Public Health Suicide
by
Ronald W. Maris
  • LAST REVIEWED: 03 February 2017
  • 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).

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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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