Public Health Suicide
by
Ronald W. Maris
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 25 February 2014
  • DOI: 10.1093/obo/9780199756797-0091

Introduction

Suicide is a major public health problem. In 2015 there were 44,193 suicides in the United States, a suicide rate of 13.8 per 100,000, which amounted to 1.6 percent of all deaths. Overall, suicide is the tenth-highest cause of death in the United States (second leading cause for those fifteen to twenty-four years old), higher than homicide rates and lower than accident rates. Suicide rates are especially high in the Mountain West. Suicide is a multidimensional, multifactorial outcome, and its treatment and prevention are complex and multifaceted. Suicide rates are much higher in the United States for white males than for any other age, gender, or racial group. This is particularly true for white males over age forty-five. Female suicides have some unique traits. Much of suicide prevention in the United States is focused on gun control, since over half of all suicides (men use guns more) use firearms to attempt suicide. Almost all (over 90 percent) suicides have a diagnosable mental disorder—mostly mood disorders (such as major depression and bipolar disorder) and concomitant anxiety disorder. Nevertheless, most people with mental disorder never commit suicide. Probably the second most important suicide risk factor is alcohol abuse. Although nonfatal suicide attempts are also a significant suicide risk factor, most male attempters die on their first suicide attempt. Much of the treatment of those with suicidal problems is pharmacological, especially by prescribing antidepressants, antipsychotics, and anxiolytics. The Food and Drug Administration (FDA) has had some serious concerns lately (including adding black-box warnings in the product descriptions) about antidepressants (and anti-epileptics) actually contributing to elevated (about two times higher) suicide rates in people up to age twenty-four. Medication management of would-be suicides is often coupled with psychotherapy. Since the early 20th century the US suicide rate has stayed about the same, vacillating around 12 per 100,000 people. There are some concerns whether or not a zero suicide rate is achievable or even desirable. Of course, the World Health Organization (World Health Organization 2016, cited under Reference Works) reminds us that suicide rates, gender ratios for suicide, methods of attempting suicide, cultural pre- and proscriptions for suicide, etc., all vary internationally. There are roughly one million suicides in the world each year, with especially high rates in the former Soviet Union, southern Africa, South Korea, India, and Cuba. For example, in the former Soviet Union, during perestroika from 1984 to 1990 there was a 32 percent decline in male suicide rates, presumably related to Gorbachev’s anti-alcohol campaign. In China and Asia (especially Japan and India), there are often higher female than male suicide rates, and hanging is often the preferred method. In Hong Kong, suicide by carbon monoxide poisoning via charcoal burning is common. Shame is an important Asian suicide risk factor. Asian suicides are often more altruistic (such as kamikaze suicides in World War II or hara-kiri suicides) or anomic (such as resulting from school and career expectations and competition). In Asian suicides there is more impulsivity and cultural expectations for suicide, rather than resulting from mental disorder or alcohol abuse. As of 2014, South Korea has the second-highest suicide rate in the world (28.9 per 100,000) due in part to economic development, anomie, and a financial meltdown. There is a high suicide rate among young adults (especially females) by using farm pesticides in rural India, China, and Sri Lanka; these suicides seem to be related to economic and social distress. Suicide intent is not elevated there, but behavior is more impulsive and the pesticide overdoses are more lethal than most other methods. Austria is an anomaly, in that it is a largely Catholic country with a high suicide rate; Austrian suicides often include elderly widows. The Germanic character includes rigid and dichotomous thinking, which may account for this elevated rate. While most Catholic countries have low suicide rates, Buenos Aires, Argentina, has an elevated rate, which seems to be related to rapid population growth, urbanization, and having many immigrants. Finally, there are many interesting cultural traditions related to suicide worldwide. For example, the Yuit Eskimos of St. Lawrence are a hunting and gathering society. If someone who is elderly, sick, or infirmed requests assisted suicide three times from his family, then the family is obligated to hang or shoot him. Never forget that although “suicide” is one word, it has many risk factors and cultural variations worldwide.

Introductory Works

Suicidal behavior and ideation are a “multidimensional malaise” (Shneidman 1985) best understood as problem solving in a needful individual with a life perceived (not always correctly) to have gone awry and to be no longer feasible or possible. Most suicide victims have longish “careers” (Maris 1981) in which they eventually acquire the ability to kill themselves (Joiner 2005). Note that one can have a suicidal career without multiple suicide attempts. Those who commit suicide tend to see themselves as a burden to others and have thwarted belongingness (Joiner 2005). Some have argued that suicide is a fundamental individual right and should be a free choice (Szasz 1999), and others contend that those contemplating suicide may deserve to be assisted both to commit (Humphry 2002) and to avoid suicide (Jamison 1999). Artists, poets, and writers have elevated suicide rates (Seinfelt 1999) related to their mood disorders and substance abuse (especially alcoholism). Treatment and prevention of suicide usually centers on psychopharmacology (Jamison 1999; also see Mann and Currier 2012, cited under Special Topics), psychotherapy (e.g., of hopelessness and other faulty cognitions; see the chapter by Aaron Beck and colleagues in Simon and Hales 2012, cited under Textbooks), and governmental strategies, policies, and procedures (Jamison 1999; also see Goldsmith, et al. 2002, cited under Prevention).

  • Humphry, D. 2002. Final exit: The practicalities of self-deliverance and assisted suicide for the dying. 3d ed. New York: Dell.

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    Derek Humphry helped his first wife commit suicide after she got cancer, as documented in Jean’s Way (New York: Quartet Books, 1978). He then moved to Los Angeles as a journalist and started the Hemlock Society, an advocacy group that helped get physician-assisted suicide made legal in Oregon and Washington (and later in Vermont and Montana). Final Exit discusses the practicalities of self-deliverance and was a New York Times bestseller in the “how to” genre. It is similar to Jack Kevorkian’s Prescription Medicide (Buffalo, NY: Prometheus, 1991).

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    • Jamison, K. R. 1999. Night falls fast: Understanding suicide. New York: Knopf.

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      In her incomparable literary style, Kay Jamison, herself bipolar and a suicide attempter at age twenty-eight, examines the cases of a young US Air Force cadet, a young woman who got herself mauled at the zoo by lions, and the grisly, prolonged suicide of young alcoholic explorer Meriwether Lewis. She claims that psychopathology, suicide methods chosen, and biology all shaped these three suicides, and that pharmacology (especially lithium) and public health initiatives might prevent such suicides.

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      • Joiner, T. 2005. Why people die by suicide. Cambridge, MA: Harvard Univ. Press.

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        A theory that argues that suicide requires the acquired ability to inflict lethal self-injury (compare Maris 1981), perceived burdensomeness, and thwarted belongingness. Arguments are founded in Thomas Joiner’s clinical experience and research and his review of the neurobiology of suicide outcomes. Reads almost like a novel.

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        • Maris, R. W. 1981. Pathways to suicide: A survey of self-destructive behaviors. Baltimore: Johns Hopkins Univ. Press.

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          In an ambitious epidemiological survey funded by the National Institute of Mental Health (NIMH), Ronald Maris went to Chicago and interviewed the survivors of a five-year sample of Cook County suicides and controls. His “suicidal careers” theory of the development of suicide was voted the fourth most impactful theory of suicide of all time (after Émile Durkheim’s, Edwin Shneidman’s, and Joiner’s; see p. 82 of “Tracking a Movement: U.S. Milestones in Suicide Prevention,” by S. Spencer-Thomas and D. R. Jahn, in Suicide and Life-Threatening Behavior 42.1 [2012]: 78–85). In addition to a cogent theory, the book is notable for its sophisticated statistical methods.

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          • Seinfelt, M. 1999. Final drafts: Suicides of world-famous authors. Amherst, NY: Prometheus.

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            Seinfelt reviews the lives and deaths of twenty-five famous authors (including Virginia Woolf, Ernest Hemingway, Sylvia Plath, Yukio Mishima, Jack London, et al.). Like Kay Jamison in Touched with Fire (New York: Free Press, 1993), Seinfelt argues that artists have elevated suicide rates (especially poets), high rates of mood disorder, and excessive substance abuse (especially of alcohol). Would treatment of psychiatrically disordered artists stymie their creativity? Artists are “gifted suicides” who often describe their suffering in exquisite prose with profound insight.

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            • Shneidman, E. 1985. Definition of suicide. New York: John Wiley.

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              In this seminal essay on the ten commonalities of suicide (solving a problem, ceasing consciousness, avoiding psychological pain, having frustrated psychological needs, feeling hopeless, being ambivalent about living, having constricted thoughts or “tunnel vision,” egressing from life (a la Herman Melville in Moby Dick), expressing the intention to die and giving clues to suicide, and having lifelong suicidogenic coping patterns), Shneidman sets the theoretical stage for the suicidal mind. Of course, suicides have differences as well.

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              • Shneidman, E. 2004. Autopsy of a suicidal mind. New York: Oxford Univ. Press.

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                The founder of American suicidology probes the self-destructive mind of a patient named Arthur, an MD-JD who committed suicide, through using idiographic data (such as Arthur’s suicide note), his pioneering “psychological autopsy” technique, and the insights of eight renowned suicide experts (Morton Silverman, Robert Litman, Jerome Motto, Norman Farberow, John Maltsberger, Maris, David Rudd, and Avery Weisman). Shneidman argues that the key to understanding individual suicide lies in the mind, not in the brain.

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                • Szasz, T. 1999. Fatal freedom: The ethics and politics of suicide. Westport, CT: Praeger.

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                  Thomas Szasz is a psychiatric iconoclast who contends that suicide is an inalienable constitutional right of the individual. Essentially he argues that our bodies and our minds are ours alone, to do with as we choose, as long as we do not harm others. If we have junk, then we may throw it away. Szasz says psychiatry ought to be housed in city hall, next to the police department. Mental illness is a myth, a religion most of us disapprove of.

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                  Textbooks

                  It is not surprising that there is a paucity of suicide textbooks, since suicide is not a separate academic discipline, a university-based department (e.g., of “suicidology”), or a degree program (such as those culminating in an MD or PhD). For the most part, suicide textbooks are supplemental to programs in clinical psychology, psychiatry, public health, and social work, and a few postdoctoral training programs in suicide assessment and prevention. This may change in the future (Pompili 2010, cited under Anthologies). One of the first true suicide textbooks was Maris, et al. 2000, in part as an outgrowth of the Johns Hopkins Medical School’s postdoctoral training certificate program in suicidology and similar training programs by the American Association of Suicidology and others. More recently the American Psychiatric Association has produced a textbook of suicide assessment and management (Simon and Hales 2012). Both Maris, et al. 2000 and Simon and Hales 2012 are focused on American suicidology, especially that growing out of the pioneering work of Edwin Shneidman at UCLA and the National Institute of Mental Health (NIMH). On the other hand, the publication of Hawton 2005 and Wasserman and Wasserman 2009 has expanded the pedagogical focus to the treatment and prevention of suicide internationally (Keith Hawton at Oxford and the Wassermans in Sweden). Suicide has been a long-time concern not just of the American Association of Suicidology and the American Foundation for Suicide Prevention, but also of the World Health Organization (see World Health Organization 2014, cited under Reference Works) and the International Association for Suicide Prevention (which publishes its own journal, Crisis). Nock 2014 is an erudite handbook by sixty distinguished authors of mainly US and Canadian researchers and clinicians.

                  • Hawton, K., ed. 2005. Prevention and treatment of suicidal behaviour: From science to practice. New York and Oxford: Oxford Univ. Press.

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                    Emphasizes the importance of research in designing and implementing effective suicide prevention strategies. Focuses on international suicide prevention and treatment issues. Hawton himself wrote five of its total twenty chapters, giving the text consistency and an integrated theoretical perspective. The book considers genetics, suicide methods, prison suicide, volunteers, and survivors, as well as the more traditional topics. There is an interesting chapter by Herman van Prag on why antidepressants have not reduced suicide rates.

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                    • Maris, R. W., A. L. Berman, and M. M. Silverman. 2000. Comprehensive textbook of suicidology. New York: Guilford.

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                      Twelve of the twenty-two chapters were written by the three primary authors. It has an integrated theoretical stance and a consistent methodological format for each chapter. Includes extensive references and both subject and author indexes. There is an unusually large section on demographic and epidemiological issues. There are rare sections on indirect self-destructive behaviors and the history of suicide, as well as a large section on medical and psychiatric topics. The text explains the concept of suicidology and its theoretical and empirical foundations.

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                      • Nock, M. K., ed. 2014. The Oxford handbook of suicide and self-injury. Oxford and New York: Oxford Univ. Press.

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                        Matthew Nock is a rising suicidologist, psychology professor, and director of the Harvard Laboratory for Clinical and Developmental Research. The handbook boasts sixty contributors who are among the best suicide clinicians and researchers in the United States and Canada. Organized into sections on classification, phenomenology and epidemiology, different approaches to understanding self-destructive behavior, assessment, prevention and intervention, and special topics (such as terrorism and physician-assisted suicide). Oxford Handbooks are less texts than handbooks of uncoordinated articles, empirical surveys of disparate secondary research topics. The editorial conclusion is too short and there are few international authors.

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                        • Simon, R. I., and R. E. Hales, eds. 2012. The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Washington, DC: American Psychiatric Publishing.

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                          The book is divided into risk assessment, mental disorders, treatment, treatment settings, special populations (young, old, jails, military, gender), and special topics (neurobiology, murder-suicide, the Internet, litigation, prevention, and the aftermath of suicide). There are noteworthy contributions by Stuart Yudofsky, M. David Rudd, Jan Fawcett, Ross Baldessarini and colleagues, Gregory Brown and colleagues, John Maltsberger and Joseph Stoklosa, Yeates Conwell and Marnin Heisel, Liza Gold J. John Mann and Dianne Currier (a superb chapter on neurobiology), David Lester, and Frank Campbell. One wishes for more socioeconomic and cultural topics and for an integrated overview and thesis.

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                          • Wasserman, D., and C. Wasserman, eds. 2009. Oxford textbook of suicidology and suicide prevention: A global perspective. New York: Oxford Univ. Press.

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                            This impressive volume is more of an encyclopedia than it is a textbook. It has fifteen sections and 134 chapters and is one of the most thorough and comprehensive suicide texts that exist, having by far the most comprehensive coverage of international suicide issues, topics, and data of any textbook. There is also an extensive consideration of health care and public health topics (twenty-nine chapters) and rare chapters on religion, culture, politics, and networking.

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                            Anthologies

                            An “anthology” is a compendium, collection, or combination of edited papers or essays focused on a central topic or subject; here, on various aspects of suicide. The selected topics include psychoanalytic essentials (Maltsberger and Goldblatt 1996), the problem of trying to assess or predict suicides and false positives (Maris, et al. 1992), how suicidologists get into and variously conceptualize the study and treatment of suicide (Pompili 2010), how suicide risk and treatment vary over the life cycle (Blumenthal and Kupfer 1990), how suicide and self-destructive behaviors differ by ethnicity and country (Schmidtke, et al. 2004), how race and gender affect suicidal behaviors (Bohannan 1960), and how cases of murder-suicide differ from suicides alone (Joiner 2014). Of course, the selected essays are idiosyncratic, and many other collections of papers on different topics could have been selected.

                            • Blumenthal, S. J., and D. J. Kupfer, eds. 1990. Suicide over the life cycle: Risk factors, assessment, and treatment of suicidal patients. Washington, DC: American Psychiatric Press.

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                              David Kupfer and Susan Blumenthal frame the study and prevention of suicide in developmental perspectives or life cycles (compare Maris 1981 and Joiner 2005, both cited under Introductory Works). They argue that suicide risk factors are different for males and females and for children, adolescents, young adults, or elderly. Suicide risk factors can be predisposing, immediate, protective (such as religion or gender), or precipitous (triggers). Individuals have many reasons and risks to commit suicide, and these vary over the life cycle. Twenty-seven chapters are divided into risk factors, assessment and management, special issues, and a synopsis, by a distinguished list of contributors.

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                              • Bohannan, P., ed. 1960. African homicide and suicide. Princeton, NJ: Princeton Univ. Press.

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                                Paul Bohannan wrote a much-needed anthology on another suicidologically neglected part of the world, Africa (compare World Health Organization 2014, cited under Reference Works). Andrew Henry and James Short Jr., in Suicide and Homicide: Some Economic, Sociological, and Psychological Aspects of Aggression (Glencoe, IL: Free Press, 1954), argued that homicide and suicide usually have a negative association: areas with high homicide rates tend to have low suicide rates. Bohannan found the opposite in Africa, with homicide and suicide tending to be positively related. Bohannan also discovered that homicide was universally justified in all of Africa in some circumstances. The Tiv of central Nigeria and the area of northern Ghana had low suicide rates; two-thirds of African suicides were by males, and most were accomplished by hanging.

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                                • Joiner, T. 2014. The perversion of virtue: Understanding murder-suicide. New York: Oxford Univ. Press.

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                                  How is murder followed by suicide different from suicide alone? Thomas Joiner presents a collection of murder-suicide cases, such as Virginia Tech (Seung-Hui Cho), Columbine High School (Eric Harris and Dylan Klebold), Ervin and Ana Lupoe (who killed their five children, then themselves), Jeffrey Dahmer’s suicide ideation, and many others. Joiner argues that suicide is the primary motive (not homicide) in murder-suicide. Most murder-suicides are either domestic violence (usually men killing women), the elderly (often the husband killing the wife), minors (e.g., parents committing pedicide), or mass murder-suicides (such as Jonestown).

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                                  • Maltsberger, J. T., and M. J. Goldblatt, eds. 1996. Essential papers on suicide. Essential Papers in Psychoanalysis. New York: New York Univ. Press.

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                                    This readable collection focuses almost exclusively on the immediate subjective experiences of actual suicidal individuals. Many other suicide papers are “clinically remote” (such as in psychopharmacology, anthropology, sociology, and economics) and are not “essential.” There are a total of forty papers arranged chronologically. Especially interesting are papers by Robert Litman on Sigmund Freud and suicide and by Edwin Shneidman on “psychache.” There are many classical papers here. John Maltsberger has remarkable insight and intuition regarding suicide.

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                                    • Maris, R. W., A. L. Berman, J. T. Maltsberger, and R. I. Yufit, eds. 1992. Assessment and prediction of suicide. New York: Guilford.

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                                      Assessment focuses on clinical risk factors for suicide, while prediction means “to foretell.” Suicide prediction leads to false positives and high error rates. The best we can hope for is prediction of group risks over longish time periods. Early prediction studies were done by Alex Pokorny, Aaron Beck, Harvey Resnik, and Dan Lettieri. The book is unique in its focus on theories and methods and in that each contributor comments on five common cases and tries to predict their suicide outcome. The book has thirty-two chapters, with a foreword by John Mann and a review by Avery Weisman. Ronald Maris states the empirical basis for his fifteen suicide risk factors.

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                                      • Pompili, M., ed. 2010. Suicide in the words of suicidologists. Psychiatry—Theory, Applications, and Treatments. Hauppauge, NY: Nova Science.

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                                        This is a fascinating first-person account by fifty-four internationally known suicidologists who discuss how and why they got into the study and prevention of suicide, via anecdotes, serendipitous events, pure accidents, and their various academic and therapeutic pathways. Suicide is explored from the personal experiences and histories of people actually involved in suicide research and treatment. The early chapters provide poignant details of the last days of one of suicidology’s founders, Shneidman (for example, by his home nurse), and his visions for the future of suicidology.

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                                        • Schmidtke, A., U. Bille-Brahe, D. De Leo, and A. Kerkhof, eds. 2004. Suicidal behaviour in Europe: Results from the WHO/EURO multicentre study of suicidal behaviour. Cambridge, MA: Hogrefe & Huber.

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                                          Schmidtke and colleagues remind us that suicide is a problem in many countries, but that there are important differences among various countries. This in turn results in a need for different strategies for understanding and preventing suicide. The book reports the results on suicidal behaviors for the WHO/EURO multicultural study. Participating countries and chapters include Austria, Belgium, Denmark, England, Estonia, Finland, France, Germany, Hungary, Ireland, Latvia, Lithuania, the Netherlands, Norway, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, Wales, and Yugoslavia. Descriptions of the study itself are also given.

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                                          Reference Works

                                          One may refer or allude to, cite, quote, mention, or recommend almost anything, Here, our references are to suicide citations, bibliographies, dictionaries, Internet addresses and sites, movies, data, and basic suicide information from organizations. In this section we reference organizations and societies that provide us with basic data and information about suicides and their management (World Health Organization 2016, World Health Organization 2014, National Suicide Statistics, American Association of Suicidology). Recupero 2012 cites Internet addresses and sites about suicide prevention and promotion. Stack and Bowman 2012 refers to 1,512 films about suicide, made from 1900 to 2009. Lester 1990–2011 offers us about two thousand biographies of famous suicide victims and of a few suicide attempters. Finally, suicide data need to be framed in the context of all death rates from all causes (Xu, et al. 2016).

                                          • American Association of Suicidology.

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                                            The American Association of Suicidology provides basic reference information on American suicide statistics by each state, survivor groups, annual suicide update conferences, a scientific journal, an online newsletter, suicide prevention training programs, a membership directory, and much more. In 2011 there were 38,285 total US suicides, for a rate of 12 per 100,000 people. Suicide equaled 1.6 percent of all deaths each year and had an especially high rate for white males, with suicides by firearm making up about 50 percent of all suicide methods (more for men). Suicide is the tenth-highest cause of death in general and the third-highest cause for people fifteen to twenty-four years old.

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                                            • Lester, D. 1990–2011. Bibliographic Studies.

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                                              In 1989 David Lester started circulating his brief biographies of famous suicide victims, published in the Proceedings of the Pavese Society. They constitute roughly 180 individual suicides (biographies written between 1990 and 2011) and about a half-dozen categorical suicides (such as those of artists, baseball players, musicians, scientists, operas, and writers). These biographies provide details about the lives both of well-known celebrities and obscure outliers and include people such as Bruno Bettelheim, Percy Bridgman, Kurt Cobain, George Eastman, James Forrestal, Sigmund Freud, Judy Garland, William Inge, Kay Jamison, Alan Ladd, Primo Levy, Marilyn Monroe, Elvis Presley, Anne Sexton, Socrates, and Vincent van Gogh.

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                                              • National Suicide Statistics. Centers for Disease Control and Prevention.

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                                                The Centers for Disease Control and Prevention (CDC) website provides various facts and figures about US suicides, including a map of suicide rates for all fifty states (rates are highest in the Mountain West and Alaska). Other related CDC web pages on suicide include those on understanding suicide, preventing suicide, suicide warning signs, national strategy for suicide prevention, antidepressant use and the risk for suicide, and suicide risk and protective factors, as well as a weekly report on morbidity and mortality.

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                                                • Recupero, P. R. 2012. Suicide and the Internet. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 515–539. Washington, DC: American Psychiatric Publishing.

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                                                  The Internet facilitates both suicide prevention and “cybersuicide” (pro-suicide) information. Suicide is correlated with Internet use; the more use, the higher the suicide rate among users. For example, in 2003, Internet users witnessed and baited or encouraged a twenty-one-year-old man to commit suicide, Anyone can google “how to commit suicide.” In fact, there is a combined software/hardware product through which you can kill yourself by pushing “Delete.” Lethal means can be acquired to commit suicide on the Internet, and the Internet can encourage copycat suicides. Of course, the Internet can also provide suicide prevention tools, too, such as the 1-800-Suicide prevention number, treatment chat rooms, access to United Way, and other suicide prevention addresses.

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                                                  • Stack, S., and B. Bowman. 2012. Suicide movies: Social patterns, 1900–2009. Cambridge, MA: Hogrefe.

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                                                    Steven Stack and Barbara Bowman watched and analyzed 1,377 American films and 135 British suicide films made from 1900 to 2009. Movies tend to depict suicide as interpersonally and socially driven, not especially as the result of psychiatric disorders. Many classical movies are presented (along with film clips), such as The Wrestler (2008), Mickey Rourke’s character; Shawshank Redemption (1994), Morgan Freeman’s character; The Hours (2002), Nicole Kidman as Virginia Woolf (who is hinted at on the book’s cover); The Sixth Sense (1999), Bruce Willis’s character; Styron’s Sophie’s Choice (1982), Meryl Streep’s and Kevin Kline’s characters; and many more.

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                                                    • World Health Organization. 2014. Age-standardized suicide rates (per 100 000 population), both sexes, 2012. Geneva, Switzerland: WHO.

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                                                      WHO published a color map of worldwide suicide rates as of 2012, estimating that there are 850,000 to 1 million suicides each year worldwide. If a “high” suicide rate is 15–16 per 100,000, then the former Soviet Union, India, South-Central Africa, and Guyana have some of the highest suicide rates. “Moderate” suicide rates (11–12 per 100,000) are found in the United States, Cuba, Germany, Sweden, Norway, the United Kingdom, and Canada. Finally, the “lowest” rates (4 or less per 100,000) are in Mexico, the Philippines, the Bahamas, Pakistan, Egypt, Syria, and Saudi Arabia.

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                                                      • World Health Organization. 2016. Suicide rates: Data by countries. Geneva, Switzerland: WHO.

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                                                        WHO ranks 170 country’s suicide rates (per 100,000) in 2015. The top suicide rate countries are (1) Guyana (44.2), (2) South Korea (28.9), (3) Sri Lanka (28.8), (4) Lithuania (28.2), (5) Suriname (27.8), (6) Mozambique (27.4), (7, tie) Tanzania (24.9), (7, tie) Nepal (24.9), and (9) Kazakhstan (23.8). The lowest suicide rate countries are (162) Libya (1.8), (163, tie) Egypt 1.7), (163, tie) Iraq (1.7), (166) Jamaica (1.2), (170, tie) Syria (0.4), (170, tie) Saudi Arabia (0.4). In high-rate countries, male rates exceed female rates by three or four times. In China, female rates exceed those of males.

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                                                        • Xu, J., S. L. Murphy, K. D. Kochanek, and B. A. Bastian. 16 February 2016. Deaths: Final data for 2013. National Vital Statistics Reports 64.2. Washington, DC: US Government Printing Office.

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                                                          In 2015 there were 44,193 suicides in the United States, a rate of 13.8 per 100,000. Suicide in the United States is the tenth-highest cause of death (second highest for those ages fourteen to twenty-five). The top-five causes of death are heart disease (the rate is 197.2), cancer (185.4), respiratory disease (48.2), accidents (45.6), and stroke (43.7). Homicide is the sixteenth-highest cause of death (5.5). About 50 percent of all suicides are by firearms, and the ratio of male to female suicide rate is 3.4.

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                                                          Journals

                                                          Many of the best articles on suicide can be found in the leading disciplinary journals (such as the Archives of General Psychiatry, JAMA, The Lancet, and the New England Journal of Medicine). Probably the two main journals specializing in suicide are Suicide and Life-Threatening Behavior (founded by Edwin Shneidman) and Archives of Suicide Research. Crisis: The Journal of Crisis Intervention and Suicide Prevention centers on more-acute intervention topics, whereas Death Studies and Omega: Journal of Death and Dying include articles not just on suicide, but also thanatology, bereavement, and grief counseling. Finally, Suicidology Online offers a modern Internet journal option with a broad range of suicide topics.

                                                          History

                                                          Although human civilization evolved over 200,000 years ago, the first historical mention of suicide is evident only in about the 1st century BCE. Some of the earliest graphic depictions of suicide (in Roman Antiquity) were for defeat in battle (Ajax, 560 BCE; see van Hooff 2000) or for revenge (Samson in the Old Testament), using methods of piercing, stabbing, or hanging, which were almost always fatal. Early on, Christian Rome did not consider suicide to be a violation of the sixth commandment, “thou shalt not kill,” but later on, by about the 6th century CE, and certainly by the Middle Ages, suicide was seen as a mortal sin and an offense against God (hubris). However, in several classical paintings, suicide was also portrayed (see The Suicide of Lucretia, by Joos van Cleve [1515], and Dido, by Peter Paul Rubens [1640]) as a solution to being dishonored (Anderson 1987). By 1776 philosopher David Hume wrote a treatise defending suicide as rational. Many poets, artists, and writers throughout history (Jamison 1993, Alvarez 1990) had elevated suicide rates and partial self-destruction (Menninger 1938) related to their mood disorder and substance abuse. In France in the 19th century, Émile Durkheim (Durkheim 1997, first published in 1897) conceived of suicide as socially engendered, including such social issues as escape, revenge, duty (altruism), and risk taking (Menninger 1938). In the United States by c. 1958 (in Los Angeles), the scientific study of suicide (suicidology) and its prevention was initiated by two psychologists, Edwin Shneidman and Norman Farberow (Leenaars 1993). They spoke of suicidal behavior as a “cry for help,” particularly among youngish female suicide attempters (Robert Litman, Shneidman, and Farberow did the psychological autopsy on actress Marilyn Monroe). Today, as in Roman Antiquity, most male suicides use highly lethal methods, which they attempt only once before succeeding. The history of suicide (van Hooff 2000) is framed by considering selected self-destructive behaviors from precivilization (c. 45,000 BCE) to modern times.

                                                          • Alvarez, A. 1990. The savage god: A study of suicide. New York: Norton.

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                                                            Alfred Alvarez worked as a freelance writer in London and wrote another well-known book, on poker in Las Vegas. Alvarez starts and ends his book with chapters describing his affair with Sylvia Plath in London just before she gassed herself. He feels like he let her down. This is a chronicle of suicide in literature (Dante, John Donne, William Cowper, Thomas Chatterton, and Johann Wolfgang von Goethe). Alvarez himself was a failed suicide; he thought attempting suicide would give him great insight into why people commit suicide, but all he got from it was a big zero, zilch. First published in 1971 (London: Weidenfeld & Nicolson).

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                                                            • Anderson, O. 1987. Suicide in Victorian and Edwardian England. New York: Oxford Univ. Press.

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                                                              A historical account of suicide in England and Wales from 1861 to 1893, utilizing coroner’s records to calculate suicide rates by gender, age, and occupation. The book has four parts: suicide rates, individual experiences, social attitudes, and prevention (“restraints”). Olive Anderson comments that the approved Victorian way out of dishonor (especially for sexual abuse of females) was suicide. See The Suicide of Lucretia, a painting by van Cleve, for an earlier historical example.

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                                                              • Durkheim, É. 1997. Suicide: A study in sociology. Edited by G. Simpson. Translated by J. A. Spaulding. New York: Free Press.

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                                                                Originally published as Le suicide: Étude de sociologie (Paris: F. Alcan, 1897). One of the first European empirical studies of suicide, on the basis of death records. As a social philosopher in France, Durkheim claimed that suicide rates were social constructs and, as such, could not be explained by individual states or traits (such as psychiatric disorder or alcoholism). His major conclusion was that the suicide rate varied negatively with social integration. The more externally constraining a social fact or situation was, the lower its suicide rate would be. Durkheim was famous for his typology of anomic, altruistic, egoistic, and fatalistic suicides.

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                                                                • Jamison, K. R. 1993. Touched with fire: Manic-depressive illness and the artistic temperament. New York: Free Press.

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                                                                  Kay Jamison discusses manic-depressive disorder, artistic temperament, and suicide in literature. Her book is founded in empirical data and facts (such as genealogical pedigrees of Vincent van Gogh, Virginia Woolf, Ernest Hemingway, and Robert Schumann; the mood disorders of British and Irish poets such as Chatterton, William Wordsworth, Samuel Coleridge, Percy Bysshe Shelley, John Keats, and Lord Byron; and the suicide rates of poets, writers, and artists) to support her theory of suicide. The book asks if treatment of mental disorder stifles or even destroys art.

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                                                                  • Leenaars, A. A., ed. 1993. Suicidology: Essays in honor of Edwin S. Shneidman. Northvale, NJ: Aronson.

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                                                                    Antoon Leenaars’s book concerns the evolution of American suicidology. The American Association of Suicidology was founded by Shneidman and Farberow in 1958 in Los Angeles (it later moved to Washington, DC). Shneidman funded a postdoctoral program in suicidology at Johns Hopkins University in 1967. In 1991 the Washington School of Psychology offered a certificate in suicidology. Early suicide research and training programs were offered at Harvard and in Calgary, Chicago, Los Angeles, New York City, Philadelphia, Pittsburgh, San Francisco, St. Louis, and Washington, DC. Psychiatrist Jerome Motto also looks back at the early years of American suicidology.

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                                                                    • Menninger, K. A. 1938. Man against himself. New York: Harcourt, Brace.

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                                                                      Karl Menninger discusses the psychodynamics of self-destructive behaviors short of suicide (sometimes called “indirect self-destructive behavior”), such as asceticism, alcoholism, antisocial personality, self-mutilation, polysurgery, accident proneness, and sexual impotence. Several celebrities were treated at Menninger’s (such as Brett Favre, Judy Garland, Marilyn Monroe, and Dorothy Dandridge). Menninger says that all suicide consists of the wish to kill, the wish to die (hopelessness), and the wish to be killed (guilt).

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                                                                      • van Hooff, A. J. L. 2000. A historical perspective on suicide. In Comprehensive textbook of suicidology. Edited by R. W. Maris, A. L. Berman, and M. M. Silverman, 96–126. New York: Guilford.

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                                                                        The first graphic portrayal of suicide was probably on a vase depicting Ajax falling on his sword after defeat in battle (540 BCE). Most early suicides were violent and unequivocal, using methods of cutting, piercing, or hanging. Samson was motivated to suicide by revenge, and Judas hanged himself after he betrayed Jesus. Suicides in the Bible itself were not condemned. By the Middle Ages, philosopher-theologians saw suicide as a mortal sin. In the 16th and 17th centuries (see Thomas More’s Utopia), suicide was seen as appropriate in some conditions, and in the 18th century, David Hume wrote a treatise defending suicide. In the 19th century, Durkheim wrote a classic book on the social causes of suicide.

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                                                                        Risk Assessment

                                                                        Suicide risk is very challenging to estimate. For one thing, suicides are rare outcomes, and predicting them usually results in false positives (Simon 2012). For another, risk assessment must be empirical and multifactorial and multitypical, such as personal, exterior, and mental-state risk factors (Maltsberger 1986). A lot of times we falsely consider a factor to be a risk for suicide, when it is really a “myth,” not a risk factor (Joiner 2010). Lists of common suicide risk factors (Jacobs 1999) need to be developed and refined for different individuals, situations, and times. Statistical methods for estimating relative suicide risk (especially for groups over longer time frames) are very different from estimating individual suicide risk in a clinical or interview situation (Rudd 2012, Maltsberger 1986). Suicide risk varies across nations, societies, cultures, and particular circumstances (Wendler, et al. 2012). Finally, one must do a risk-benefit analysis when prescribing psychiatric medications (Maris 2015, Healy 2012). Paradoxically, medications designed to help reduce or prevent suicide risk may actually increase the risk. For example, the Food and Drug Administration (FDA) has issued a black-box warning for antidepressants doubling the suicidality risk of young people up to age twenty-four.

                                                                        • Healy, D. 2012. Pharmageddon. Berkeley: Univ. of California Press.

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                                                                          David Healy, a long-time critic of the psychiatric drug industry, argues that drugs are as likely to harm as to help us, including contributing to suicide. Drug companies tend to be guided by profit and market considerations, often compromising scientific standards to obscure and minimize the treatment and suicide risks of their products. Experts (“hired guns”) are paid to promote new psychiatric drugs as well as downplay their risks; these well-known physicians are often hired as “ghost writers” for scientific articles actually written by the drug companies themselves. Concludes that medicine and psychopharmacology are at death’s door.

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                                                                          • Jacobs, D. G., ed. 1999. The Harvard Medical School guide to suicide assessment and intervention. San Francisco: Jossey-Bass.

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                                                                            An early risk assessment guideline by Douglas Jacobs and his colleagues. Later, Jacobs chaired formulation of the American Psychiatric Association’s suicide risk guidelines for clinical assessment. The book is divided into (1) assessment (chapters by Eve Mościcki, John Maltsberger, Edwin Shneidman, J. John Mann, Jan Fawcett, Marsha Linehan, Armando Favazza, Leston Havens, Jerome Motto, et al.), (2) intervention (Kay Jamison, David Clark, Ross Baldessarini, et al.), and (3) special issues (such as children, adolescent, the elderly, primary care, assisted suicide, liability).

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                                                                            • Joiner, T. 2010. Myths about suicide. Cambridge, MA: Harvard Univ. Press.

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                                                                              Thomas Joiner considers “myths” about suicide. For example, (1) mind: suicide is not cowardly, whimsical, selfish, unplanned, or readily apparent; (2) behavior: suicide victims do not routinely leave notes, most death scenes are not ambiguous, suicide is not all that contagious, suicide is not just a “cry for help” and is not always irrational; (3) cause: animals cannot commit suicide but young children can, you should not lie to the young about suicide, suicide does not peak at Christmas time. Joiner implies that by not realizing that the above are suicide myths, we in effect misestimate suicide risk.

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                                                                              • Maltsberger, J. T. 1986. Suicide risk: The formulation of clinical judgment. New York: New York Univ. Press.

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                                                                                Maltsberger emphasizes that the relationship of the therapist with the patient is crucial in suicide outcomes and that one should not rely only on “impersonal strategies” such as psychopharmacology, suicide watches, and restraints. He considers personal, exterior, and mental-state suicide risk factors. He points out unique psychoanalytic suicidal mental phenomena such as mental pain, self-hate, rage and homicidal fury, profound aloneness, fatigue and exhaustion, worthlessness, and hopelessness (such as having no good enough or even possible future).

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                                                                                • Maris, R. W. 2015. Pillaged: Psychiatric medications and suicide risk. Columbia: Univ. of South Carolina Press.

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                                                                                  The FDA has issued suicidality risk warnings for (1) antidepressants (selective serotonin reuptake inhibitors [SSRIs] and serotonin-norepinephrine reuptake inhibitors [SNRIs] in 2004 and 2006), (2) mood stabilizers (such as gabapentin/Neurontin in 2008), (3) hypnotics (such as Ambien, Sonata, and Lunesta in 2006), and (4) benzodiazepines (such as Valium and Xanax in 2001). Ronald Maris also examines the suicide risk of alcohol, opiates and narcotics, cocaine, methamphetamines, attention-deficit/hyperactivity disorder (ADHD) medications such as Adderall, and hallucinogens. The book evaluates suicide risks for antidepressants, antipsychotics, anxiolytics, mood stabilizers, and residual drugs (including street drugs).

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                                                                                  • Rudd, M. D. 2012. The clinical risk assessment interview. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 57–74. Washington, DC: American Psychiatric Publishing.

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                                                                                    The focus is on specific practical guidelines for the structured clinical interview of specific potentially suicidal individuals. Targeted domains (rated 1 to 10) include a hierarchical approach to suicidal thinking (e.g., reasons for living), markers of intent, past suicide attempts, and related risk factors (such as predisposing and precipitating factors, impulsivity, morbid ruminations, protective factors, hopelessness, and symptoms of mental disorder).

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                                                                                    • Simon, R. I. 2012. Suicide risk assessment: Gateway to treatment and management. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 3–28. Washington, DC: American Psychiatric Publishing.

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                                                                                      Robert Simon originally (1st ed., 2006) called this piece “Suicide: Assessing the Unpredictable.” He stresses how difficult it is to predict rare false-positive outcomes, such as suicide. By far, most suicidal individuals (such as the depressed) will never commit suicide. Simon lists multiple, diverse factors that are related to suicide outcomes. He says that one should not just accept the patient’s denial of suicide intent (but, rather, one should probe). He considers various special populations at risk for suicide and concludes with consideration of risk assessment methodology.

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                                                                                      • Wendler, S., D. Matthews, and P. T. Morelli. 2012. Cultural competence in suicide risk assessment. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 75–88. Washington, DC: American Psychiatric Publishing.

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                                                                                        This book explores the meaning and risk of suicide from the particular patient’s cultural point of view. Suicide risk varies across cultures, and there are considerable international differences in suicide risk, such as the high suicide rates of older males in most of the world, but higher suicide rates for younger females in China and India. Eastern religions do not vigorously condemn suicide. Suicide can be appropriate in some cultures (including altruistic suicide, jihad, kamikaze pilots, suttee, etc.). American Indian suicides vary among tribes; Apaches have high suicide rates, but the Navajo and Pueblo have low rates.

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                                                                                        Prevention

                                                                                        Prevention of suicide can be primary (reduce new cases), secondary (reduce prevalence of total cases), or tertiary (reduce disability and suffering in advanced suicidal careers); see Gerald Caplan’s Principles of Preventive Psychiatry [New York: Basic Books, 1964] and Maris, et al. 2000, p. 530, the latter cited under Textbooks). There is no suicide vaccine, and the US suicide rate has remained relatively constant since the early 20th century (namely, about 12 per 100,000 people). The optimum suicide rate is probably not zero and could not be realized if it were. Nevertheless, we can reduce self-destruction, compromised life quality, and premature death from suicide by (1) restricting lethal means to suicide (Lester 2012; Goldsmith, et al. 2002; Mann, et al. 2005; US Department of Health and Human Services 2012), (2) better diagnosis and treatment (especially with psychiatric medications) of mood disorders (O’Connor, et al. 2011; Mann, et al. 2005; Silverman and Maris 1995; US Department of Health and Human Services 2012), (3) better training and tools for suicide screening by primary-care physicians (Goldsmith, et al. 2002; Mann, et al. 2005), (4) targeting nontreated populations (O’Connor, et al. 2011; Silverman and Maris 1995), (5) developing national suicide prevention strategies and programs (US Department of Health and Human Services 2012, Silverman and Maris 1995), (6) improving suicide prediction (especially identifying who is at high risk for suicide; O’Connor, et al. 2011; Silverman and Maris 1995), and (7) reducing violence and impulsivity in societies (US Department of Health and Human Services 2012). Notice that personal intervention of individuals predisposed to commit suicide, through undergoing psychotherapy, is not prominent on any of the referenced lists.

                                                                                        • Goldsmith, S. K., T. C. Pellmar, A. M. Kleinman, and W. E. Bunney, eds. 2002. Reducing suicide: A national imperative. Washington, DC: National Academies Press.

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                                                                                          The Institute of Medicine (IOM) of the National Academies undertook a study on how to reduce suicide. Suicide is complex, not one thing; thus, prevention and treatment are multifactorial, subtle, and often need to be individualized. The IOM prevention recommendations are (1) to do interdisciplinary research, (2) to have national suicide monitoring, (3) to develop prevention tools for primary-care providers, and (4) to test suicide prevention programs. Specific recommendations include restricting access to lethal means (such as pill blister packs and guns) and increasing psychiatric medication treatment of high-risk individuals. One caveat: we can reduce depression and not reduce suicide.

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                                                                                          • Lester, D. 2012. Suicide prevention by lethal means restrictions. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 581–592. Washington, DC: American Psychiatric Publishing.

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                                                                                            One of the more recent suicide prevention strategies is to restrict lethal means. David Lester cites detoxifying coal gas in Great Britain, installing jumping restraints on bridges (such as at Cornell University or the Golden Gate Bridge) and high places, controlling carbon monoxide emission from cars and eliminating flattened tail exhaust pipes, securing high buildings and dangerous sites, controlling drug prescriptions, limiting pesticides in China and elsewhere (such as India), and not publicizing copycat methods. One should always ask about the individual’s preferred suicide method and if it is readily available. It remains unclear what proportion of people would switch to other more available methods. Means restriction is never sufficient by itself to prevent suicide.

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                                                                                            • Mann, J. J., A. Apter, J. Bertolote, et al. 2005. Suicide prevention strategies: A systematic review. Journal of the American Medical Association 294.16: 2064–2074.

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                                                                                              J. John Mann and colleagues review meta-analytical, quantitative, and population-based studies and produce a narrative synthesis. Key prevention recommendations are improved screening of depressed patients by primary-care physicians and better treatment of major depression by such physicians. Educating physicians and restricting access to lethal suicide means were found to prevent suicide. Suicide has multiple causes divided into predisposing and proximal stressors or “triggers.” Psychiatric illness is a major contributing factor to suicide. Other suicide factors include availability of lethal means, alcohol and drug abuse, access to psychiatric treatment, attitudes toward suicide and help-seeking behavior, physical illness, marital status, age, and sex.

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                                                                                              • O’Connor, R. C., S. Platt, and J. Gordon, eds. 2011. International handbook of suicide prevention: Research, policy and practice. Malden, MA: Wiley-Blackwell.

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                                                                                                This is a handbook written by eighty international scholars (thirty-six chapters) and three editors from Scotland (in the tradition of Norman Kreitman). In Part III they summarize the achievements in suicidology since the mid-1980s and then state the suicide prevention challenges for the next twenty-five years, including standardizing suicide risk assessment, improving suicide prediction, developing evidence-based treatment practices, helping people who do not seek treatment, developing more-effective ER interventions, improving understandings of medications and suicide, and distinguishing iatrogenic medication effects from events associated with the illness itself.

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                                                                                                • Silverman, M. M., and R. W. Maris, eds. 1995. Suicide prevention: Toward the year 2000. New York: Guilford.

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                                                                                                  Sixteen chapters and five parts (risk factors, theory and models, settings, population ages, and special topics) on future suicide prevention strategies. Specific prevention recommendations include developing a more unified diagnostic and classification system, targeting high-risk groups for intervention and prevention, clarifying if we are trying to prevent nonfatal suicide attempts or completed suicides, developing better treatment of psychiatric disorders, reporting suicidal events better, proposing national legislation, restricting lethal means, developing educational programs, and distinguished predisposing from precipitating risk factors.

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                                                                                                  • US Department of Health and Human Services. 2012. 2012 national strategy for suicide prevention: Goals and objectives for action. Washington, DC: US Department of Health and Human Services.

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                                                                                                    Effort by the US Surgeon General’s office, private-sector prevention (Jerry Reed, director of the Suicide Prevention Resource Center), and task force members to develop a national strategy in the United States to prevent suicide. From 1950 to 2009, suicide rates in the United States have been essentially unchanged. Among the specific risk and protective-factor recommendations are reducing the availability of lethal means, managing unsafe media portrayals of suicide, providing better access to providers and medications, reducing violent relationships, managing individual mental illness, and reducing substance abuse, suicide attempts, and impulsivity/aggression. US suicide continues to be a problem especially for older white males. Suicide prevention requires universal, selective, and indicated or individual strategies.

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                                                                                                    Treatment

                                                                                                    Today, most suicidal patients are treated initially (if not exclusively) with antidepressants and anxiolytics (and perhaps with lithium, Lamictal/lamotrigine, another mood stabilizer such as Latdua/lurisadone, or a benzodiazepine; Fawcett 2012, Black and Andreasen 2011) under the rubric of “medication management.” Sadly, most psychiatrists no longer even do psychotherapy themselves (see Daniel J. Carlat’s Unhinged: The Trouble with Psychiatry—a Doctor’s Revelations about a Profession in Crisis, New York: Free Press, 2010). This immediately raises problems of coordination of a patient’s “treatment team” (Maltsberger and Stoklosa 2012). Most suicide treatment is simply titrating the patient’s neurotransmitters and neurosystems (such as serotonin, norepinephrine, dopamine, gamma-aminobutyric acid [GABA], etc.). Of course, treatment often includes concomitant (“split”) treatment of the suicidal patient by a psychotherapist (usually a psychologist, social worker, or counselor). The most-common psychotherapies for suicidal patients include cognitive behavioral therapy (Jobes 2016; Rudd, et al. 2001) and dialectical behavioral therapy (Linehan 1993). Shneidman 1993 insists that, in essence, suicidal behavior is problem solving; an inappropriate effort to resolve psychic pain or “psychache” by abandoning life itself. All suicide psychotherapies are designed to help patients find reasons, the will, and the resources and ability to keep living. This may involve transference dependency (Maltsberger and Stoklosa 2012) both on therapists and psychiatric medications, at least until the patient is better. Treating chemical imbalances has led to an epidemic of psychiatric disorders and medications (Whitaker 2010).

                                                                                                    • Black, D. W., and N. C. Andreasen. 2011. Introductory textbook of psychiatry. 5th ed. Washington, DC: American Psychiatric Publishing.

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                                                                                                      Chapters 6 (“Mood Disorders,” pp. 141–168) and 20 (“Psychopharmacology and Electroconvulsive Therapy,” pp. 501–552) are especially relevant. Suicide is highly associated with mental disorder; thus, psychiatrists routinely treat suicidal patients with psychopharmacology. Suicide tends to be seen as a disease of the brain (dysfunctions) and not of the mind. After an extended initial assessment and evaluation, most psychiatrists start suicidal patients on a trial of a selective serotonin reuptake inhibitor (SSRI) antidepressant or a selective norepinephrine reuptake inhibitor (SNRI) antidepressant coupled with an anxiolytic, a major tranquilizer, or both. The neurobiology of suicide (Mann and Currier 2012, cited under Special Topics) assumes that most suicidal patients need their serotonin, norepinephrine, dopamine, GABA, or other medication titrated. If suicide risk is acute or depression is refractory, then electroconvulsive therapy treatments may be initiated.

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                                                                                                      • Fawcett, J. 2012. Depressive disorders. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 109–122. Washington, DC: American Psychiatric Publishing.

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                                                                                                        Jan Fawcett addresses how to assess suicide risk and to manage mood disorders, with an emphasis on controlling anxiety. He cites research that found severe anxiety, global insomnia, severe panic, and recent onset of alcohol abuse were all associated with acute suicidality. He claims that a majority of suicide attempts occur within five minutes of making the decision to commit suicide. Fawcett urges treatment of anxious/depressed suicidal patients with benzodiazepines, second-generation antipsychotics, and lithium, in addition to SSRI and SNRI antidepressants.

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                                                                                                        • Jobes, D. A. 2016. Managing suicidal risk: A collaborative approach. 2d ed. New York: Guilford.

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                                                                                                          This is a well-written, readable, pragmatic clinical guide by a competent and compassionate psychologist. The book is a clinical manual for collaboratively managing suicidal outpatients. In part on the basis of Edwin Shneidman’s “psychache” concepts and Aaron Beck’s cognitive behavioral therapy (CBT), David Jobes provides step-by-step instructions in nine chapters over three difference phases: (1) evaluating suicide status, early identification, risk assessment, and treatment planning, (2) status tracking, and (3) outcomes. Jobes believes that most patients do not want to die but instead want to find a viable alternative to suicide that will manage their extreme psychic pain.

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                                                                                                          • Linehan, M. M. 1993. Skills training manual for treating borderline personality disorder. Diagnosis and Treatment of Mental Disorders. New York: Guilford.

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                                                                                                            A training manual for treating borderline personality disorder. An empirically based psychosocial treatment manual, which includes rationale, practical issues, session formats, structural strategies, session outlines, core mindfulness, interpersonal effectiveness, and skills training in distress tolerance. Dialectical behavioral therapy is based on behavioral techniques (not just cognition). Chronically suicidal individuals lack self-regulation of their behavior and emotions, and they need distress tolerance skills. Therapists implement alternative problem-solving analyses and a commitment to learn nonsuicidal behavioral responses, while tolerating negative affect.

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                                                                                                            • Maltsberger, J. T., and J. B. Stoklosa. 2012. Outpatient treatment. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 303–314. Washington, DC: American Psychiatric Publishing.

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                                                                                                              John Maltsberger and Joseph Stoklosa emphasize building an initial treatment alliance, assessing suicide risk, and obtaining informed consent. Treatment may not be suitable if the patient is unable or unwilling to commit to staying alive and developing reasons for living. Most suicidal patients have a treatment team. Treatment should be well monitored and tracked, being especially watchful for mental states of intense anxiety, hopelessness, desperation, rage, feelings of abandonment, self-hate, and anhedonia. Do not let the patient control the treatment, and make sure prompt inpatient treatment is available.

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                                                                                                              • Rudd, M. D., T. Joiner, and M. H. Rajab. 2001. Treating suicidal behavior: An effective, time-limited approach. Treatment Manuals for Practitioners. New York: Guilford.

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                                                                                                                This work is unique in establishing a theoretical and empirical foundation for CBT. A working manual of techniques, advice, suggestions, and instructions (with session-by-session guidelines) about the evaluation process, suicide risk assessment, crisis intervention, reduction of suicide-related behaviors, cognitive restructuring, and skill building.

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                                                                                                                • Shneidman, E. 1993. Suicide as psychache: A clinical approach to self-destructive behavior. Northvale, NJ: Aronson.

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                                                                                                                  Shneidman argues that suicide is a problem-solving effort to stop intolerable emotional pain (“psychache”). Neurobiological or neurochemical adjustments of the patient’s brain and impersonal restraints alone do not get to the heart of the suicidal matter, since suicidal issues are in essence psychological, not biological or physical. Shneidman states his well-known definition of “suicide” (chapter 1) as problem solving. Suicidal people are “perturbed” because they have unmet, frustrated psychological needs, not just biological deficiencies or excesses. Treatment needs to help the patient see, learn, and accept nonsuicidal alternative problem solving. Shneidman says the four-letter word in suicide is “only,” as in “it was the only thing I could do.”

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                                                                                                                  • Whitaker, R. 2010. Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Crown.

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                                                                                                                    Argues that the number of psychiatric disorders have increased despite drug treatment, from about 100 psychiatric diagnoses in 1952 (Diagnostic and Statistical Manual of Mental Disorders [DSM] I) to 478 in 2013 (DSM-5). While treating mental disorder, drug companies create new psychiatric disorders to justify new medications, assuming “chemical imbalance” in our brains (such as too-low cerebrospinal-fluid serotonin with depression) and try to fix it by titrating our neurotransmitters. However (for example), antipsychotics perturb dopamine (D2) receptors by continually blocking dopamine in schizophrenics, leading to adverse effects. Robert Whitaker claims most clinical trials are too short to see if drugs are even needed, and tend to test people not seriously depressed or suicidal.

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                                                                                                                    Special Populations

                                                                                                                    Obviously, all suicides kill themselves and tend to share what is called “commonalities” in Shneidman 1985 (cited under Introductory Works). But even though “suicide” is just one word, it is many different phenomena and populations, each with their own distinctive characteristics (Durkheim 1997, cited under History). For example, suicide varies by age groups. The prototypical US suicide victim is an older white male (Conwell and Heisel 2012), who typically has mood disorder, abuses alcohol, is isolated, and uses a gun to commit suicide. On the other hand, for adolescent suicides (Berman, et al. 2005), substance abuse (not just alcohol) is especially important, along with rising teen depression and gun control issues. Most of the increase in teen suicides from 1950 to 1980 was among males. At all ages (but especially in the older populations), male suicide rates exceed female suicide rates (Gold 2012), even though women have higher rates of depression. Women tend to have more suicide protective factors. Hayes 2010 claims that among jail and prison populations, suicide (mainly of white males) is a leading cause of death and needs special assessment and screening tools. Even the officers who put inmates in jail have high suicide rates (Violanti 2007); police officers kill themselves at a higher rate than they are killed in the line of duty. In the early 21st century, US veterans have been thought possibly to have higher suicide rates than nonvets and to have gotten substandard suicide prevention treatment at Veterans Affairs (VA) hospitals. Whether or not military suicide is related to posttraumatic stress disorder (PTSD) and combat stress or more to the type of special population that goes into the military (namely, young, lower socioeconomic status, and antisocial males who abuse alcohol), who are trained to fight and kill, and are given guns, is an open question. Suicide bombers related to radical Muslim military strategies against Jews and Americans are also an interesting special suicide population (Merari 2010). Although young, male, and single, most of them are not wanting to commit suicide, nor are they mentally ill; rather, they seem to be motivated by personality traits and conditions in their private lives, not primarily a wish to die or religious altruism.

                                                                                                                    • Berman, A. L., D. A. Jobes, and M. M. Silverman. 2005. Adolescent suicide: Assessment and intervention. 2d ed. Washington, DC: American Psychological Association.

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                                                                                                                      Nine chapters on research and clinical practice versus prevention and postvention. Over forty case illustrations. Between 1950 and 1980 there was over a 300 percent increase (mostly among males) in suicide rates among fifteen- to twenty-four-year-olds in the United States. Suicide is the third-highest cause of death among adolescents, with substance abuse, firearm control, and rising teen depression rates all major suicide risk factors. One needs to understand adolescent suicide as a life stage developmental issue and its associated psychopathology.

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                                                                                                                      • Conwell, Y., and M. J. Heisel. 2012. The elderly. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 367–388. Washington, DC: American Psychiatric Publishing.

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                                                                                                                        Suicide rates are the highest in white males of age seventy-five and older (according to 2012 data from NSSP [National Supplemental Screening Program]), even though suicides also have a peak in midlife. Elderly suicide victims tend to make only one fatal suicide attempt, such as the case of George Eastman (Eastman Kodak) in 1932. Suicide risk factors of the elderly include multiple losses of family members and friends, physical illnesses, increasing social isolation, personality vulnerabilities, and the availability of a gun, all of which are catalyzed by episodes of major depression (antidepressants were the most effective later in life). Three-fourths of older suicide victims saw their primary-care doctor within thirty days prior to their suicide.

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                                                                                                                        • Gold, L. H. 2012. Suicide and gender. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 453–480. Washington, DC: American Psychiatric Publishing.

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                                                                                                                          Except in China, male suicide rates exceed those of females by about three to four times, even though depression is about two times higher in women. This results in what Liza Gold calls “the gender paradox” of female suicide. Females should have higher suicide rates than they do, given their risk factors. Male suicide attempters are more likely to use firearms and are more socialized to be aggressive. Females also have more suicide protective factors than males do.

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                                                                                                                          • Hayes, L. 2010. National study of inmate suicides. Washington, DC: National Center on Institutions and Alternatives.

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                                                                                                                            Suicide is one of the leading causes of death in jails and prisons. The jail suicide rate is about two to nine times that of the general population. Most jail suicides were not screened adequately and manage to hang themselves early on in their incarceration (50 percent in the first twenty-four hours). Jail suicides are mainly white, male, young, and single; are close to a court hearing; are in single-occupancy cells; and are on fifteen-minute watches. Surveys were mailed to 15,978 facilities across all fifty states. There were 696 jail suicides in 2005 and 2006 (combined), in a total of forty-seven states.

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                                                                                                                            • Merari, A. 2010. Driven to death: Psychological and social aspects of suicide terrorism. New York: Oxford Univ. Press.

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                                                                                                                              Ariel Merari studied fifteen would-be Palestinian suicide bombers in depth (controls were nonbomber terrorists). A total of 2,622 suicide attacks from 1981 to 2008 were reviewed. Most of the bombers were male, under age twenty-five, single, and, of course, Muslim. Compared to the nonbomber terrorist controls, the suicide bombers had more dependent-avoidant and impulsive-unstable personalities. They tended to be shy and school failures and felt like they were a disappointment to their parents. The majority of the bombers did not have suicidal wishes or mental illness. Although some bombers were like Émile Durkheim’s 1897 “altruistic” suicides (see Durkheim 1997, cited under History), most of the bombers’ motivations derived from their own private lives.

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                                                                                                                              • Violanti, J. M. 2007. Police suicide: Epidemic in blue. 2d ed. American Series in Behavioral Science and Law. Springfield, IL: Charles Thomas.

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                                                                                                                                Police officers kill themselves more than they are killed by others. The police suicide rate is about two times higher than that of the general population. Suicide accounts for 13.8 percent of all police deaths versus just 3 percent of all other occupations. Chapters include classic foundation theories, case histories, and data from police departments. There are also chapters on murder-suicides, survivors, and prevention. Risk factors for police officer suicides include stress, living with violence and death experiences, readily available firearms, alcohol abuse, marital stress, divorce and separation, dealing with retirement, and “honorably” intentionally getting themselves killed in the line of duty.

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                                                                                                                                Special Topics

                                                                                                                                There are some suicide-related leftovers and loose ends that require specific topic citations and notes. Primary among these is the role of mental disorders in suicide outcomes (Harris and Barraclough 1997). Over 90 percent of all suicide victims have a disorder that is diagnosable through the Diagnostic and Statistical Manual of Mental Disorders (DSM), and mood disorders are the number-one suicide risk factor (Black and Andreasen 2011, cited under Treatment; Simon and Hales 2012, cited under Textbooks). Disturbingly, the DSM-5 seems to be trying to make suicide a mental disorder. Most of the treatment of suicidal patients consists of at least (often with conjoint psychotherapy) titrating their neurotransmitters and adjusting their neurosystems, mainly by administering psychiatric medications (Mann and Currier 2012). However, Kirsch 2010 argues that antidepressant medications are not very neurobiologically effective. For example, placebo effects are 75 to 80 percent as effective as antidepressant medications. Trimble and George 2010 examines the neurobiology of several psychiatric disorders and concludes that in some cases, medications such as gabapentin have adverse effects that themselves increase the risk both of depression and suicide. Premature, unnecessary death by suicide causes severe damage to survivors, family, friends, and colleagues. Thus, the question naturally arises, was there malpractice or negligence (Bongar, et al. 1998; Scott and Resnick 2012)? Should someone or something (such as a product) be liable for the suicidal patient’s damages? Finally, suicide does not end the matter. Suicides have ripple effects for those left behind (Campbell 2012). Cerel, et al. 2014 claims that survivors themselves are at greater risk to suicide, often feel guilt and anger, may have physical reactions, often feel stigmatized by the suicide, can be suddenly alone, experience financial or religious problems, wonder why the suicide happened, and may need to make major life adjustments, among other suicide sequelae.

                                                                                                                                • Bongar, B., A. L. Berman, R. W. Maris, M. M. Silverman, E. A. Harris, and W. L. Packman, eds. 1998. Risk management with suicidal patients. New York: Guilford.

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                                                                                                                                  When patients commit suicide, litigation often follows. The “standard of care” is what a reasonable and prudent practitioner or professional would have done in the same or similar circumstances. Medical negligence usually refers to dereliction of duty leading directly to damages (DDDD). Bruce Bongar and colleagues state outpatient and inpatient standards of care for suicidal patients. Among them are the failure to medicate properly or at all; failure to diagnose correctly; failure to do a mental-status exam; failure to safeguard, watch, or protect the patient; failure to hospitalize; and others.

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                                                                                                                                  • Campbell, F. R. 2012. Aftermath of suicide: The clinician’s role. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 651–666. Washington, DC: American Psychiatric Publishing.

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                                                                                                                                    Frank Campbell estimates that each suicide affects six to forty-five family, friend, and colleague survivors. Survivors are at increased suicide risk themselves. They often need an exploration of the “whys” of the suicide, as well as counseling. Guilt is often intertwined with grief. Many big cities (such as Baton Rouge, Louisiana) have an active volunteer service associated with the coroner’s or medical examiner’s office. Clinicians who have lost a patient to suicide may also need postvention care. Many communities have survivor support groups (such as Survivors of Suicide, or SOS). Many survivors will be older white partners or spouses, or parents of adolescent suicides.

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                                                                                                                                    • Cerel, J., J. L. McIntosh, R. A. Neimeyer, M. Maple, and D. Marshall. 2014. The continuum of “survivorship”: Definitional issues in the aftermath of suicide. Suicide and Life-Threatening Behavior 44.6: 591–600.

                                                                                                                                      DOI: 10.1111/sltb.12093Save Citation »Export Citation »E-mail Citation »

                                                                                                                                      Through a domino effect, pain is transferred to suicide survivors (256,638—1,924,785 of them in 2014 alone). Survivors can be exposed, affected, or short-term or long-term bereaved. “Exposed” means anyone who knows or identifies with a suicide, “affected” means those experiencing significant distress, “short-term” requires an attachment, and “long-term” implies a close or intimate family, close-friend, or therapist survivor. Suicide increases the risk of survivor suicide; it’s stigmatizing, and survivors are suddenly alone, may have financial problems, or require major life adjustments. They may feel guilt, anger, and confusion; have a religious crisis; or experience physical and biological problems.

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                                                                                                                                      • Harris, E. C., and B. Barraclough. 1997. Suicide as an outcome for mental disorders: A meta-analysis. British Journal of Psychiatry 170.3: 205–228.

                                                                                                                                        DOI: 10.1192/bjp.170.3.205Save Citation »Export Citation »E-mail Citation »

                                                                                                                                        A meta-analysis was done of 249 MEDLINE cases with two or more years of follow-up from 1964 to 1993, which determined the relative suicide risks of forty-four common mental disorders. The observed numbers of suicides were compared with their estimated numbers to arrive at a standardized mortality (suicide) ratio (SMR). Eighty-two percent of all mental disorders had a statistically significantly raised SMR. Thus, virtually all mental disorders (except mental retardation and dementia) were associated with raised suicide risk.

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                                                                                                                                        • Kirsch, I. 2010. The emperor’s new drugs: Exploding the antidepressant myth. New York: Basic Books.

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                                                                                                                                          Irving Kirsch and his colleagues at Harvard suggest that psychiatric medications may have very small main effects, such as reducing depression. Kirsch reviewed every clinical-trial FDA review for six antidepressants (Paxil, Prozac, Zoloft, Celexa, Serzone, and Effexor) and found that on average, placebos were 75 to 80 percent as effective as antidepressants were. That is, most of the antidepressant effects were not related to the antidepressant medication itself. Like the “Emperor’s New Clothes,” the effects of antidepressants may be largely imaginary, not neurobiological.

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                                                                                                                                          • Mann, J. J., and D. Currier. 2012. Neurobiology of suicidal behavior. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 481–500. Washington, DC: American Psychiatric Publishing.

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                                                                                                                                            Early serotonin studies found lower serotonin metabolites (5-HIAA) in the cerebrospinal fluid (CSF) of suicide victims. Serotonin neurons are dysfunctional in those who commit suicide, and serotonin deficits are observed across psychiatric diagnoses. The prefrontal cortex of the brain is important in the control of impulse, risky decision making, and aggression. The noradrenergic system is overactive and dysfunctional in suicide victims, leading to excessive norepinephrine release in response to stress. Early-life adversity is related to adult suicidal behavior and alteration in the hypothalamic-pituitary-adrenal (HPA) axis. Genes related to the serotonin system and alteration in the HPA axis are at the forefront of early-21st-century research on suicide and genes. Depression and suicide may be related to neurodegeneration and neurogenesis.

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                                                                                                                                            • Scott, C. L., and P. J. Resnick. 2012. Patient suicide and litigation. In The American Psychiatric Publishing textbook of suicide assessment and management. 2d ed. Edited by R. I. Simon and R. E. Hales, 539–552. Washington, DC: American Psychiatric Publishing.

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                                                                                                                                              Charles Scott and Phillip Resnick review common claims of negligence after suicide. Only about 22 percent of doctors report any medical claim against them. Suicide claims are normally civil claims or “torts” and usually involve alleged negligence. Suicide claims can consist of medical malpractice, contested life insurance, manner-of-death determination, workman’s compensation related to product liability, or suicides in institutional or physical settings. Between 10 and 15 percent of psychiatric patients will eventually commit suicide. One retrospective analytic tool for suicide experts is the psychological autopsy. Of course, there can be criminal cases in which the manner of death is unclear.

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                                                                                                                                              • Trimble, M. R., and M. S. George. 2010. Biological psychiatry. 3d ed. Oxford: Wiley-Blackwell.

                                                                                                                                                DOI: 10.1002/9780470689394Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                Much of the modern research on suicide focuses on genetics, brain anatomy, and neurobiology. Michael Trimble and Mark George review the biochemical bases for several psychiatric disorders related to suicide. For example, gabapentin/Neurontin prevents seizures and has been used off-label for pain control and treatment of bipolar disorder. Gamma-aminobutyric acid (GABA) has an inhibiting effect on the transmission of monoamines, such as brain serotonin and norepinephrine. Gabapentin decreases their release. Depleting serotonin, norepinephrine, or both in the CSF of the brain is related to higher rates both of suicide and depressive disorder. Some of the Trimble and George results are contested by drug companies.

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