Suicide: Recognizing the Threat

Most people who commit suicide are depressed, but what triggers this irrevocable step varies from person to person. Suicide may stem from intense feelings of anger, despair, hopelessness, or panic. Sometimes it's carried out under the sway of a highly distorted or psychotic idea. If you think you might harm yourself, seek help. If you believe a friend or loved one might become self-destructive, urge him or her to do the same.

A number of factors can put someone at a higher risk for suicide in the short term, including:

• an episode of depression, psychosis, or anxiety
• a significant loss, such as the death of a spouse or the loss of a job
• loss of social support, for example, because of a move or when a close friend relocates
• a personal crisis or life stress, especially one that increases a sense of isolation or leads to a loss of self-esteem, such as a separation or divorce
• an illness or taking medication that triggers a change in mood.

None of these circumstances necessarily leads to suicide. In fact, most people in these circumstances do not commit suicide, and there is no way to predict who will. But any blow that upsets a person's life can set a vulnerable individual on a self-destructive course. Treatment can help you or someone you care about change that course.

Other grounds for concern

Mental health experts also observe that many cases of suicide involve some of the following factors. Although these circumstances can't reveal states of mind or predict actions, they should be taken seriously. Family members and health care professionals may be able to reduce the chances of suicide by watching for these factors and taking action if they notice them.

Family history. People with a biological relative with a history of suicide or suicide attempts have a risk of suicide that is much higher than average. For example, the child of a person who attempts suicide has six times the average risk of committing suicide. And 13% of people with an identical twin who commits suicide take their own lives, compared with less than 1% among fraternal twins. Some research indicates that this apparent inherited vulnerability may be the product of common genes that cause neurotransmitters to act in a way that predisposes a person toward rage and impulsive behavior. However, the gene studies are preliminary, and neurotransmitter levels are not simply hereditary but vary with a person's state of mind.

Access to handguns. In the United States, although not in other countries, most suicides are by gunshot. The suicide rate is among the highest in those states where gun ownership is highest (Nevada and Montana) and among the lowest in those states with the fewest gun owners (New York and New Jersey). The American Academy of Pediatrics has urged parents to keep guns and ammunition out of the house if a child might be depressed or suicidal. The same recommendation holds true for adults.

Substance abuse. The combination of depression and alcohol or drug use can be deadly because these substances can erase inhibitions and anxiety that might help keep suicide at bay. Or, as the more pleasing effects of such self-medication wear off, hopelessness may take hold.

Previous attempts. When someone has survived one or more attempted suicides, friends and relatives may take further attempts less, rather than more, seriously. But people with a history of a suicide attempt are about 40 times more likely to commit suicide than those who haven't attempted it before.

Setting affairs in order. Individuals who have decided on suicide may sort out their finances, give away mementos, or call or visit loved ones. People who have been agitated or depressed may seem calmer and happier. But rather than being a sign of returning health, this shift may stem from their relief at having made a final decision. Although this phenomenon is usually noted only in hindsight, friends and family members may be in the position to recognize it before a doctor or counselor does.

Suicides in the United States Reliable statistics on suicide aren't easy to compile because reporting is not always candid and records are not always thorough. Family members and others may have many reasons for denying that a death is suicide, and official sources cannot always distinguish suicide from accidents in cases like drunk driving and drug overdoses. Still, despite these limitations, we know that suicide is an important public health problem. Here is a look at some of the figures that are available: Suicide is the 11th leading cause of death in the United States. In 2002, the number of known suicide deaths in the United States was 31,655. Men account for 80% of suicide victims. Whites are twice as likely to commit suicide as blacks and Hispanics. The risk of suicide rises with age, and older Americans are disproportionately likely to die by suicide. According to the National Institute of Mental Health, individuals ages 65 and older made up 13% of the population, but accounted for 18% of all suicide deaths in 2000. Adolescents constitute a growing percentage of suicides. People ages 15–24, who once accounted for 5% of suicides, now account for 14%. Suicide is the third leading cause of death among American adolescents.

Help is available

If you or a loved one feels suicidal, there are many places to turn for help. Experts recommend these steps:

• Talk with your doctor or a mental health professional. Very often, treatment eases or entirely eliminates suicidal urges. In some cases, hospitalization is necessary until a sense of equilibrium returns.
• Call 1-800-SUICIDE or a local hotline and speak with a crisis counselor.
• Discuss your feelings with trusted family members, friends, or religious advisers who can assist you in getting help.

Can antidepressants trigger suicide? Suicidal thoughts (although no suicides) were first reported in people taking SSRIs in 1990, shortly after the drugs were introduced. An FDA committee rejected the association, and most mental health professionals accepted its conclusion, but the issue was never fully resolved. But the debate was revived as a result of an increase in the number of children and adolescents receiving prescriptions for antidepressants. In 2003, British drug authorities announced a possible connection between the antidepressant paroxetine (Paxil) and thoughts of suicide and self-destructive behavior in some teenagers and children. The FDA performed its own review of these medications, and in 2004 it began requiring that drug manufacturers include a warning on all antidepressants. This "black box" warning — the FDA's strongest available measure short of withdrawing a drug from the market — is placed on package inserts for all commonly used antidepressants. The warning mentions the risk of suicidal thoughts, hostility, and agitation in both children and adults. Although results from many subsequent studies have varied, there is a consistent trend. When compared with a placebo, all antidepressants, including SSRIs, seem to double the risk of suicidal thinking, from 1%–2% to 2%–4%, in both children and adults. But keep in mind that these studies did not report any cases of completed suicides. So far there's no evidence from controlled research that links suicide to antidepressant use. In addition, depression in itself increases the risk of suicide. And self-destructive and impulsive behavior is common in adolescence, so it's hard to know what to make of the data. There are a few theories that may explain the trend. In a small percentage of patients, antidepressants may have the paradoxical effect of making moods worse. Self-injury may result from an antidepressant side effect known as akathisia — an extremely uncomfortable form of restlessness. Or perhaps severely depressed people recover the energy to act on suicidal thoughts before their mood improves or hope returns. In addition, giving an antidepressant to a person with bipolar disorder may trigger mania or irritability, increasing the risk of self-destructive behavior. Regular follow-ups and close monitoring by a doctor are the best ways to avoid medication-related suicide. Experts recommend that all people starting on or changing their dose of an antidepressant — either increasing or decreasing — be closely monitored. Watch for signs that the depression is worsening or that suicidal thoughts or behaviors have emerged. Careful monitoring is particularly important in the first month or two. If you feel worse after beginning treatment or if you develop uncomfortable symptoms (like anxiety or restlessness), let your doctor know. The same advice holds true for children: If your child's symptoms seem to worsen or you notice any signs of suicidal thinking or behavior, contact the child's doctor immediately.

Source: from Harvard Health Publications, Copyright © 2008 Harvard University. All rights reserved. Harvard Medical School does not endorse products.
Used with permission of StayWell.
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