name	Suicide
icd10	–| ICD9 | MedlinePlus 001554
emedicinesubj	article
emedicinetopic	288598
meshname	Suicide
meshnumber	F01.145.126.980.875 }}

Suicide (Latin ''suicidium'', from ''sui caedere'', "to kill oneself") is the act of a human being intentionally causing his or her own death. Suicide is often committed out of despair, or attributed to some underlying mental disorder which includes depression, bipolar disorder, schizophrenia, alcoholism and drug abuse. Pressures or misfortunes such as financial difficulties or troubles with interpersonal relationships may play a significant role.

Over one million people die by suicide every year. The World Health Organization (WHO) estimates that it is the thirteenth-leading cause of death worldwide and the National Safety Council rates it sixth in the United States. It is a leading cause of death among teenagers and adults under 35. The rate of suicide is higher in men than in women. There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide.

Views on suicide have been influenced by broader cultural views on existential themes such as religion, honor, and the meaning of life. The Abrahamic religions consider suicide an offense towards God due to religious belief in the sanctity of life. In the West it was often regarded as a serious crime. Conversely, during the samurai era in Japan, seppuku was respected as a means of atonement for failure or as a form of protest. In the 20th century, suicide in the form of self-immolation has been used as a form of protest, and in the form of kamikaze and suicide bombing as a military or terrorist tactic. Sati is a Hindu funeral practice in which the widow would immolate herself on her husband's funeral pyre, either willingly or under pressure from the family and in-laws.

Medically assisted suicide (euthanasia, or the right to die) is currently a controversial ethical issue involving people who are terminally ill, in extreme pain, or have (perceived or construed) minimal quality of life through injury or illness. Self-sacrifice for others is not always considered suicide, as the goal is not to kill oneself but to save another; however, Émile Durkheim's theory termed such acts "altruistic suicide."

Classification

Self-harm

Self-harm is not a suicide attempt; however, initially self-harm was erroneously classified as a suicide attempt. There is a non-causal correlation between self-harm and suicide; both are most commonly a joint effect of depression. This may also be classified as Deliberate self-harm and is most common in younger people but has been increasing in recent years in people of all ages.

Euthanasia and assisted suicide

Individuals who wish to end their own lives may enlist the assistance of another person to achieve death. The other person, usually a family member or physician, may help carry out the act if the individual lacks the physical capacity to do so even with the supplied means. Assisted suicide is a contentious moral and political issue in many countries, as seen in the scandal surrounding Dr. Jack Kevorkian, a medical practitioner who supported euthanasia, was found to have helped patients end their own lives, and was sentenced to prison time.

Murder–suicide

A murder–suicide is an act in which an individual kills one or more other persons immediately before or at the same time as him or herself.

The motivation for the murder in murder–suicide can be purely criminal in nature or be perceived by the perpetrator as an act of care for loved ones in the context of severe depression.

Suicide attack

A suicide attack is when an attacker perpetrates an act of violence against others, typically to achieve a military or political goal, that results in his or her own death as well. Suicide bombings are often regarded as an act of terrorism. Historical examples include the assassination of Czar Alexander II and the in-part successful kamikaze attacks by Japanese air pilots during the Second World War, as well as more recent attacks, such as the September 11th attacks.

Mass suicide

Some suicides are done under peer pressure or as a group. Mass suicides can take place with as few as two people, in a "suicide pact", or with a larger number of people. An example is the mass suicide that took place by members of the Peoples Temple, an American cult led by Jim Jones in Guyana in 1978.

Suicide pact

A suicide pact describes the suicides of two or more individuals in an agreed-upon plan. The plan may be to die together, or separately and closely timed. Suicide pacts are generally distinct from mass suicide. The latter refers to incidents in which a larger number of people kill themselves together for the same ideological reason, often within a religious, political, military or paramilitary context. Suicide pacts, on the other hand, usually involve small groups of people (such as married or romantic partners, family members, or friends) whose motivations are intensely personal and individual.

Metaphorical suicide

The metaphorical sense of "willful destruction of one's self-interest", for example political suicide.

Risk factors

A number of factors are associated with the risk of suicide including: mental illness, drug addiction, and socio-economic factors. While external circumstances, such as a traumatic event, may trigger suicide it does not seem to be an independent cause.

Mental illness

Mental disorders are frequently present at the time of suicide with estimates from 87% to 98%. When broken down into type mood disorders are present in 30%, substance abuse in 18%, schizophrenia in 14%, and personality disorders in 13% of suicides. About 5% of people with schizophrenia die of suicide. Depression, one of the most commonly diagnosed psychiatric disorders is being diagnosed in increasing numbers in various segments of the population worldwide, and is often a precipitating factor in suicide. Depression in the United States alone affects 17.6 million Americans each year or 1 in 6 people. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the United States.

In approximately 75% of completed suicides the individuals had seen a physician within the prior year before their death, 45%-66% within the prior month. Approximately 33% - 41% of those who completed suicide had contact with mental health services in the prior year, 20% within the prior month.

Conservative estimates are, that 10% of all psychological symptoms may be due to medical reasons, with the results of one study, suggesting that about 50% of individuals with a serious mental illness ''have general medical conditions that are largely undiagnosed and untreated and may cause or exacerbate psychiatric symptoms'' (Rothbard AB,''et al.'' 2009)

Substance abuse

Substance abuse is the second most common risk factor for suicide after mood disorders. Both chronic substance misuse as well as acute substance abuse is associated with suicide. This is attributed to the intoxicating and disinhibiting effects of many psychoactive substances; when combined with personal grief such as bereavement the risk of suicide is greatly increased. More than 50% of suicides are related to alcohol or drug use. Up to 25% of suicides are committed by drug addicts and alcoholics. In adolescents the figure is higher with alcohol or drug misuse playing a role in up to 70% of suicides. It has been recommended that all drug addicts or alcoholics are investigated for suicidal thoughts due to the high risk of suicide. An investigation in the New York Prison Service found that 90% of inmates who committed suicide had a history of substance abuse.

Cocaine

Misuse of drugs such as cocaine have a high correlation with suicide. Suicide is most likely to occur during the "crash" or withdrawal phase of cocaine in chronic abusers. Polysubstance misuse has been found to more often result in suicide in younger adults whereas suicide from alcoholism is more common in older adults. In San Diego it was found that 30% of suicides in people under the age of 30 had used cocaine. In New York City during a crack epidemic one in five people who committed suicide were found to have recently consumed cocaine. The "come down" or withdrawal phase from cocaine can result in intense depressive symptoms coupled with other distressing mental effects which serve to increase the risk of suicide.

Methamphetamine

Methamphetamine use has a high association with depression and suicide as well as a range of other adverse effects on physical and mental health.

Opioids

Heroin users have a death rate 13 times that of their peers, and deaths among heroin users attributed to suicide range from 3-35%. Overall, heroin users are 14 times more likely than peers to die from suicide. Major depressive disorder was found in a 25% of entrants to treatment for heroin dependence in Australia.

Alcohol

Alcohol misuse is associated with a number of mental health disorders, and alcoholics have a very high suicide rate. It has been found that drinking 6 drinks or more per day results in a sixfold increased risk of suicide. High rates of major depressive disorder occur in heavy drinkers and those who abuse alcohol. Controversy has previously surrounded whether those who abused alcohol who developed major depressive disorder were self medicating (which may be true in some cases) but recent research has now concluded that chronic excessive alcohol intake itself directly causes the development of major depressive disorder in a significant number of alcohol abusers.

Benzodiazepines

Chronic prescribed benzodiazepine use or chronic misuse is associated with depression as well as suicide. Care should be taken when prescribing especially to at risk patients. Depressed adolescents who were taking benzodiazepines were found to have a greatly increased risk of self harm or suicide, although the sample size was small. The effects of benzodiazepines in individuals under the age of 18 requires further research. Additional caution is required in using benzodiazepines in depressed adolescents. Benzodiazepine dependence often results in an increasingly deteriorating clinical picture which includes social deterioration leading to comorbid alcoholism and drug abuse. Suicide is a common outcome of chronic benzodiazepine dependence. Benzodiazepine misuse or misuse of other CNS depressants increases the risk of suicide in drug misusers. 11% of males and 23% of females with a sedative hypnotic misuse habit commit suicide. Benzodiazepine withdrawal also leads to an increased risk of suicide.

Cigarette smoking

There have been various studies done showing a positive link between smoking, suicidal ideation and suicide attempts. In a study conducted among nurses, those smoking between 1-24 cigarettes per day had twice the suicide risk; 25 cigarettes or more, 4 times the suicide risk, than those who had never smoked. In a study of 300,000 male U.S. Army soldiers, a definitive link between suicide and smoking was observed with those smoking over a pack a day having twice the suicide rate of non-smokers.

Problem gambling

Problem gambling is often associated with increased suicidal ideation and attempts compared to the general population.

Early onset of problem gambling increases the lifetime risk of suicide. However, gambling-related suicide attempts are usually made by older people with problem gambling. Both comorbid substance use and comorbid mental disorders increase the risk of suicide in people with problem gambling.

A 2010 Australian hospital study found that 17% of suicidal patients admitted to the Alfred Hospital's emergency department were problem gamblers.

Biological

Genetics has an effect on suicide risk accounting for 30–50% of the variance. Much of this relationship acts through the heritability of mental illness. There is also evidence to suggest that if a parent has committed suicide, it is a strong predictor of suicide attempts among the offspring.

Social

As a form of defiance or protest

In Ireland protesting via hunger strike to the death has been used as a tactic in recent times for political causes. During The Troubles in Northern Ireland a hunger strike was launched by the provisional IRA to demand that their prisoners be reclassified as prisoners of war rather than as terrorists, during the infamous 1981 hunger strikes, led by Bobby Sands; this protest resulted in 10 deaths. The cause of death was recorded as "starvation, self-imposed" rather than suicide by the coroner, modified to simply "starvation" on the death certificates after protests from the striker's families.

Judicial suicide

A person who has committed a crime may commit suicide to avoid prosecution and disgrace, such as in murder–suicides. Nazi leader Hermann Göring, a high-ranked Nazi and head of the Luftwaffe, committed suicide with cyanide capsules rather than be hanged after his conviction at the Nuremberg Trials. Some school shootings, including the Columbine and Virginia Tech massacres, concluded with the perpetrators committing suicide.

Military suicide

In the final days of World War II, some Japanese pilots volunteered for kamikaze missions in an attempt to forestall defeat for the Empire of Japan, while Japanese ground forces initiated banzai charges. Near the end of WWII the Japanese designed the Ohka, a small aircraft whose only purpose was kamikaze missions. Similarly, units of the Luftwaffe flew Selbstopfereinsatz (self-sacrifice missions) against Soviet bridges.

Dutiful suicide

Dutiful suicide is an act, or non-fatal attempt at the act, of fatal self-violence at one's own hands done in the belief that it will secure a greater good, rather than to escape harsh or impossible conditions. It can be voluntary, to relieve some dishonor or punishment, or imposed by threats of death or reprisals on one's family or reputation (a kind of murder by remote control). It can be culturally traditional or generally abhorred; it can be heavily ritualized as in seppuku or purely functional. Dutiful suicide can be distinguished from a kamikaze or suicide bomb attack, in which a fighter consumes his own life in delivering a weapon to the enemy.

Disgraced Roman aristocrats were sometimes allowed to commit suicide to spare themselves a trial and penalties against their families. An example of this was Emperor Nero who reportedly committed forced suicide facing a revolt and execution. A more modern case is Erwin Rommel, who was found to have foreknowledge of the July 20 Plot on Hitler's life. Rommel was threatened with public trial, execution and reprisals on his family unless he killed himself, which he did.

Suicide as an escape

In situations where continuing to live is intolerable, some people use suicide as a means of escape. Some inmates in Nazi concentration camps are known to have killed themselves by deliberately touching the electrified fences.

As Germany faced inevitable defeat in mid–1945, there were unprecedented waves of suicides amongst Germans in the final weeks of the war (see Mass suicides in 1945 Nazi Germany) These included many senior figures in the regime (e.g., Adolf Hitler, Heinrich Himmler and Joseph Goebbels), as well as many ordinary people who were fearful of suffering atrocities at the hands of the advancing Red Army. The behaviour of Soviet troops also played a role, as many Germans committed suicide to avoid rape or out of shame at having been raped.

Emperor Tewodros II of Ethiopia, facing defeat at the hands of the British expeditionary force committed suicide rather than be taken captive, announcing ""It is finished! Sooner than fall into his hands I will kill myself".

According to a report by Tata Institute of Social Sciences in Mumbai, 150,000 debt-ridden farmers in India have committed suicide in the past decade.

Other

Socio-economic factors such as unemployment, poverty, homelessness, and discrimination may trigger suicidal thoughts. Poverty may not be a direct cause but it can increase the risk of suicide, as it is a major risk group for depression. Advocacy of suicide has been cited as a contributing factor. Intelligence may also factor. Initially proposed as a part of an evolutionary psychology explanation, which posited a minimum intelligence required for one to commit suicide, the positive correlation between IQ and suicide has been replicated in a number of studies. Some scientists doubt however that intelligence can be a cause of suicide, and the intelligence is no longer a predictor of suicide when regressed with national religiousness and perceptions of personal health. According to the American Psychiatric Association, "religiously unaffiliated subjects had significantly more lifetime suicide attempts and more first-degree relatives who committed suicide than subjects who endorsed a religious affiliation." Moreover, individuals with no religious affiliation had fewer moral objections to suicide than believers.

One study found that a lack of social support, a deficit in feelings of belongingness and living alone were crucial predictors of a suicide attempt. One study found that among prison inmates, suicide was more likely among inmates who had committed a violent crime.

Suicide methods

The leading method of suicide varies dramatically between countries. The leading methods in different regions include hanging, pesticide poisoning, and firearms. A 2008 review of 56 countries based on WHO mortality data found that hanging was the most common method in most of the countries, accounting for 53 percent of the male suicides and 39 percent of the female suicides. Worldwide 30% of suicides are from pesticides. The use of this method however varies markedly from 4% in Europe to more than 50% in the Pacific region. In the United States 52% of suicides involve the use of firearms. Asphyxiation (such as with a suicide bag) and poisoning are fairly common as well. Together they comprised about 40% of U.S. suicides. Other methods of suicide include blunt force trauma (jumping from a building or bridge, self-defenestrating, stepping in front of a train, or car collision, for example). Exsanguination or bloodletting (slitting one's wrist or throat), intentional drowning, self-immolation, electrocution, and intentional starvation are other suicide methods. Individuals may also intentionally provoke another person into administering lethal action against them, as in suicide by cop.

Whether or not exposure to suicide is a risk factor for suicide is controversial. A 1996 study was unable to find a relationship between suicides among friends, while a 1986 study found increased rates of suicide following the televisation of news stories regarding suicide.

Prevention

Suicide prevention is a term used for the collective efforts to reduce the incidence of suicide through prevention measures. While crisis hotlines are common there is little evidence to support or refute their effectiveness. Asking about or screening for suicide however does not appear to increase the risk.

Epidemiology

[[File:Self-inflicted injuries world map - Death - WHO2004.svg|thumb|Deaths for self inflicted injuries per 100,000 inhabitants in 2004. ]]

Suicide is the tenth leading cause of death worldwide According to 2007 data, suicides in the U.S. outnumber homicides by nearly 2 to 1 and ranks as the 11th leading cause of death in the country, ahead of liver disease and Parkinson's. Worldwide suicide rates have increased by 60% in the past 50 years, mainly in the developing countries.

A disproportionate amount of suicides in the world occur in Asia, which is estimated to account for up to 60% of all suicides. According to the WHO, China, India and Japan may account for 40% of all world suicides.

In the U.S., the rate of suicide is increasing for the first time in a decade. The increase in the overall suicide rate between 1999 and 2005 has been due primarily to an increase in suicides among whites aged 40–64, with white middle-aged women experiencing the largest annual increase.

Gender

In the Western world, males die much more often by means of suicide than do females, although females attempt suicide more often. Some medical professionals believe this stems from the fact that males are more likely to end their lives through effective violent means, while women primarily use less severe methods such as overdosing on medications. In most countries, drug overdoses account for about two-thirds of suicides among women and one-third among men. Alcoholics are 5 to 20 times more likely to kill themselves while the misuse of other drugs increases the risk 10 to 20 times. About 15% of alcoholics commit suicide, and about 33% of suicides in the under 35's have a primary diagnosis of alcohol or other substance misuse; over 50% of all suicides are related to alcohol or drug dependence. In adolescents alcohol or drug misuse plays a role in up to 70% of suicides.

Ethnicity

National suicide rates differ significantly between countries and amongst ethnic groups within countries. For example, in the U.S., non-Hispanic Caucasians are nearly 2.5 times more likely to kill themselves than African Americans or Hispanics. In the United Kingdom suicide rates vary significantly between different parts of the country. In Scotland, for example, the suicide rate is approximately double that of England.

Social aspects

Intervention

The predominant view of modern medicine is that suicide is a mental health concern, associated with psychological factors such as the difficulty of coping with depression, inescapable suffering or fear, or other mental disorders and pressures. A suicide attempt is sometimes interpreted as a "cry for help" and attention, or to express despair and the wish to escape, rather than a genuine intent to die. Most people who attempt suicide do not complete suicide on a first attempt; those who later gain a history of repetitions have a significantly higher probability of eventual completion of suicide.

In the United States, individuals who express the intent to harm themselves may be automatically determined to lack the ''present mental capacity'' to refuse treatment, and can be transported to the emergency department against their will. An emergency physician will determine whether inpatient care at a mental health care facility is warranted. This is sometimes referred to as being "committed". A court hearing may be held to determine the individual's ''competence''. In most states, a psychiatrist may hold the person for a specific time period without a judicial order. If the psychiatrist determines the person to be a threat to himself or others, the person may be admitted involuntarily to a psychiatric treatment facility. This period is usually of three days duration. After this time the person must be discharged or appear in front of a judge. As in any judicial proceeding this person has a right to legal counsel.

Switzerland has recently taken steps to legalize assisted suicide for the chronically mentally ill. The high court in Lausanne, in a 2006 ruling, granted an anonymous individual with longstanding psychiatric difficulties the right to end his own life. At least one leading American bioethicist, Jacob Appel of Brown University, has argued that the American medical community ought to condone suicide in certain individuals with mental illness.

Legislation

In some jurisdictions, an act or incomplete act of suicide is considered to be a crime. More commonly, a surviving party member who assisted in the suicide attempt will face criminal charges.

In Brazil, if the help is directed to a minor, the penalty is applied in its double and not considered as homicide. In Italy and Canada, instigating another to suicide is also a criminal offense. In Singapore, assisting in the suicide of a mentally handicapped person is a capital offense. In India, abetting suicide of a minor or a mentally challenged person can result in a maximum 1 year prison term with a possible fine.

In Germany, the following laws apply to cases of suicide:

Active euthanasia (killing on request) is prohibited by article 216 of the StGB (Strafgesetzbuch, German Criminal Code), punishable with six months to five years in jail

German law interprets suicide as an accident and anyone present during suicide may be prosecuted for failure to render aid in an emergency. A suicide legally becomes emergency when a suicidal person loses consciousness. Failure to render aid is punishable under article 323c of the StGB, with a maximum one year jail sentence.

Religious views

In most forms of Christianity, suicide is considered a sin, based mainly on the writings of influential Christian thinkers of the Middle Ages, such as St. Augustine and St. Thomas Aquinas; suicide was not considered a sin under the Byzantine Christian code of Justinian, for instance. In Catholic doctrine, the argument is based on the commandment "Thou shalt not kill" (made applicable under the New Covenant by Jesus in Matthew 19:18), as well as the idea that life is a gift given by God which should not be spurned, and that suicide is against the "natural order" and thus interferes with God's master plan for the world. However, it is believed that mental illness or grave fear of suffering diminishes the responsibility of the one completing suicide. Counter-arguments include the following: that the sixth commandment is more accurately translated as "thou shalt not murder", not necessarily applying to the self; that God has given free will to humans; that taking one's own life no more violates God's Law than does curing a disease; and that a number of suicides by followers of God are recorded in the Bible with no dire condemnation.

Judaism focuses on the importance of valuing this life, and as such, suicide is tantamount to denying God's goodness in the world. Despite this, under extreme circumstances when there has seemed no choice but to either be killed or forced to betray their religion, Jews have committed individual suicide or mass suicide (see Masada, First French persecution of the Jews, and York Castle for examples) and as a grim reminder there is even a prayer in the Jewish liturgy for "when the knife is at the throat", for those dying "to sanctify God's Name". (See: ''Martyrdom''). These acts have received mixed responses by Jewish authorities, regarded both as examples of heroic martyrdom, whilst others state that it was wrong for them to take their own lives in anticipation of martyrdom.

Suicide is not allowed in Islam; however, martyring oneself for Allah (during combat) is not considered the same as completing suicide. Suicide in Islam is seen as a sign of disbelief in God.

In Hinduism, suicide is generally frowned upon and is considered equally sinful as murdering another in contemporary Hindu society. Hindu Scriptures state that one who commits suicide will become part of the spirit world, wandering earth until the time one would have otherwise died, had one not committed suicide. However, Hinduism accept a man's right to end one's life through the non-violent practice of fasting to death, termed ''Prayopavesa''. But Prayopavesa is strictly restricted to people who have no desire or ambition left, and no responsibilities remaining in this life. Jainism has a similar practice named ''Santhara''. Sati, or self-immolation by widows was prevalent in Hindu society during the Middle Ages.

Philosophy

Some see suicide as a legitimate matter of personal choice and a human right (colloquially known as the right to die movement), and maintain that no one should be forced to suffer against their will, particularly from conditions such as incurable disease, mental illness, and old age that have no possibility of improvement. Proponents of this view reject the belief that suicide is always irrational, arguing instead that it can be a valid last resort for those enduring major pain or trauma. This perspective is most popular in continental Europe, where euthanasia and other such topics are commonly discussed in parliament and has a good deal of support.

A narrower segment of this group considers suicide something between a grave but condonable choice in some circumstances and a sacrosanct right for anyone (even a young and healthy person) who believes they have rationally and conscientiously come to the decision to end their own lives. Notable supporters of this school of thought include German pessimist philosopher Arthur Schopenhauer, Friedrich Nietzsche, and Scottish empiricist David Hume. Bioethicist Jacob Appel has become the leading advocate for this position in the United States. Adherents of this view often advocate the abrogation of statutes that restrict the liberties of people known to be suicidal, such as laws permitting their involuntary commitment to mental hospitals.

Locations

Some landmarks have become known for high levels of suicide attempts. The four most popular locations in the world are reportedly San Francisco's Golden Gate Bridge, Toronto's Bloor Street Viaduct (before the construction of the Luminous Veil), Japan's Aokigahara Forest and England's Beachy Head. In 2005 the Golden Gate Bridge had a count exceeding 1,200 jumpers since its construction in 1937, in 1997 the Bloor Street Viaduct had one suicide every 22 days, and in 2002 Aokigahara had a record of 78 bodies found within the forest, replacing the previous record of 73 in 1998. The suicide rate of these places is so high that numerous signs, urging potential victims of suicide to seek help, have been posted.

Language

Because suicide was a crime in various countries, including in England and Wales until 1961, the word 'commit' has traditionally been used in reference to it. Organisations such as the BBC and the Samaritans have stopped using this word because of its negative connotation. 'Attempt' suicide or other phrases are preferred.

In other species

"Suicide" has been observed in salmonella seeking to overcome competing bacteria by triggering an immune system response against them. Suicidal defences by workers are also noted in a Brazilian ant ''Forelius pusillus'' where a small group of ants leaves the security of the nest after sealing the entrance from the outside each evening.

Pea aphids, when threatened by a ladybug, can explode themselves, scattering and protecting their brethren and sometimes even killing the lady bug. Some species of termites have soldiers that explode, covering their enemies with sticky goo. There have been anecdotal reports of dogs, horses, and dolphins committing suicide, but with little conclusive evidence. There has been little scientific study of animal suicide.

See also

American Foundation for Suicide Prevention

Assessment of suicide risk

Bullycide

CALM, Campaign Against Living Miserably

Cult suicide

Jack Kevorkian

National Suicide Prevention Lifeline

Organ donation#In suicides

Parasuicide

Quantum suicide

Rational suicide

Samaritans (charity)

Senicide

Suicide Act 1961

Suicide bridge

Suicide note

Suicide Prevention Action Network USA

Suicide tree

Suicide watch

;Books

''The Complete Manual of Suicide''

''Final Exit''

''The Peaceful Pill Handbook''

''Suicide''

;Film

''The Bridge'' (2006 film)

;Lists

List of countries by suicide rate

List of suicide sites

List of suicides

Footnotes

Further reading

External links

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