7.1 Suicide and self-harm

Suicide and self-harm are complex issues with far-reaching impacts. These behaviors stem from a mix of individual, environmental, and societal factors. Understanding the risk factors, warning signs, and protective elements is crucial for effective prevention and intervention.

Suicide rates vary across demographics, with certain groups facing higher risks. Various theories, from interpersonal to sociological, shed light on the underlying causes. Prevention strategies range from universal approaches to targeted interventions, aiming to reduce suicide rates and support those affected.

Risk Factors for Suicide and Self-Harm

Individual and Environmental Risk Factors

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• Mental health disorders increase the likelihood of suicide or self-harm (depression, bipolar disorder, schizophrenia)
• Substance abuse, including alcohol and drug misuse, heightens the risk of suicidal behavior
• Prior suicide attempts are a strong predictor of future suicidal behavior
• Family history of suicide may contribute to an increased risk due to genetic and environmental factors
• Access to lethal means, such as firearms or toxic substances, facilitates the act of suicide
• Chronic physical illness or disability can lead to feelings of hopelessness and suicidal ideation
• Traumatic life events, such as childhood abuse, sexual assault, or the loss of a loved one, may trigger suicidal thoughts and behaviors
• Social isolation and lack of support from family, friends, or community can exacerbate feelings of loneliness and despair

Warning Signs and Protective Factors

• Talking about wanting to die, expressing a desire to end one's life, or making specific plans for suicide are critical warning signs
• Expressing feelings of hopelessness, purposelessness, or believing that life is not worth living may indicate an immediate risk for suicide
• Withdrawing from friends, family, and previously enjoyed activities can be a sign of suicidal ideation
• Displaying extreme mood swings, such as sudden calmness after a period of depression, may signal a decision to act on suicidal thoughts
• Giving away prized possessions or putting affairs in order without a clear reason may suggest an intention to die by suicide
• Strong social support from family, friends, and community serves as a protective factor against suicide and self-harm
• Effective coping skills, such as problem-solving abilities and emotional regulation techniques, can help individuals manage distress without resorting to self-harm
• Access to mental health care, including therapy and medication management, is crucial in preventing suicide and treating underlying mental health conditions
• Cultural and religious beliefs that discourage suicide may act as protective factors

Demographic and Cultural Considerations

• The presence of multiple risk factors and the absence of protective factors significantly increase an individual's vulnerability to suicidal thoughts and behaviors
• Risk factors and warning signs may vary across different age groups (adolescents, older adults)
• Gender differences in suicide risk factors and warning signs exist (males more likely to use lethal means, females more likely to attempt suicide)
• Cultural background can influence the expression of suicidal ideation and the interpretation of warning signs (stigma, communication styles)
• Marginalized communities, such as LGBTQ+ individuals and racial/ethnic minorities, may face unique risk factors related to discrimination and minority stress

Prevalence of Suicide and Self-Harm

Global and National Statistics

• Approximately 800,000 people die by suicide each year globally, making it a leading cause of death worldwide
• In the United States, over 48,000 individuals died by suicide in 2018, making it the 10th leading cause of death
• Suicide rates have been steadily increasing in recent years, with a 35% increase in the U.S. suicide rate between 1999 and 2018
• Suicide attempts are estimated to be 20-30 times more frequent than completed suicides
• Self-harm, or non-suicidal self-injury (NSSI), has an estimated lifetime prevalence of 5-6% in the general population
• Among adolescents, the prevalence of NSSI is significantly higher, ranging from 17-35%

Age and Gender Differences

• Suicide rates vary by age, with the highest rates observed among middle-aged (45-54 years) and older adults (75+ years)
• Suicide is the second leading cause of death among individuals aged 10-34 years in the United States
• In adolescents and young adults, suicide rates have been increasing at an alarming rate, particularly among females
• Gender differences in suicide are evident, with males having a higher rate of completed suicide (3.5 times higher than females)
• Females have a higher rate of attempted suicide and are more likely to engage in non-lethal self-harm behaviors
• The gender gap in suicide rates narrows in later life, with the ratio of male to female suicides decreasing among older adults

High-Risk Populations

• LGBTQ+ individuals have disproportionately higher rates of suicide and self-harm compared to the general population (2-4 times higher)
• Native American and Alaska Native populations have the highest suicide rates among racial/ethnic groups in the United States
• Veterans and military personnel are at increased risk for suicide, with rates 1.5 times higher than the general population
• Individuals with chronic health conditions, such as cancer, HIV/AIDS, and chronic pain, have elevated rates of suicidal ideation and behavior
• People who have experienced adverse childhood experiences (ACEs), such as abuse or neglect, are at greater risk for suicide and self-harm throughout their lives

Theories of Suicide and Self-Harm

Interpersonal Theory of Suicide

• The interpersonal theory of suicide (Joiner, 2005) posits that suicidal desire arises from the combination of perceived burdensomeness, thwarted belongingness, and acquired capability for suicide
• Perceived burdensomeness is the belief that one is a burden to others and that others would be better off without them
• Thwarted belongingness is the experience of social isolation and lack of meaningful connections with others
• Acquired capability for suicide is the habituation to pain and fear of death through repeated exposure to painful or provocative experiences
• The theory suggests that individuals who experience high levels of both perceived burdensomeness and thwarted belongingness, along with an acquired capability for suicide, are at the greatest risk for lethal suicidal behavior

Sociological Theories

• Durkheim's sociological theory of suicide (1897) proposes four types of suicide based on the degree of social integration and regulation: egoistic, altruistic, anomic, and fatalistic
• Egoistic suicide occurs when individuals are not well-integrated into society and lack a sense of belonging (social isolation, individualism)
• Altruistic suicide happens when individuals are overly integrated into a group and sacrifice themselves for the benefit of the group (military, religious cults)
• Anomic suicide results from a lack of social regulation and a breakdown of moral norms during times of social upheaval (economic crises, rapid social change)
• Fatalistic suicide occurs in highly regulated societies where individuals feel oppressed and hopeless (slavery, totalitarian regimes)
• Durkheim's theory highlights the importance of social factors in understanding suicidal behavior and the need for a balance between social integration and individual autonomy

Psychological Theories

• The diathesis-stress model suggests that suicidal behavior is the result of an interaction between predisposing vulnerabilities (diathesis) and triggering stressors or life events (stress)
• Diatheses may include genetic predispositions, personality traits, and cognitive styles that increase an individual's susceptibility to suicidal behavior
• Stressors can be acute (relationship breakup, job loss) or chronic (poverty, discrimination) and may overwhelm an individual's coping resources
• The escape theory of suicide (Baumeister, 1990) proposes that suicide is an attempt to escape from aversive self-awareness and negative emotions arising from a perceived failure to meet standards
• The theory posits that suicidal individuals experience a narrowing of cognitive focus, a sense of hopelessness, and a desire to escape from an unbearable psychological state
• Psychodynamic theories emphasize the role of early childhood experiences, unconscious conflicts, and attachment patterns in the development of suicidal tendencies

Prevention of Suicide and Self-Harm

Universal Prevention Strategies

• Universal prevention strategies target the general population and focus on promoting mental health, reducing stigma, and increasing awareness of suicide prevention resources
• Public education campaigns aim to increase knowledge about suicide risk factors, warning signs, and available support services (National Suicide Prevention Lifeline)
• School-based programs, such as curriculum-based interventions and peer support groups, promote social-emotional learning and help-seeking behaviors among students
• Means restriction, such as limiting access to firearms and lethal medications, is an effective universal prevention strategy
• Media guidelines for responsible reporting of suicide can help prevent suicide contagion and promote help-seeking behaviors

Selective Prevention Strategies

• Selective prevention strategies target high-risk groups and aim to provide targeted interventions and support
• Screening programs for depression and suicide risk can identify individuals who may benefit from early intervention and treatment
• Gatekeeper training for professionals who interact with high-risk populations, such as healthcare providers, teachers, and clergy, can improve recognition of warning signs and referral to appropriate services
• Crisis hotlines and online chat services provide immediate support and resources for individuals in distress
• Peer support programs, such as those for LGBTQ+ youth or survivors of suicide loss, offer a sense of belonging and understanding for individuals at increased risk

Indicated Prevention Strategies

• Indicated prevention strategies focus on individuals who have already exhibited suicidal thoughts or behaviors and aim to prevent further escalation
• Safety planning involves collaboratively developing a written plan with an individual at risk, outlining coping strategies, social supports, and emergency contacts
• Cognitive-behavioral therapy (CBT) helps individuals identify and challenge negative thought patterns, develop problem-solving skills, and enhance coping abilities
• Dialectical behavior therapy (DBT) is an evidence-based treatment for individuals with borderline personality disorder and chronic suicidality, focusing on emotion regulation and distress tolerance skills
• Pharmacotherapy, such as antidepressants and mood stabilizers, can be used to treat underlying mental health conditions and reduce suicidal ideation
• Hospitalization may be necessary for individuals at imminent risk of suicide to ensure safety and provide intensive treatment

Postvention Strategies

• Postvention strategies aim to support survivors of suicide loss and prevent suicide contagion in the aftermath of a suicide
• Providing grief counseling and support groups for family members, friends, and communities affected by suicide can facilitate the healing process
• Implementing protocols for responding to suicides in schools and workplaces, such as crisis response teams and communication guidelines, can minimize the risk of suicide clusters
• Promoting responsible media coverage of suicide, including avoiding sensationalism and providing resources for help, can reduce the likelihood of imitation suicides
• Conducting psychological autopsies, which involve gathering information about the circumstances surrounding a suicide, can inform future prevention efforts and identify gaps in support systems