly. Others urge use of numbers to describe level of relative or (preferably) absolute risk of completed suicide.

Scale for Suicide Ideation

The Scale for Suicide Ideation (SSI) was developed in 1979 by Aaron T. Beck, Maria Kovacs, and Arlene Weissman to quantify intensity in suicide ideators. It was developed for use by clinicians during semi-structured interviews. The scale contained 19 items rated on a scale from 0 to 2, allowing scores between 0 and 38. The items could be grouped into three categories: “Active Suicidal Desire, Preparation, and Passive Suicidal Desire.” Initial findings showed promising reliability and validity.

Modified Scale for Suicide Ideation

The Modified Scale for Suicide Ideation (MSSI) was developed by Miller et al., using 13 items from the SSI and 5 new items. The modifications increased both reliability and validity. The scale was also changed to range from 0 to 3, yielding a total score ranging from 0 to 54. Joiner found two factors, Suicidal Desire and Ideation, and Resolved Plans and Preparation. The MSSI was also shown to have higher discrimination between groups of suicide ideators and attempters than the BDI, BHS, PSI, and SPS.

Suicide Intent Scale

The Suicide Intent Scale (SIS) was developed in order to assess the severity of suicide attempts. The scale consists of 15 questions which are scaled from 0-2, which take into account both the logistics of the suicide attempt as well as the intent. The scale has high reliability and validity. Completed suicides ranked higher in the severity of the logistics than attempted suicides (it was impossible to measure intent for the completed suicides), and those with multiple attempts had higher scores than those who only attempted suicide once.

Suicidal Affect Behaviour Cognition Scale

The Suicidal Affect Behaviour Cognition Scale (SABCS) is a six-item self-report measure based on both suicide and psychological theory, developed to assess current suicidality for clinical, screening, and research purposes. Substantial empirical evidence was found, from four independent studies, confirming the importance of assessing suicidal affect, behaviours, and cognition as a single suicidal construct. The SABCS was the first suicide risk measure to be developed through both classical test theory (CTT) and item response theory (IRT) psychometric approaches and to show significant improvements over a highly endorsed comparison measure. The SABCS was shown to have higher internal reliability, and to be a better predictor of both future suicidal behaviours and total suicidality over an existing standard.

Suicide Behaviours Questionnaire

Refer to the Suicide Behaviours Questionnaire-Revised.

The Suicide Behaviours Questionnaire (SBQ) is a self-report measure developed by Linehan in 1981. In 1988 it was transformed from a long questionnaire to a short four questions that can be completed in about 5 minutes. Answers are on a Likert scale that ranges in size for each question, based on data from the original questionnaire. It is designed for adults and results tend to correlate with other measures, such as the SSI. It is popular because it is easy to use as a screening tool, but at only four questions, fails to provide detailed information.

Life Orientation Inventory

The Life Orientation Inventory (LOI) is a self-report measure that comes in both a 30 question and 110 question form. Both forms use a 4-point Likert scale to answer items, which are divided into six sub-scales on the longer form: self-esteem vulnerability, over-investment, overdetermined misery, affective domination, alienation, and suicide tenability. This scale has strong reliability and validity, and has been shown to be able to differentiate between control, depressed, possibly suicidal, and highly suicidal individuals. It also contains 3 validity indices, similar to the MMPI. However, while useful, this inventory is now out of print.

Reasons For Living Inventory

The Reasons For Living Inventory (RFL) is theoretically based, and measures the probability of suicide based on the theory that some factors may mitigate suicidal thoughts. It was developed in 1983 by Linehan and colleagues. and contains 48 items answered on a Likert scale from 1 to 6. The measure is divided into six subscales:

  • Survival and coping beliefs;
  • Responsibility to family;
  • Child concerns;
  • Fear of suicide;
  • Fear of social disproval; and
  • Moral objections.

Scores are reported as an average for the total and each sub-scale. The scale is shown to be fairly reliable and valid, but is still mostly seen in research as compared to clinical use. Other variations of the scale include the College Students Reasons for Living Inventory, and the Brief Reasons for Living Inventory. The college students reasons for living inventory replaced the responsibility to family sub-scale with a responsibility to family and friends sub-scale and that replaced the child concerns sub-scale with a college/future concerns sub-scale. The Brief Reasons for Living Inventory uses only 12 of the items from the RFL. Prolonged stress releases hormones that damage over time the hippocampus. The hippocampus is responsible for storing memories according to context (spatial, emotional and social) as well as activating memories according to context. When the hippocampus is damaged, events will be perceived in the wrong context, or memories with the wrong context might be activated.

Nurses Global Assessment of Suicide Risk

The Nurses Global Assessment of Suicide Risk (NGASR) was developed by Cutcliffe and Barker in 2004 to help novice practitioners with assessment of suicide risk, beyond the option of the current lengthy checklists currently available. It is based on 15 items, with some such as “Evidence of a plan to commit suicide” given a weighting of 3, while others, such as “History of psychosis” are weighted with a 1, giving a maximum total score of 25. Scores of 5 or less are considered low level of risk, 6-8 are intermediate level of risk, 9-11 are high level of risk, and 12 or more are very high level of risk. Each item is supported theoretically by studies that have shown a connection between the item and suicide. However, the validity and reliability of the test as a whole have not yet been empirically tested

Demographic Factors

Within the United States, the suicide rate is 11.3 suicides per 100,000 people within the general population.

Age

In the United States, the peak age for suicide is early adulthood, with a smaller peak of incidence in the elderly. On the other hand, there is no second peak in suicide in black men or women, and a much more muted and earlier-peaking rise in suicide amongst non-Hispanic women than their male counterparts. Older white males are the leading demographic group for suicide within the United States, at 47 deaths per 100,000 individuals for non-Hispanic white men over age 85. For Americans aged 65 and older, the rate is 14.3 per 100,000. Suicide rates are also elevated among teens. For every 100,000 individuals within an age group there are 0.9 suicides in ages 10-14, 6.9 among ages 15-19, and 12.7 among ages 20-24.

Sex

China and São Tomé and Príncipe are the only countries in the world where suicide is more common among women than among men.

In the United States, suicide is around 4.5 times more common in men than in women. US men are 5 times as likely to commit suicide within the 15- to 19-year-old demographic, and 6 times as likely as women to commit suicide within the 20- to 24-year-old demographic. Gelder, Mayou and Geddes reported that women are more likely to commit suicide by taking overdose of drugs than men. Transgender individuals are at particularly high risk. Prolonged stress lasting 3 to 5 years, such clinical depression co-morbid with other conditions, can be a major factor in these cases.

Ethnicity and Culture

In the United States white persons and Native Americans have the highest suicide rates, Black persons have intermediate rates, and Hispanic persons have the lowest rates of suicide. However, Native American males in the 15-24 age group have a dramatically higher suicide rate than any other group. A similar pattern is seen in Australia, where Aboriginal people, especially young Aboriginal men, have a much higher rate of suicide than white Australians, a difference which is attributed to social marginalisation, trans-generational trauma, and high rates of alcoholism. A link may be identified between depression and stress, and suicide.

Sexual Orientation

There is evidence of elevated risk of suicide among non-heterosexual individuals (e.g. homosexual or bisexual individuals), especially among adolescents

Biographical and historical Factors

The literature on this subject consistently shows that a family history of committed suicide in first-degree relatives, adverse childhood experiences (parental loss and emotional, physical and sexual abuse), and adverse life situations (unemployment, isolation and acute psychosocial stressors) are associated with suicide risk.

Recent life events can act as precipitants. Significant interpersonal loss and family instability, such as bereavement, poor relationship with family, domestic partner violence, separation, and divorce have all been identified as risk factors. Financial stress, unemployment, and a drop in socioeconomic status can also be triggers for a suicidal crisis. This is also the case for a range of acute and chronic health problems, such as pain syndromes, or diagnoses of conditions like HIV or cancer.

Mental State

Certain clinical mental state features are predictive of suicide. An affective state of hopelessness, in other words a sense that nothing will ever get better, is a powerful predictive feature. High risk is also associated with a state of severe anger and hostility, or with agitation, anxiety, fearfulness, or apprehension. Research domain criteria symptom burdens, particularly the positive and negative valence domains, are associated with time varying risk of suicide. Specific psychotic symptoms, such as grandiose delusions, delusions of thought insertion and mind reading are thought to indicate a higher likelihood of suicidal behaviour. Command hallucinations are often considered indicative of suicide risk, but the empirical evidence for this is equivocal. Another psychiatric illness that is a high risk of suicide is schizophrenia. The risk is particularly higher in younger patients who have insight into the serious effect the illness is likely to have on their lives.

The primary and necessary mental state Federico Sanchez called idiozimia (from idios “self” and zimia “loss”), followed by suicidal thoughts, hopelessness, loss of will power, hippocampal damage due to stress hormones, and finally either the activation of a suicidal belief system, or in the case of panic or anxiety attacks the switching over to an anger attack, are the converging reasons for a suicide to occur.

Suicidal Ideation

Refer to Suicidal Ideation.

Suicidal ideation refers to the thoughts that a person has about suicide. Assessment of suicidal ideation includes assessment of the extent of preoccupation with thoughts of suicide (for example continuous or specific thoughts), specific plans, and the person’s reasons and motivation to attempt suicide.

Planning

Assessment of suicide risk includes an assessment of the degree of planning, the potential or perceived lethality of the suicide method that the person is considering, and whether the person has access to the means to carry out these plans (such as access to a firearm). A suicide plan may include the following elements:

  • Timing;
  • Availability of method;
  • Setting;
  • Actions made towards carrying out the plan (such as obtaining medicines, poisons, rope or a weapon);
  • Choosing and inspecting a setting; and
  • Rehearsing the plan.

The more detailed and specific the suicide plan, the greater the level of risk. The presence of a suicide note generally suggests more premeditation and greater suicidal intent. The assessment would always include an exploration of the timing and content of any suicide note and a discussion of its meaning with the person who wrote it.

Motivation to Die

Suicide risk assessment includes an assessment of the person’s reasons for wanting to commit suicide. Some are due to overwhelming emotions or others can have a deep philosophical belief. The causes are highly varied.

Other Motivations for Suicide

Suicide is not motivated only by a wish to die. Other motivations for suicide include being motivated to end the suffering psychologically and a person suffering from a terminal illness may intend to commit suicide as a means of managing physical pain and/or their way of dealing with possible future atrophy or death.

Reasons to Live

Balanced against reasons to die are the suicidal person’s reasons to live, and an assessment would include an enquiry into the person’s reasons for living and plans for the future.

Past suicidal Acts

There are people who commit suicide the first time they have suicidal thoughts and there are many who have suicidal thoughts and never commit suicide.

Suicide Risk and Mental Illness

All major mental disorders carry an increased risk of suicide. However, 90% of suicides can be traced to depression, linked either to manic-depression (bipolar), major depression (unipolar), schizophrenia or personality disorders, particularly borderline personality disorder. Comorbidity of mental disorders increases suicide risk, especially anxiety or panic attacks.

Anorexia nervosa has a particularly strong association with suicide: the rate of suicide is forty times greater than the general population. The lifetime risk of suicide was 18% in one study, and in another study 27% of all deaths related to anorexia nervosa were due to suicide.

The long-term suicide rate for people with schizophrenia was estimated to be between 10 and 22% based upon longitudinal studies that extrapolated 10 years of illness for lifetime, but a more recent meta-analysis has estimated that 4.9% of schizophrenics will commit suicide during their lifetimes, usually near the illness onset. Risk factors for suicide among people with schizophrenia include a history of previous suicide attempts, the degree of illness severity, comorbid depression or post-psychotic depression, social isolation, and male gender. The risk is higher for the paranoid subtype of schizophrenia, and is highest in the time immediately after discharge from hospital.

While the lifetime suicide risk for mood disorders in general is around 1%, long-term follow-up studies of people who have been hospitalised for severe depression show a suicide risk of up to 13%. People with severe depression are 20 times more likely and people with bipolar disorder are 15 times more likely to die from suicide than members of the general population. Depressed people with agitation, severe insomnia, anxiety symptoms, and co-morbid anxiety disorders are particularly at-risk. Antidepressants have been linked with suicide as Healy (2009) stated that people on antidepressant have the tendency to commit suicide after 10-14 days of commencement of antidepressant.

People with a diagnosis of a personality disorder, particularly borderline, antisocial or narcissistic personality disorders, are at a high risk of suicide. In this group, elevated suicide risk is associated with younger age, comorbid drug addiction and major mood disorders, a history of childhood sexual abuse, impulsive and antisocial personality traits, and recent reduction of psychiatric care, such as recent discharge from hospital. While some people with personality disorders may make manipulative or contingent suicide threats, the threat is likely to be non-contingent when the person is silent, passive, withdrawn, hopeless, and making few demands.

A history of excessive alcohol use is common among people who commit suicide, and alcohol intoxication at the time of the suicide attempt is a common pattern. Meta analytic research conducted in 2015 indicates that a person with co-occurring alcohol use disorder and major depression is more likely to ideate, attempt, and complete suicide than those with individual disorders.

What is the Suicide Behaviours Questionnaire-Revised?

Introduction

The Suicide Behaviors Questionnaire-Revised (SBQ-R) is a psychological self-report questionnaire designed to identify risk factors for suicide in children and adolescents between ages 13 and 18.

Background

The four-question test is filled out by the child and takes approximately five minutes to complete. The questionnaire has been found to be reliable and valid in recent studies. One study demonstrated that the SBQ-R had high internal consistency with a sample of university students. However, another body of research, which evaluated some of the most commonly used tools for assessing suicidal thoughts and behaviours in college-aged students, found that the SBQ-R and suicide assessment tools in general have very little overlap between them. One of the greatest strengths of the SBQ-R is that, unlike some other tools commonly used for suicidality assessment, it asks about future anticipation of suicidal thoughts or behaviours as well as past and present ones and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts.

Question Breakdown, Scoring, and Interpretation

Each of the four questions addresses a specific risk factor: the first concerns presence of suicidal thoughts and attempts, the second concerns frequency of suicidal thoughts, the third concerns the threat level of suicidal attempts, and the fourth concerns likelihood of future suicidal attempts. The first item has often been used on its own in order to assign individuals to a suicidal and a non-suicidal control group for studies. Each question has an individual scale, and each response corresponds to a certain point value.

Domain Breakdown

A maximum score of 18 is possible on the SBQ-R, and the following responses to the 4 questions correspond to the following point values:

Point ValueQuestion 1 ResponseQuestion 2 ResponseQuestion 3 ResponseQuestion 4 Response
0Never
11Never1No chance at all
22, 3a, or 3bRarely2a or 2bRather unlikely
3Sometimes3a or 3bUnlikely
44a or 4bOftenLikely
5Very oftenRather likely
6Very likely

Interpretation of Subscale Scores

A total score of 7 and higher in the general population and a total score of 8 and higher in patients with psychiatric disorders indicates significant risk of suicidal behaviour.

What is a Suicide Prevention Contract?

Introduction

A suicide prevention contract is a contract that contains an agreement not to attempt/commit suicide.

Refer to Suicidal Ideation, Suicide Awareness, Suicide Prevention, and Assessment of Suicide Risk.

Background

It was historically used by health professionals dealing with depressive clients. Typically, the client was asked to agree to talk with the professional prior to carrying out any decision to commit suicide. Suicide prevention contracts have been shown not to be effective and have risk of harm. Suicide prevention contracts were once a “widely used but overvalued clinical and risk-management technique.” Indeed, it has been argued that such contracts “may in fact increase danger by providing psychiatrists with a false sense of security, thus decreasing their clinical vigilance.” It has also been argued that such contracts can anger or inhibit the client and introduce coercion into therapy.

What is Suicidal Ideation?

Introduction

Suicidal ideation (or suicidal thoughts) means having thoughts, ideas, or ruminations about the possibility of ending one’s life.

Refer to Coping (Psychology), Suicide Prevention, and Suicide Awareness.

It is not a diagnosis, but is a symptom of some mental disorders and can also occur in response to adverse events without the presence of a mental disorder.

On suicide risk scales, the range of suicidal ideation varies from fleeting thoughts to detailed planning. Passive suicidal ideation is thinking about not wanting to live or imagining being dead. Active suicidal ideation is thinking about different ways to die or forming a plan to die.

Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered a risk factor. During 2008-2009, an estimated 8.3 million adults aged 18 and over in the United States, or 3.7% of the adult US population, reported having suicidal thoughts in the previous year. An estimated 2.2 million in the US reported having made suicide plans in 2014. Suicidal thoughts are also common among teenagers.

Suicidal ideation is generally associated with depression and other mood disorders; however, it seems to have associations with many other mental disorders, life events, and family events, all of which may increase the risk of suicidal ideation. Mental health researchers indicate that healthcare systems should provide treatment for individuals with suicidal ideation, regardless of diagnosis, because of the risk for suicidal acts and repeated problems associated with suicidal thoughts. There are a number of treatment options for people who experience suicidal ideation.

Definitions

The ICD-11 describes suicidal ideation as “thoughts, ideas, or ruminations about the possibility of ending one’s life, ranging from thinking that one would be better off dead to formulation of elaborate plans”.

The DSM-5 defines it as “thoughts about self-harm, with deliberate consideration or planning of possible techniques of causing one’s own death”.

The CDC defines suicidal ideation “as thinking about, considering, or planning suicide”.

Terminology

Another term for suicidal ideation is suicidal thoughts.

When someone who has not shown a history of suicidal ideation experiences a sudden and pronounced thought of performing an act which would necessarily lead to their own death, psychologists call this an intrusive thought. A commonly experienced example of this is the high place phenomenon, also referred to as the call of the void. The urge to jump is called “mountain fever” in Brian Biggs’ book Dear Julia.

Euphemisms related to mortal contemplation include internal struggle, voluntary death, and eating one’s gun.

Risk Factors

The risk factors for suicidal ideation can be divided into three categories:

  1. Psychiatric disorders;
  2. Life events; and
  3. Family history.

Psychiatric Disorders

Suicidal ideation is a symptom for many mental disorders and can occur in response to adverse life events without the presence of a mental disorder.

There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation. For example, many individuals with borderline personality disorder exhibit recurrent suicidal behaviour and suicidal thoughts. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts. The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. These are not the only disorders that can increase risk of suicidal ideation. The disorders in which risk is increased the greatest include:

Medication Side Effects

Antidepressant medications are commonly used to decrease the symptoms in patients with moderate to severe clinical depression, and some studies indicate a connection between suicidal thoughts and tendencies and taking antidepressants, increasing the risk of suicidal thoughts in some patients.

Some medications, such as selective serotonin re-uptake inhibitors (SSRIs), can have suicidal ideation as a side effect. Moreover, these drugs’ intended effects, can themselves have unintended consequence of an increased individual risk and collective rate of suicidal behaviour: Among the set of persons taking the medication, a subset feel bad enough to want to attempt suicide (or to desire the perceived results of suicide) but are inhibited by depression-induced symptoms, such as lack of energy and motivation, from following through with an attempt. Among this subset, a “sub-subset” may find that the medication alleviates their physiological symptoms (such as lack of energy) and secondary psychological symptoms (e.g. lack of motivation) before or at lower doses than it alleviates their primary psychological symptom of depressed mood. Among this group of persons, the desire for suicide or its effects persists even as major obstacles to suicidal action are removed, with the effect that the incidences of suicide attempt and of completed suicide increase.

In 2003, the US Food and Drug Administration (FDA) issued the agency’s strictest warning for manufacturers of all antidepressants (including tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) due to their association with suicidal thoughts and behaviours. Further studies disagree with the warning, especially when prescribed for adults, claiming more recent studies are inconclusive in the connection between the drugs and suicidal ideation.

Individuals with anxiety disorders who self-medicate with drugs or alcohol may also have an increased likelihood of suicidal ideation.

Life Events

Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previous listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk most significantly are:

  • Alcohol use disorder.
    • Studies have shown that individuals who binge drink, rather than drink socially, tend to have higher rates of suicidal ideation.
    • Certain studies associate those who experience suicidal ideation with higher alcohol consumption.
    • Not only do some studies show that solitary binge drinking can increase suicidal ideation, but there is a positive feedback relationship causing those who have more suicidal ideation to have more drinks per day in a solitary environment.
  • Minoritised gender expression and/or sexuality.
  • Unemployment.
  • Chronic illness or pain.
  • Death of family members or friends.
  • End of a relationship or being rejected by a romantic interest.
  • Major change in life standard (e.g. relocation abroad).
  • Other studies have found that tobacco use is correlated with depression and suicidal ideation.
  • Unplanned pregnancy.
  • Bullying, including cyberbullying and workplace bullying.
  • Previous suicide attempts.
    • Having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts.
  • Military experience.
  • Community violence.
  • Undesired changes in body weight.
    • Women: increased BMI increases chance of suicidal ideation.
    • Men: severe decrease in BMI increases chance of suicidal ideation.
      • In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight.
  • Exposure and attention to suicide related images or words.

Family History

  • Parents with a history of depression.
    • Valenstein et al. studied 340 adult offspring whose parents had depression in the past.
    • They found that 7% of the offspring had suicidal ideation in the previous month alone.
  • Abuse.
    • Childhood: physical, emotional and sexual abuse.
    • Adolescence: physical, emotional and sexual abuse.
  • Family violence.
  • Childhood residential instability.
    • Certain studies associate those who experience suicidal ideation with family disruption.

Relationships with Parents and Friends

According to a study conducted by Ruth X. Liu of San Diego State University, a significant connection was found between the parent-child relationships of adolescents in early, middle and late adolescence and their likelihood of suicidal ideation. The study consisted of measuring relationships between mothers and daughters, fathers and sons, mothers and sons, and fathers and daughters. The relationships between fathers and sons during early and middle adolescence show an inverse relationship to suicidal ideation. Closeness with the father in late adolescence is “significantly related to suicidal ideation”. Liu goes on to explain the relationship found between closeness with the opposite sex parent and the child’s risk of suicidal thoughts. It was found that boys are better protected from suicidal ideation if they are close to their mothers through early and late adolescence; whereas girls are better protected by having a close relationship with their father during middle adolescence.

An article published in 2010 by Zappulla and Pace found that suicidal ideation in adolescent boys is exacerbated by detachment from the parents when depression is already present in the child. Lifetime prevalence estimates of suicidal ideation among nonclinical populations of adolescents generally range from 60% and in many cases its severity increases the risk of completed suicide.

Prevention

Refer to Suicide Prevention.

Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts.[citation needed] If signs, symptoms, or risk factors are detected early then the individual might seek treatment and help before attempting to take their own life. In a study of individuals who did commit suicide, 91% of them likely suffered from one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness. This emphasizes the importance of early detection; if a mental illness is detected, it can be treated and controlled to help prevent suicide attempts. Another study investigated strictly suicidal ideation in adolescents. This study found that depression symptoms in adolescents early as 9th grade is a predictor of suicidal ideation. Most people with long-term suicidal ideation do not seek professional help.

The previously mentioned studies point out the difficulty that mental health professionals have in motivating individuals to seek and continue treatment. Ways to increase the number of individuals who seek treatment may include:

  • Increasing the availability of therapy treatment in early stage.
  • Increasing the public’s knowledge on when psychiatric help may be beneficial to them.
  • Those who have adverse life conditions seem to have just as much risk of suicide as those with mental illness.

A study conducted by researchers in Australia set out to determine a course of early detection for suicidal ideation in teens stating that “risks associated with suicidality require an immediate focus on diminishing self-harming cognitions so as to ensure safety before attending to the underlying etiology of the behavior”. A Psychological Distress scale known as the K10 was administered monthly to a random sample of individuals. According to the results among the 9.9% of individuals who reported “psychological distress (all categories)” 5.1% of the same participants reported suicidal ideation. Participants who scored “very high” on the Psychological Distress scale “were 77 times more likely to report suicidal ideation than those in the low category”.

In a one-year study conducted in Finland, 41% of the patients who later committed suicide saw a health care professional, most seeing a psychiatrist. Of those, only 22% discussed suicidal intent on their last office visit. In most of the cases, the office visit took place within a week of the suicide, and most of the victims had a diagnosed depressive disorder.

There are many centers where one can receive aid in the fight against suicidal ideation and suicide. Hemelrijk et al. (2012) found evidence that assisting people with suicidal ideation via the internet versus more direct forms such as phone conversations has a greater effect. In a 2021 research study, Nguyen et al. (2021) propose that maybe the premise that suicidal ideation is a kind of illness has been an obstacle to dealing with suicidal ideation. They use a Bayesian statistical investigation, in conjunction with the mindsponge theory, to explore the processes where mental disorders have played a very minor role and conclude that there are many cases where the suicidal ideation represents a type of cost-benefit analysis for a life/death consideration, and these people may not be called “patients”.

Assessment

Assessment seeks to understand an individual by integrating information from multiple sources such as clinical interviews; medical exams and physiological measures; standardised psychometric tests and questionnaires; structured diagnostic interviews; review of records; and collateral interviews.

Interviews

Psychologists, psychiatrists, and other mental health professionals conduct clinical interviews to ascertain the nature of a patient or client’s difficulties, including any signs or symptoms of illness the person might exhibit.

  • Clinical interviews are “unstructured” in the sense that each clinician develops a particular approach to asking questions, without necessarily following a predefined format.
  • Structured (or semi-structured) interviews prescribe the questions, their order of presentation, “probes” (queries) if a patient’s response is not clear or specific enough, and a method to rate the frequency and intensity of symptoms.

Standardised Psychometric Measures

Refer to Assessment of Suicide Risk.

  • Beck Scale for Suicide Ideation.
  • Nurses’ Global Assessment of Suicide Risk.
  • Suicidal Affect-Behaviour-Cognition Scale (SABCS).
  • Columbia Suicide Severity Rating Scale.

Treatment

Treatment of suicidal ideation can be problematic due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include:

  • Therapy;
  • Hospitalisation;
  • Outpatient treatment; and
  • Medication or other modalities.

Therapy

In psychotherapy a person explores the issues that make them feel suicidal and learns skills to help manage emotions more effectively.

Hospitalisation

Hospitalisation allows the patient to be in a secure, supervised environment to prevent the suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalised involuntarily. These circumstances are:

  • If an individual poses danger to self or others; and/or
  • If an individual is unable to care for oneself.

Hospitalisation may also be a treatment option if an individual:

  • Has access to lethal means (e.g. a firearm or a stockpile of pills).
  • Does not have social support or people to supervise them.
  • Has a suicide plan.
  • Has symptoms of a psychiatric disorder (e.g. psychosis, mania, etc.).

Outpatient Treatment

Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Being at home may improve quality of life for some patients, because they will have access to their personal belongings, and be able to come and go freely. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patient’s level of social support, impulse control and quality of judgment. After the patient passes the evaluation, they are often asked to consent to a “no-harm contract”. This is a contract formulated by the physician and the family of the patient. Within the contract, the patient agrees not to harm themselves, to continue their visits with the physician, and to contact the physician in times of need. There is some debate as to whether “no-harm” contracts are effective. These patients are then checked on routinely to assure they are maintaining their contract and avoiding dangerous activities (drinking alcohol, driving fast, and not wearing a seat belt, etc.).

Medication

Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients’ energy levels before lifting their mood. This puts them at greater risk of following through with attempting suicide. Additionally, if a person has a comorbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation.

Antidepressants may be effective. Often, SSRIs are used instead of TCAs as the latter typically have greater harm in overdose.

Antidepressants have been shown to be a very effective means of treating suicidal ideation. One correlational study compared mortality rates due to suicide to the use of SSRI antidepressants within certain counties. The counties which had higher SSRI use had a significantly lower number of deaths caused by suicide. Additionally, an experimental study followed depressed patients for one year. During the first six months of that year, the patients were examined for suicidal behaviour including suicidal ideation. The patients were then prescribed antidepressants for the six months following the first six observatory months. During the six months of treatment, experimenters found suicide ideation reduced from 47% of patients down to 14% of patients. Thus, it appears from current research that antidepressants have a helpful effect on the reduction of suicidal ideation.

Although research is largely in favour of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation. Upon the start of using antidepressants, many clinicians will note that sometimes the sudden onset of suicidal ideation may accompany treatment. This has caused the FDA to issue a warning stating that sometimes the use of antidepressants may actually increase the thoughts of suicidal ideation. Medical studies have found antidepressants help treat cases of suicidal ideation and work especially well with psychological therapy. Lithium reduces the risk of suicide in people with mood disorders. Tentative evidence finds clozapine in people with schizophrenia reduces the risk of suicide.

What is Suicide Awareness?

Introduction

Suicide awareness is a proactive effort to raise awareness around suicidal behaviours.

Refer to Coping (Psychology), Suicide Prevention, and Suicidal Ideation.

It is focused on reducing social stigmas and ambiguity, by bringing attention to suicide statistically and sociologically, and encouraging positive dialogue and engagement as a means to prevent suicide. Suicide awareness is linked to suicide prevention as both address suicide education and the dissemination of information to ultimately decrease the rate of suicide. Awareness is a first stage that can ease the need for prevention.

Awareness signifies a fundamental consciousness of the threat, while prevention focuses on stopping the act. Suicide awareness is not a medical engagement, but a combination of medical, social, emotional and financial counselling. Suicide awareness in adolescents focuses on the age group between 10-24 years, beginning with the onset of puberty.

Stigma and Ambiguity

Stigma is a negative impact that society can often attribute to the suicidal condition, and which can hinder and prevent positive engagement with those demonstrating suicidal behaviour. It can be experienced as self-stigma or cultural, public stigma. Self-stigma is the adverse effect of internalised prejudice, manifesting itself in reduced self-esteem, decreased self-efficacy, and a feeling of “why try” or self-deprecation (undervaluing any attempts to get a job, be social, etc. because of lack of self-worth). It is experienced not only by those facing suicidal thoughts, but also by those directly and indirectly affected such as family members and friends. Public stigma is experienced by prejudice and discrimination through public misuse of stereotypes associated with suicide.

Stigma can create a detrimental barrier for some seeking help. Research has consistently illustrated the physical link between suicide and mental illness, but ignorance and outdated beliefs can sometimes lead to these disorders being identified as a weakness or a lack of willpower. Stigma can prevent survivors of suicide attempts, and those affected by suicide deaths, from reaching out for support from professionals and advocates to make positive change.

Historical Stigma

Historically, suicide has not always been considered a societal taboo. It is critical to understand the historical context in order to raise awareness of suicide’s impact on our current culture.

Suicide was embraced as a philosophical escape by the followers of the Greek philosopher Epicurus when life’s happiness seemed lost. It has been glorified in self-immolation as an act of martyrdom as in the case of Thich Quang Duc who burned himself to death in protest of South Vietnam’s religious policy. Assisted suicide as a release from suffering can be traced back to ancient Roman society. In Jewish culture, there is a reverence for the mass suicide at Masada in the face of attack by the Roman empire, showing how suicide has sometimes had a contradictory relationship with established religion. This indicates a tension between the presentation of suicide in this historical context, and its associations in our current society with personal anguish. Today, suicide is generally perceived as an act of despair or hopelessness, or a criminal act of terrorism (suicide attack). This negative backdrop was seen in Colonial America, where suicides were considered criminal and brought to trial, even if mental illness had been present.

Suicide was identified in Roman Catholicism as a sinful act, with religious burial prohibited until 1983, when the Catholic Church altered the canon law to allow funerals and burials within the church of those who died by suicide. Today, many current societies and religious traditions condemn suicide, especially in Western culture. Public consideration of suicide in our culture is further complicated by society’s struggle to rationalize such cult events as the Jonestown mass suicide. In light of these mixed historical messages, it can be confusing for youth, presented with an academic and historical profile for suicide. The ambiguity of accepted suicide and suicidal behaviour definitions impedes progress with its utilisation of variable terminology.

Public and Cultural Stigma

Today, even though suicide is considered a public health issue by advocates, the general public often still consider it a private shame; a final desperate solution for the emotionally weak. It is stigmatised in the public perception by being associated with weakness, a “cry for attention,” shame, and depression, without understanding the contributing factors. There can be a visceral and emotional reaction to suicide rather than an attempt to understand it. This reaction is based on stereotypes (overgeneralisations about a group: weak or crazy), prejudices (agreement with stereotypical beliefs and related emotional reactions: Sue attempted suicide; ‘I’m afraid of her’), and discrimination (unfair behaviour towards the suicidal individual or group: avoidance; ‘suicidal persons should be locked up’). Erving Goffman defined courtesy stigma as the discrimination, prejudice and stereotypes which family and friends experience as suicide survivors. Public stigma is felt by medical professionals whose clients die by suicide and whose treatment is then questioned by colleagues and in lawsuits, often contributing to their being less inclined to work with suicidal patients. Property can also be stigmatized by suicide: property sellers in certain jurisdictions in the United States, in California for example, are required by law to reveal if a suicide or murder occurred on the premises in the past three years, putting suicide in the same category as homicide. These issues compound and perpetuate the public stigma of suicide, exacerbating the inclination for suicidal individuals, and their family and friends, to bury their experiences, creating a barrier to care.

Emotional Stigma

Emotionally, the negative stigma of suicide is a powerful force creating isolation and exclusion for those in suicidal crisis. The use of stereotypes, discrimination and prejudices can strip the dignity of those experiencing suicidal behaviour. It also has the potential to inhibit compassion from others and to diminish hope. Fear of being socially rejected and labelled suicidal can prevent communication and support. Distress and reduced life satisfaction are directly affected by subjective feelings of being devalued and marginalised. This develops into an internalized stigma; it creates self-stigmatised emotions, self-deprecation and self-actualisation of negative stereotypes, causing further withdrawal, reduction in quality of life and the inhibiting access to care.

This emotional stigma also affects suicide survivors: those suffering a loved one’s loss, stirring up guilt, self-blame, isolation, depression and post-traumatic stress. Subjective experiences of feeling shunned or blamed for an incident can cause those close to the victim to bury the truth of what transpired.

Awareness Factors

Suicide awareness expresses the need for open constructive dialogue as an initial step towards preventing incidents of adolescent suicide. Once the stigmas have been overcome, there is an increased possibility that education, medical care and support can provide a critical framework for those at risk. Lack of information, awareness of professional services, judgement and insensitivity from religious groups, and financial strain have all been identified as barriers to support access for those youth in suicidal crisis. The critical framework is a necessary component to implementing suicide awareness and suicide prevention, and breaking down these barriers.

Protective Factors

Protective factors are characteristics or conditions that may have a positive effect on youth and reduce the possibility of suicide attempts. These factors have not been studied in as much depth as risk factors, so there is less research. They include:

  • Receiving effective mental health care.
  • Positive social connections and support with family and peers provides coping skills.
  • Participation in community and social groups (i.e. religious) that foster resilience.
  • Optimism enables youth to engage and acquire adaptive skills in reinterpreting adverse experiences to find meaning and benefit.
  • Life satisfaction, spiritual wellbeing and belief that a person can survive beyond their pain is protective against suicide.
  • Resiliency based on adaptive coping skills has can reduce suicide risk, and research suggests these skills can be taught.
  • Finding hope can be a key protective factor and a catalyst for the recovery process.

It is important to note, however, that in-depth training is paramount for those involved in any service that looks to the awareness and needs of those touched by suicide.

Social Media

Suicide awareness and prevention have in the past only relied on research from clinical observation. In bringing insights, intimate experience, and real-world wisdom of suicide attempt survivors to the table, professionals, educators, other survivors and suicide attempt survivors can learn firsthand from their “lived experience.”

Media and journalism, when reporting on suicide, have moved forward in their discussion of suicide. The Recommendations for Reporting on Suicide discovered the powerful impact media coverage, newspapers and journalists can have on the perpetuating stigma of suicide, and that it can lead to greater risk of occurrence. The specific rules that media representatives should follow are:

  • Don’t sensationalise the suicide.
  • Don’t talk about the contents of the suicide note, if there is one.
  • Don’t describe the suicide method.
  • Report on suicide as a public health issue.
  • Don’t speculate why the person might have done it.
  • Don’t quote or interview police or first responders about the causes of suicide.
  • Describe suicide as “died by suicide” or “completed” or “killed themselves,” rather than “committed suicide.”
  • Don’t glamorise suicide.

This is to prevent certain types of messaging around suicide that could increase the chances of at-risk youth considering or attempting suicide. This initiative brought awareness to the sensitivity of reporting on suicide in a constructive, destigmatised method of messaging.

Social Agency

Education in a non-threatening environment is critical to a growth in awareness among adolescents. Health education is closely related to health awareness. School can be the best place to implement a suicide education program because it is the pivotal location that brings together the major influences in an adolescent’s life. Pilot programmes for awareness, and coping and resiliency training should be put into place for all adolescent school-aged children to combat life stressors and to encourage healthy communication.