Understanding and Addressing Suicide

The recent suicide of the brilliant entertainer Robin Williams has stirred considerable interest in this serious problem. According to the World Health Organization (WHO), the Center for Disease Control (CDC), suicide researchers and others, suicide is a global health problem affecting individuals, families, and society (WHO, 2014; CDC, 2014; Brent, 2011; Goodwin & Jamison, 2007; Mann & Currier, 2006; Nock, Millner, Deming, & Glenn, 2014; SAMHSA, 2009; Daley & Moss, 2002). Over 800,000 people complete suicide each year throughout the world and over 39,000 do so in the United States. Suicide is the tenth leading cause of death in the US and the second leading cause among those ages fifteen to twenty-nine.  Women have much higher rates of suicidal ideation, plans and attempts, but completed suicides occur four times more often among males, and even higher among white and Native American men due to making more lethal attempts. To put this into perspective by comparing deaths by suicide to deaths in a war among young men, the researcher Dr. Kay Redfield Jamison found that nearly twice as many men under the age of thirty-five died from suicide (101,732) than died from combat in the Vietnam War (54,708) during the period of this war (1999). Many more have died from suicide since the end of this war.

More people attempt suicide than complete it. Unfortunately, the majority who experience suicidal behavior never seek help for problems that may contribute to their desire to end their lives.  

Suicidal behaviors include ideation (thoughts of ending one’s life), plans (having a strategy to end one’s life), attempts with some intention of dying that do not lead to death, and self-inflicted death. More than one in six adults in the US report suicidal ideation, about one in twenty report a plan, and about one in twenty make an actual attempt to kill themselves. The risk of making an attempt is highest within the first year of experiencing suicidal ideation.

Suicide can be planned or result from impulsive behaviors. Methods of suicide vary in terms of degree of lethality with shooting or hanging associated with more completions.

Whether an individual expresses suicidal thoughts, makes an attempt, hurts oneself but does not die during the attempt, or dies from the attempt families and significant others are affected in many ways.   It creates heartache and heartbreak for those left behind who often struggle to try to understand why a loved one committed suicide.

There are several risk or vulnerability factors associated with a greater likelihood of suicidal behaviors (Brent, 2011; Goodwin & Jamison, 2007; Nock et al., 2014).  Both “promixal” (e.g., agitation, anxiety, current suicidal ideation with a plan, recent loss) and “distal” risk factors (personal or family suicidal history, poor response to treatment, abuse or trauma history) can interact to increase the risk of suicide. A major risk factor includes having a mood disorder, other mental disorders, and/or a substance use disorder. Instability caused by mixed mood states or rapid cycling of bipolar illness increase the risk as well. Deep feelings of hopelessness and demoralization often accompany mood disorders. Most suicide attempters and nearly all completers have at least one Axis 1 psychiatric disorder (mood, anxiety, psychotic, substance use, eating or other disorders).  

The risk increases for individuals with substance use disorders (SUDs), those who relapse, and those who have three or more psychiatric disorders (with or without SUDs).  The use of substances can lead to an impulsive decision or impair judgment, which can lead to a person feeling less inhibited to make a suicide attempt. Also, it is impossible to know how many drug overdoses or accidents ending in a death resulted from suicide.

Other risk factors are: 

• A prior history of suicidal behaviors as well as self-harm behaviors
• A family history of suicidal behavior or a mental disorder, or a completed suicide by a role model
• Stressful life events such as childhood abuse or parental divorce
• Recent losses (relationship, job, financial, health, or legal crisis)
• Traumatic experiences
• Chronic medical disorders (e.g., epilepsy, MS, dementia, chronic pain, cancer, sleep disorders)
• Current insomnia  

Availability of a gun in the home is another risk factor. However, keep in mind that not all risk factors will impact on a person at a specific given time. 

Although risk factors are widely known, it is difficult to know exactly why a specific person commits suicide. I suspect it is largely due to the personal suffering a person experience’s that is difficult to describe or understand by others who have never wanted to end their own lives. One of the most prolific authors on mood disorders and suicide is Dr. Jamison, who also happens to be in recovery from a mood disorder. Dr. Jamison suffered terribly in the past from her own suicidal desires. In her informative and thorough book Night Falls Fast: Understanding Suicide, Dr. Jamison provides a critical insight about suicide when she states the following:

This comment clearly conveys the personal suffering of the person who feels suicidal as well as others who experience the loss of a loved one through suicide. The personal agony, suicidal thoughts and actions are also expressed eloquently by many who share their personal stories of depression or mental illness (Cronkite, 1994; Styron, 1992).

Protective factors are factors that lower the risk of suicide. These include: 

• Being involved in effective treatment for a psychiatric illness, substance use disorder or medical illness
• Feeling a sense of connectedness to and support from family, friends or health care professionals
• Having a sense of purpose in life; coping skills to solve problems and resolve conflicts with others
• Cultural or religious beliefs that support the desire to live and discourage a person from making a suicide attempt 

Restricted access to lethal means such as firearms can also reduce suicide risk.

Joan Rivers, another well-known entertainer who recently died from medical complications, shared her personal story in the book written by Kathy Cronkite titled On the Edge of Darkness (1994), which tells the stories of depression and recovery of many celebrities. Ms. Rivers talked about feeling depressed and suicidal following the suicide of her husband and the loss of a network television show, both of which devastated her. As she looked at a gun and thought about whether to take her own life, her dog jumped on to her lap, making her think about what she was considering. Who would take care of the dog if she killed herself?  But more importantly, how could she expose her daughter to the suicide of both parents? Thinking about the love of her daughter and dog gave her the courage to continue living and dealing with her depression and other life problems.

Clearly, this serious health problem affects individuals, families, communities and society in numerous adverse ways. A range of reactions may be experienced from shock, anger, guilt, abandonment, and helplessness. Some may even feel embarrassed that a loved one committed suicide. Loved ones left behind may need help dealing with their grief reactions or other problems created when a loved one dies unexpectedly (e.g., caring for young children left behind when a parent commits suicide).

Following is a brief review of strategies to address suicidality in behavioral health treatment settings to help clients and families. Following this list are resources specific to the problem of suicide that may be of interest to clinicians, clients, families and concerned others.

• Assess and monitor clients for suicidal thoughts, desires, plans or history of attempts.  Continue to assess and monitor until a client is stable, during the first several months after hospital discharge, when there is a recurrence of psychiatric illness after a period of remission, if other substance use or new psychiatric problems show, or the client experiences major stresses, problems, losses or other risk factors.
• Insure that the client is receiving treatment for psychiatric disorders and/or substance use disorders. All individuals who are suicidal need help, regardless of their specific disorder(s). Treatment can help the client learn about the disorder(s), treatment and recovery, as well as strategies to cope with the challenges of recovery, including suicidal thoughts or plans. Having a therapeutic relationship with a therapist, physician or both can be a protective factor against suicide. Getting the right treatment is not always easy, but important. For example, effective treatment of bipolar or more severe depressive disorders with medications combined with therapy often lowers the risk of suicide significantly.  Having access to crisis intervention services may also help reduce suicidal behaviors.  In cases when a suicide attempt is likely, psychiatric hospitalization can be provided until the client is stable. Clients with both psychiatric and substance use disorders need help focusing on both disorders since each disorder can affect recovery from the other (Daley, 2003).
• Facilitate prompt entry into follow-up treatment before a client is discharged from a psychiatric hospital, medical detoxification or residential rehabilitation program. Care coordination is especially important to clients with both a psychiatric and substance use disorder, and those with a history of poor adherence to treatment. Peer mentors, patient navigators or case managers can help if their services are available to the client.
• Engage the family (or significant other), especially with adolescents. Other may help spot worsening of symptoms or suicidal risk factors. They can also be involved in devising a safety plan with the client and therapist or treatment team.
• Help develop and use a safety plan and coping strategies. This can involve having specific people or organizations to call or see immediately (therapist, peer in recovery, confidante, crisis center) if the client feels suicidal and worried about hurting oneself.  It also helps to have specific coping strategies to use (e.g., engaging in activities that are self-comforting, reviewing reasons for living, exercising, going somewhere safe, calling a crisis line, or even going to an emergency room). This may also involve removing or securing weapons in the home or locking up medications so the client only has access to a day’s dosage. For those with a substance use disorder, not using substance and not having access to alcohol or other drugs is important. Once substances are use, judgment is affected and the risk of acting on suicidal thoughts increases.
• Increase or use social support. Connections with family or friends, or involvement in mutual support programs that provide support can help a client through difficult times. The client should be encouraged to stay connected to others and share problems and struggles before these problems become too overwhelming. Or, if the client is worried about making an attempt, sharing this with a concerned other can help put the safety plan into effect.
• Help the client focus on reasons for living. Relationships with family including children and others, pets, and peers in recovery, and religious or spiritual beliefs are common reasons to go on living, but some clients may need a reminder when they feel overwhelmed with suicidal thoughts.
• Encourage client to maintain treatment and recovery activities. Regular and ongoing involvement can help the client catch problems and warning signs of illness early, learn ways to increase social support, and learn ways to manage specific symptoms, problems, or stresses.  
• Learn from past experiences. If a client has made a previous attempt, exploring the context can help teach about thoughts, feelings or behaviors that preceded the attempt. This also conveys the message that the client can learn to cope with suicidal thoughts or desires should they occur again.

Acknowledgements: Thanks to David Brent, MD, for sharing his ideas, experiences, and research in a discussion and in his educational materials.

• American Association of Suicidology: www.cuicidology.org/home 
• American Foundation for Suicide Prevention: www.afsp.org 
• National Suicide Prevention Lifeline: www.suicidepreventionlifeline.org; 1-800-273-8255
• Suicide Prevention Resource Center: www.sprc.org 

Brent, D. A. (2011). Suicide risk across the lifespan: Comprehensive assessment and clinical management. University of Pittsburgh Medical Center, Pittsburgh, PA.

Center for Disease Control (CDC). (2014). Injury prevention and control: Suicide prevention. Retrieved from http://www.cdc.gov/violenceprevention/suicide/

Cronkite, K. (1994). On the edge of darkness: Conversations about conquering depression. New York, NY: Delta.

Daley, D. C., & Moss, H. M. (2002). Dual disorders: Counseling clients with chemical dependency and mental illness (3rd ed.). Center City, MN: Hazelden.

Daley, D. C. (2003). Understanding suicide and addiction. Center City, MN: Hazelden.

Goodwin, F. K., & Jamison, K. R. (2007). Manic depressive illness: Bipolar disorders and recurrent depression. New York, NY: Oxford University Press.

Jamison, K. R. (1999). Night falls fast: Understanding suicide. New York, NY: Alfred A. Knopf.

Mann, J. J., & Currier, D. (2006). Understanding and preventing suicide. In D. J. Stein, D. J. Kupfer, & A. F. Schatzberg (Eds.), Textbook of mood disorders (pp. 485–96). Washington, DC: American Psychiatric.

Nock, M. K., Millner, A. J., Deming, C. A., & Glenn, C. R. (2014). Depression and suicide. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (3rd ed.) (pp. 448–68). New York, NY: Guilford Press. 

Styron, W. (1992). Darkness invisible: A memoir of madness. New York, NY: Random House

Substance Abuse and Mental Health Services Administration (SAMHSA). (2009). Addressing suicidal thoughts and behaviors in substance abuse treatment: A treatment improvement protocol TIP 50. Rockville, MD: Author.

World Health Organization (WHO). (2014). Health topics: Suicide. Retrieved from http://www.who.int/topics/suicide/en/