Suicide Prevention: Risk Factors

As we come out of September, National Suicide Prevention Awareness Month, and into October, Depression Awareness Month, it seems like the right time to talk about this powerful issue. Suicide is the number one cause of death globally¹ and takes almost one million lives per year^{2, 3}. The chances are that the vast majority of us knows someone who has died by suicide. Some may even have lost close family or friends and know the pain and destruction suicide causes. But suicide is preventable.

One key component to suicide prevention is knowing the risk factors. Before delving into these, it’s important to acknowledge that research shows that the risk factors I’m referring to are statistically poor predictors of suicidal behavior⁴. If prediction was the goal, that would be a problem, but it’s not. But as noted in my previous blog in this series, prevention is the goal. So, while the risk factors in and of themselves are not great at predicting who will engage in suicidal behavior, knowing what the risk factors are so that they can be managed or even alleviated, helps to reduce the likelihood suicidal behavior will occur⁵: This is crucial to prevention.

Prior Attempts
Prior suicide attempts are considered one of, if not the strongest, predictors of suicidal behavior.⁶ The greatest period of risk is within 3 to 6 months after an attempt⁷ with 80% of suicides taking places within one year after an attempt⁸.

Psychiatric Illness
Having a mental health diagnosis significantly increases the risk for suicidal behavior. Of note, 90% of those who die by suicide have a psychiatric diagnosis. (But, only 10% of those with a psychiatric diagnosis will die by suicide)^9,10.  The most common diagnoses associated with suicide are depression or dysthymia^11,12. Additional diagnoses associated with suicidal behavior are bipolar disorder, substance use disorders, schizophrenia and other psychotic disorders, borderline personality disorder, antisocial personality disorder, paranoid personality disorder, histrionic personality disorder, dependent personality disorder, and anorexia^{13,14,15,16,17,18}.

Access to Means
Access to lethal means of suicide is a strong risk factor for suicide. The most common method of suicide is firearms at just over 50%¹⁹, with firearms having an 85% fatality rate²⁰. In the United States, 1 in 3 homes has a firearm²¹. The second most common method is hanging/suffocation (23%) and the third most common is poisoning (19%). The latter can include overdosing on medications, pesticides/chemicals, or toxic gases²².

Additional risk factors include but are not limited to:

• Male gender^23,24
• Caucasian or Native American^25,26,27
• Living in a rural area^28,29,30,31
• Bisexual orientation³²
• Isolation³³
• Impulsivity³⁴
• Ruminative³⁵
• Presence of negative life events/crises³⁶
• Certain occupations (fishing, farming, and forestry have the highest suicide rates)³⁷
• Recent psychiatric hospital discharge³⁸
• Chronic physical condition³⁹
• Domestic violence- either the victim or the perpetrator⁴⁰
• Military history⁴¹
• Low to middle socioeconomic status⁴²
• Part of the criminal justice population⁴³

The next blog in this series on suicide prevention will focus on protective factors and intervention strategies.

National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or visit suicidepreventionlifeline.org/

References

1. World Health Organization. (2014). Preventing suicide: A Global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
2. World Health Organization. (2012). Public health action for the prevention of suicide: A Framework. Retrieved from http://apps.who.int/iris/bitstream/10665/75166/1/9789241503570_eng.pdf
3. World Health Organization. (2014). Preventing suicide: A Global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
4. deBeurs, D., Kirtley, O., Kerhof, A., Portzky, G., & O’Connor, R. (2015). The Role of mobile phone technology in understanding and preventing suicidal behavior. Crisis, 36(2), 79-82. doi: 10.1027/0227-5910/a000316
5. Doyle, M. & Dolan, M. (2002). Violence risk assessment: Combining actuarial and clinical information to structure clinical judgments for the formulation and management of risk. Journal of Psychiatric and Mental Health Nursing, 9, 649-657. doi: 10.1046/j.1365-2850.2002.00535.x
6. World Health Organization. (2012). Public health action for the prevention of suicide: A Framework. Retrieved from http://apps.who.int/iris/bitstream/10665/75166/1/9789241503570_eng.pdf
7. Chung, C., Pai, L. Kao, S., Lee, M., Yang, T. & Chien, W. (2013). The Interaction effect between low income and severe illness on the risk of death by suicide after self-harm. Crisis, 34(6) 398-405. doi: 10.1027/0227-5910/a000218
8. Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094-1100.
9. Dennis, B. B., Roshanov, P. S., Bawor, M., ElSheikh, W., Garton, S., DeJesus, J., Rangarajan, S., Vair, J., Sholer, H., Hutchinson, N., Lordan, E., Thabane, L., & Samaan, Z. (2015). Re-examination of classic risk factors for suicidal behavior in the psychiatric population. Crisis 36(4), 231-240. doi: 10.1027/0227-5910/a000342
10. Lewis, K. C., Meehan, K. B., Cain, N. M., & Wong, P. S. (2016). Within the confines of character: A Review of suicidal behavior and personality style. Psychoanalytic Psychology, 33(1), 179-202. doi: 10.1037/a0038956
11. Bertolote, J. M., Fleischmann, A., DeLeo, D., & Wasserman, D. (2004). Psychiatric diagnoses and suicide: Revisiting the evidence. Crisis, 25(4), 147-155. doi: 10.1027/0227-5910.25.4.147
12. Centers for Disease Control and Prevention Department of Health and Human Services. (2010). Morbidity and Mortality Weekly Report. Retrieved from cdc.gov/mmwr
13. Ibid.
14. Stefenson, A. & Titelman, D. (2016) Psychosis and suicide: Suicidal communication and critical life events before suicide in a 1-year psychiatric cohort. Crisis, 37(3), 224-231. doi: 10.1027/0227-5910/a000372
15. Lipschitz, A. (1995). Suicide prevention in young adults (age 18-30). Suicide and Life-Threatening Behavior, 25(1), 155-170.
16. Berman, A. L. & Jobes, D. A. (1995). Suicide prevention in adolescents (age 12-18). Suicide and Life-Threatening Behavior, 25(1), 143-154.
17. Keel, P., Dorer, D., Eddy, K., Selwyn, S., Franko, D., Charatan, D. & Herzog, D, (2003). Predictors of mortality in eating disorders. Archives of General Psychiatry, 60, 170-183.
18. Bulik, C., Sullivan, P., & Joyce, P. (1999). Temperament, character and suicide attempts in anorexia nervosa, bulimia nervosa and major depression. Acta Psychiatrica Scandinavica, 100, 27-32.
19. Centers for Disease Control and Prevention Department of Health and Human Services. (2010). Morbidity and Mortality Weekly Report. Retrieved from cdc.gov/mmwr
20. Runyan, C. W., Brown, T. L., & Brooks-Russell, A. (2015) Preventing the invisible plague of firearm suicide. American Journal of Orthopsychiatry, 85(3), 221-224. doi: 10.1037/ort0000065
21. Miller, M., Azrael, D., & Barber, C. (2012). Suicide mortality in the U.S.: The Importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health, 33, 393-408.
22. Centers for Disease Control and Prevention Department of Health and Human Services. (2010). Morbidity and Mortality Weekly Report. Retrieved from cdc.gov/mmwr.
23. American Foundation for Suicide Prevention. (2015) Facts and figures. Retrieved from: www://afsp.org/about-suicide/suicide-statistics/
24. Drapeau, C. W., & McIntosh, J.L. (2015) S.A. Suicide 2013: Official final data. Retrieved from: http://www.suicidology.org
25. Moscicki, E. K. (1995). Epidemiology of suicidal behavior. Suicide and Life-Threatening Behavior, 25(1), 22-35.
26. Bertolote, J. M., Fleischmann, A., DeLeo, D., & Wasserman, D. (2004). Psychiatric diagnoses and suicide: Revisiting the evidence. Crisis, 25(4), 147-155. doi: 10.1027/0227-5910.25.4.147
27. Miller, M., Azrael, D., & Barber, C. (2012). Annual Review of Public Health, 33, 393-408.
28. Singh, G.K., Azuine, R., Siahpush, M., & Kogan, M. (2013). All-cause and cause-specific mortality among US youth: Socioeconomic and rural-urban disparities and international patterns. Journal of Urban Health, 90, 388-405. doi: 10.1007/s11524-012-9744-0
29. Hirsch, J. K. & Cukrowicz, K. C. (2014). Suicide in rural areas: An Updated review of the literature. Journal of Rural Mental Health 38(2), 65-78. doi: 1037/rmh0000018
30. US Census Bureau. Population by rank, 2015. Retrieved at: infoplease.com/us/states/state-population-rank-2015
31. Centers for Disease Control and Prevention. Suicide mortality by state, 2015. Retrieved at: wonder.cdc.gov
32. Haas, A. P., Eiason, M., Mays, V. M., Mathy, R. M., Cochran, S. D., D’Augelli, D. R., & Clayton, P. J., et al. (2011). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality, 58, 10-51. doi: 10.1080/00918369.2011.534038
33. World Health Organization. (2014). Preventing suicide: A Global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
34. Lindner, R. (2006). Suicidality in men in psychodynamic psychotherapy. Psychoanalytic Psychology, 20, 197-217.
35. Surrence, K., Miranda, R., Marroquin, B. M., & Chan, S. (2009) Brooding and reflective rumination among suicide attempters: Cognitive vulnerability to suicidal ideation. Behaviour, Research and Therapy, 47, 803-808. doi: 10.1016/j.brat.2009.06.001
36. Harvard Injury Control Research Center, Harvard School of Public Health. (2102). Means Matter: Suicide, Guns & Public Health. Boston, MA: n.p.
37. Spruill, T. (2017). Disarming the suicidal mind: Evidence-based assessment and intervention. Vyne Education. Minneapolis, MN.
38. Qin, P. & Nordentoft, M. (2005). Suicide risk in relation to psychiatric hospitalization: Evidence based on longitudinal resisters. Archives of General Psychiatry, 62, 427-432.
39. Hawton, K. & van Heeringen, K. (2009). Suicide. Lancet, 373, 1372-1381.
40. Sunami, H., Hammersley, J. J. & Keefe, K. M. (2017). The Role of alcohol problems in the association between intimate partner abuse and suicidality among college students. Psychology of Violence. Advance online publication. doi: 10.1037/vio0000122
41. Centers for Disease Control and Prevention Department of Health and Human Services. (2010). Morbidity and Mortality Weekly Report. Retrieved from cdc.gov/mmwr.
42. World Health Organization. (2014). Preventing suicide: A Global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
43. United States Census Bureau (2011). Statistical abstract of the United States: 2011. Retrieved from: https://www.census.gov/library/publications/2010/compendia/statab/130ed.html