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CHAPTER 12 CHAPTER OUTLINE I. Correlates of suicide. People may commit suicide if they feel depressed, like a failure, as though the quality of their life is poor, unwanted, as though their death is for a greater good and for many other reasons. Suicide is not a disorder in DSM-IV-TR, but is important in abnormal psychology, and the suicidal person has clear psychiatric symptoms. Suicide and suicidal ideation (thinking about it) may be separate from depression. As a topic, suicide has been hidden, but as the eleventh leading cause of death in the United States, it is now emerging as a focus of research and social discussion. Those who complete suicide attempts cannot be asked their reasons. Patterned after medical autopsies, a psychological autopsy attempts to make psychological sense of suicide by examining the person’s case history, interviewing family and friends, and analyzing suicide notes. However, these sources of information are often unavailable or unreliable. Every sixteen minutes or so, someone in the United States takes his or her own life. Approximately 31,000 persons kill themselves each year. Suicide is among the top eleven causes of death in the industrialized parts o f the world; it is the eighth leading cause of death among American males and the third leading cause of death among young people ages fifteen to twenty-four. Some evidence shows that the number of actual suicides is probably 25 to 30 percent higher than that recorded. Many deaths that are officially recorded as accidental—such as single-auto crashes, drownings, or falls from great heights—are actually suicides. Suicides among the young have increased dramatically in the past decade. Reasons for suicide include hopelessness, loneliness, helplessness, relationship problems, unspecified depression, money problems, and problems with their parents. Men complete suicide three times as often as women, but women attempt suicide three times as often. Suicides in the 15 to 24 year-old age group increased more than 40 percent during the past decade, and it is now the second leading cause of death for that age group. Media reports of suicides, especially of celebrities, seem to spark an increase in suicide. The complete d suicide rate for men is about four times that for women, although recent findings suggest that the gap is closing as many more women are now incurring a higher risk. Further, women are more likely to make attempts, but it appears that men are more successful because they use more lethal means. Being widowed as compared to divorced appears to be associated with higher risk of suicide for white men and women and African American men. At older ages, however, divorce rather than widowhood increases the risk. Interestingly, the pattern reversal occurs much earlier among white women than for men. Physicians, lawyers, law enforcement personnel, and dentists have higher than average rates of suicide. Among medical professionals, psychiatrists have the highest rate and pediatricians the lowest. Suicide is represented proportionately among all socioeconomic levels. Level of wealth does not seem to affect the suicide rate as much as do changes in that level. Over 50 percent of suicides are committed by firearms, and 70 percent of attempts are accounted for by drug overdose. Men most frequently choose firearms as the means of suicide; poisoning and asphyxiation via barbiturates are the preferred means for women. Religious affiliation is correlated with suicide rates. Although the U.S. rate is 12.2 per 100,000, in countries in which Catholic Church influences are strong—Latin America, Ireland, Spain, and Italy—the suicide rate is relatively low. Suicide rates vary among ethnic minority groups in the United States. American Indian groups have the highest rate, followed by white Americans, Mexican Americans, African Americans, Japanese Americans, and Chinese Americans. American Indian youngsters have frighteningly high rates (26 per 100,000) as compared with white youths (14 per 100,000). As might be expected, suicide is the most frequent cause of death in U.S. jails. A suicide number that ranges from 90 to 230 per 100,000 means that the suicide rate in prisons is 16 times higher than in the general population. II. A multi-path perspective of suicide. Most discussions on the correlates of suicide seem to stress psychological, social, and sociocultural factors. But biological factors and the interplay of all four seem to be operating in determining suicides. Two sets of findings—from biochemistry and from genetics—suggest that suicide may have a strong biological component. There are many psychological factors that have been found to be significantly related to suicide. Findings have consistently revealed that a number of individuals who commit suicide suffer from a DSM-IV-TR disorder. One of the most consistently reported correlates of suicidal behavior is alcohol consumption . Social factors that operate to separate people or to make them somehow less connected to other people or to their families, religious institutions, or their community can increase susceptibility to suicide. Rates of suicide vary with age, gender, marital status, occupation, socioeconomic level, religion and ethnic group. Higher rates are associated with high- and low-status (as opposed to middle-status) occupations, urban living, middle-aged men, single or divorced status, and upper and lower socioeconomic classes. III. Victims of suicide. Suicide among the young is an unmentioned tragedy in our society. We have traditionally avoided the idea that some of our young people find life so painful that they consciously and deliberately take their own lives. Children and adolescents take their lives at an alarming rate. Those who attempt suicide tend to show clinical symptoms of psychological disturbance, to use drug overdose as the method, to make their attempt at home, and to come from families with high levels of stress as a result of economic instability, substance abuse, or other life events. Copycat suicides, in which adolescents imitate media portrayals of other adolescents' suicides, are less common than the media suggest and tend to occur among those already contemplating suicide. However, highly publicized suicides can increase the chances of attempts. The many stresses of life among the elderly place them at high risk for suicide. Suicide rates are particularly high for white males and first-generation Asian Americans. Native Americans and African Americans show low rates of suicide among older adults, although both groups are at high risk during young adulthood. IV. Preventing suicide. People who attempt suicide have a wish to live along with a wish to die. They usually leave verbal or behavioral clues of their intentions, although these may be subtle. A clinical approach to suicide intervention stresses that most individuals are ambivalent about ending their lives and that counselors must be comfortable discussing the subject. Crisis intervention strategies are used to assess lethality, and to abort suicide attempts by offering intensive counseling to the individual and stabilizing him or her, sometimes in a hospital environment, while clarifying ways to deal with the crisis. Suicide prevention centers usually use paraprofessionals to take telephone calls from potentially suicidal individuals. These paraprofessionals are trained to establish rapport with the caller, evaluate suicidal potential, clarify the nature of the problem and the caller’s ability to cope, and recommend a plan of action. There is no conclusive evidence for the effectiveness of suicide prevention centers. Community prevention efforts can involve going into a school where a suicide has occurred and educating and providing counseling to survivors. Such an institutional response serves to minimize the mental health problems of survivors and can prevent future suicides V. The right to suicide: Moral, ethical, and legal issues The quality of life is a significant moral and ethical issue that has led to right-to-die legislation and “living wills” that are recognized in several states. Dr. Jack Kevorkian, a physician in Michigan, has assisted patients to commit suicide, an act that a new law states is illegal. Oregon voters passed a bill to allow physicians to help terminally ill patients die. VI. Implications. There is a saying that goes like this: “We know much about suicide but we know very little about it.” While this may sound contradictory, this chapter has been filled with an impressive array of facts, statistics, and information about many aspects of suicide. We are able to construct fairly accurate portraits of individuals most as risk, delineate protective factors, and even develop intervention strategies in working with suicidal individuals. We know that people commit suicide for many reasons. We know that biological, psychological, social, and sociocultural factors are related to suicides.