Suicide

Suicide is the act of ending one's own life. From a historical perspective, for thousands of years, the concept of suicide has been debated philosophically and from religious viewpoints. Today, suicide is seen from a combination of medical, social, legal, and political lenses.^[1][2][3] From a medical and psychiatric perspective, suicide attempts are a major cause of disability for patients, and completed suicide attempts present a significant challenge to the patient's healthcare providers and can be devastating for family members.

• The average prevalence of suicide in most psychiatric illnesses is about 10% and eating disorders is >10%. Suicide affects all socioeconomic levels and all professions.^[4]
• Most completed suicides are not preceded by previous suicide attempts.^[5]

Suicide attempts can often have a ripple effect on other individuals, including those who witness it, and family members. Subway operators who are involved in a suicide death can often report higher rates of absenteeism, as well as develop other psychiatric conditions.^[6]

• Sanati, A. (2009). Does suicide always indicate a mental illness?.
• Sisti, D. A., & Joffe, S. (2018). Implications of zero suicide for suicide prevention research. Jama, 320(16), 1633-1634.

• Suicide varies on a cultural level, both in terms of stigma, means of suicide, and incidence.^[7]

• Chambers, A. (2010). Japan: ending the culture of the ‘honourable’suicide. The Guardian, 3.

• In the US, between 2011 to 2020, the absolute number of suicide attempts in the United States was found to increase more than threefold.^[8]

• In women, the risk for suicide attempts is higher, and while th risk for suicide completion is lower (compared to men).^[9]

• Overall, the risk for suicide in dementia is the same of that in the general population.^[10]
• Exceptions to this are that rates of self-harm increase in mild dementia; is higher before than after predictive testing for Huntington's disease; and is higher in patients diagnosed with dementia during hospitalization.

Suicide risk assessment remains a daunting and elusive task that mental health professionals face. One of the main challenges in risk-stratifying individuals is that almost half of completed suicide attempts are by individuals who are considered low risk.

Individuals for high risk of suicide include those recently discharged from a psychiatric hospital.^[11]

The role of machine learning and artificial intelligence in predicting suicide risk is currently being investigated.^[12]

Suicide contagion is of significant public health concern. Unfortunately, the term contagion is has a heterogenous definition, making research on contagion challenging.^[13] There is strong evidence that vulnerable youth are especially susceptible to the influence of reports and portrayals of suicide in the mass media.^[14] More recently, this became an issue of discussion when Netflix released 13 Reasons Why, a show about a teenager who completed suicide. Debate has continued about the role that media plays in the portrayal of suicide and the negative effects that result from it.^[15][16]

One approach to reducing the harmful effects of media portrayals is to educate journalists and media programmers about ways to present suicide so that imitation will be minimized and help-seeking encouraged.

The role of the media in suicide prevention is often underestimated. The media plays an important role and have an important responsibility reporting suicide. Various media guidelines exist for the reporting of suicides.^[17]

Copycat suicides, also known as the Werther effect, is the phenomenon of an individual copying suicidal behaviour that they have in the media.^[18][19] In Canada, the Aboriginal population recently dealt with a series of youth suicides on reserves, some of which could also be attributed to suicide contagion.^[20]

Suicide prevention can be implemented on an individual, local, and systemic levels.^[21]

On inpatient psychiatric units, removing ligature anchor points (i.e. - protrusions capable of supporting the weight of a person more than 100 pounds, such as doors, hooks or handles, windows, belts, and sheets or towels) decreases the risk for suicide.^[22]

The co-prescription of a non-benzodiazepine hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients with severe insomnia.^[23]

There is some research that suggests the installation of blue lights may reduce the incidence of suicide.^[24]

It is difficult to research the exact effect of suicide hotlines and distress helplines, but most of the research suggests it is effective in reducing the crisis state of callers. Anecdotally, of course, phone line counsellors are able to recall specific situations where callers had lethal means (e.g. - a gun) while on the phone, and stopped the attempt by talking to the caller. Helplines continue to play a supportive role on the population level.^[25]

High lethality suicide attempts include deaths by jumping from lethal heights, or in front of high speed objects, such as trains or in the subways. Current studies have demonstrated that installing barriers reduced the incidence of deaths at the location, but more importantly, did not result in an increase in suicide by other means.^[26] This means that the installation of barriers actually led to an overall decrease in suicide attempts. Work is being done around the world to install more barriers, including at the famous Golden Gate Bridge.

Other high lethality means of suicide include firearms and toxins like pesticides. Worldwide, pesticides account for an estimated one-third of the world's suicides. In the United States, suicide by firearms.

• Management of suicidal behaviours or ideation may include the use medications, psychotherapy, and/or hospitalization.
• Psychotherapies may include cognitive therapy for suicidal behavior, dialectical behavioral therapy, Collaborative Assessment and Management of Suicidality, and the Safety Planning Intervention.^[27]
• Medications that have been shown to reduce the risk of suicide include lithium (for bipolar disorder) and clozapine (for schizophrenia).