• Suicide is the 8^th leading cause of death in the US
• 30,000 reported cases/year; 50,000 estimated cases/year

• (1) Gender: Men:women - 3:1, however women are 4 X more likely to attempt suicide
• Men select more violent methods of suicide such as firearms, hanging or jumping from high places
• Women often select overdose, which leaves more room for error
• (2) Age: suicide rates Ý with age; highest rate occurs in Caucasian males ³ 75 years old - approximately twice as many people in this age group commit suicide than people in the 45 to 54 year old range
• Children: suicide is rare before age 12, but suicidal thoughts are not uncommon and should be investigated for possibility of depression
• Adolescents: in the 15 - 24 year old age group suicide is the 3^rd leading cause of death with about 6,000 completed suicides; suicide is the 2^nd leading cause of death on college campuses (and the first leading cause of death among medical students!); as with adults, boys are 3X more likely to complete suicide than girls, while girls attempt suicide 3X more frequently than boys; also as in adults, depressive illness is associated with a higher risk
• adolescent suicides often occur because of intense over-identification with one another in a peer group consistent with altruistic suicide (see below) Þ also associated with copycat suicide
• treatment of child and adolescent suicide risk must be multi-faceted including family, social and individual treatments
• (3) Descent: African American (AA) males are an exception to the rule that suicide increases with age; their highest incidence of suicide occurs within the 26-34 year olds; overall the suicide rate for white men to black men is 3:1
• Eastern Europeans, Scandinavians and Japanese have Ý rates of suicide; Caucasians to non-Caucasians is 2:1
• (4) Religion: people with a strong religious affiliation are generally less likely to attempt suicide
• (5) Family: suicide rate for married is half that of those people who have never been married
• widowed and divorced individuals have higher rate of suicide (divorced men: 60/100,000; divorced women 18/100,000)
• (6) National Status: ß rates of suicide during times of prosperity or war; Ý with Ý unemployment;
• (7) Occupations: physicians, dentists, musicians, law enforcement officials, and insurance agents have Ý risk of suicide
• (8) Other Illnesses: mental illness, chronic physical illness and substance abuse associated with Ý risk
• Mental Illness: most important factor leading to 95% of all suicides; especially depression
• 80% of people who kill themselves are depressed, manic/depressed or have some other type of mood disorder
• 80% of depressed people express suicidal ideation, 20% exhibit suicidal behaviorÞ it becomes a means of escape
• Suicide rates by mental illness diagnosis:
• Untreated Depression = 15-20%
• Treated Depression = 2%
• Bipolar = 20%
• Schizophrenia = 10%
• Borderline = 7%
• Dementia/Delirium = 5%
• Physical Illness: 32% of people who commit suicide have physical illness; 50% saw a physician in the previous week

• Carl Menninger: Three Dynamic models which are active in suicidal patients
• (1) The wish to kill Þ revenge, frustration and extreme frustration turned inward; Many people have murderous impulses that are inhibited by the superego. A person’s fear of their own destructive impulses causes them to turn their anger and frustration toward an accessible target, which becomes themselves
• (2) The wish to be killed Þ Want someone to give them a gun, provided them a pill, or make the act of suicide in some way certain and relatively painless
• (3) The wish to die Þ response to a significant loss in a susceptible individual; loss of a close person, self-esteem, hope, sense of security, valued job or material wealth is a central theme in suicide victims
• suicide patients also have a wish to be rescued; want to feel that someone desires him or her to live and that he or she deserves to live; often suicide attempts are arranged in a way that there is a possibility of rescue if someone cares enough (ex. Woman married to an alcoholic takes overdose when husband should return from work: if he goes to the bar she dies, but if he comes right home she is saved. In this way, she can be rescued if he cares and will "escape" if he doesn’t.)
• Emily Durkeim: Divided suicide into three social categories
• (1) Egoist suicide (Undercommitted)Þ people not strongly integrated into a social network
• Example: unmarried, socially isolated
• (2) Altruistic suicides (Overcommitted)Þ opposite of egoistic; people are overinvolved in a social group
• Example: cult worship
• (3) Anomic suicide Þ people with a disrupted social network; disenfranchised or suffered major loses
• Example: divorced, bankrupt, criminals
• Schneidman and Farberow: studied attempted suicide survivors and divided them into four categories
• suicide may be a means of seeking revenge, a means of release from suffering or a consequence of psychotic thinking such as paranoid delusions or command hallucinations

• violent suicides (guns, jumping from high places) are associated with ß serotonin metabolites found in the CSF
• low platelet monoamine oxidase has been linked to suicide; suicide rate is up to 10 times higher for people with ß MAO
• ß binding of imipramine, Ý postsynaptic binding of serotonin and Ý beta adrenergic receptor binding in the frontal cortices of patients who have committed suicide - imipramine, serotonin and beta adrenergic receptors are all associated with depression
• PET Scan Study - Depressed people demonstrated Ý activity in the frontal lobes with ß activity of the midbrain structures; non-depressed people had normal activity in the frontal lobes and more activity in the same midbrain structures
• Theory: ß activity in the midbrain structures of the depressed people decreased their level of motivation and decreased metabolic activity. This prevented most people with depression from having the motivation to commit suicide. The people with depression who commit suicide either overcome the decreased motivation or do not have the decreased activity in the midbrain structures and have the motivation to commit suicide.

Suicide and Substance Abuse - Ý risk in substance abusers

• The SAD PERSONS Scale - one point for each of the following:
• Sex, Age, Depression, Previous attempts, Ethanol Abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, Sickness
• Score:
• 1-2 = low risk
• 2-3 = moderate risk
• 4-5 = high risk
• Assessment of Suicidal Behavior - 80% of people who commit suicide give warning signs of intent and 50% say openly that they want to die
• suicide idealization
• suicide plan
• suicide intent
• evidence of a plan with intent to act demonstrates Ý risk and the patient should be hospitalized immediately

• assure safety of the patient, plan to prevent future episodes of suicide thought, addressing underlying issues
• direct and active approach is advised over in-depth psychotherapy
• physician must establish trust, provide options, hope and a chance for recovery; physician must also make frequent contact and always be available
• medications should be prescribed in limited amounts and medications with low toxicity should be used when appropriate (new antidepressants)