1. Problems in the study of suicide (p. 389) In 1999 the White House reported the devastating toll of suicide and the steps needed to prevent it. People may commit suicide if they feel depressed, like a failure, as though the quality of their life is poor, unwanted, as though their death is for a greater good, and for many other reasons. Suicide is not a disorder in DSM-IV-TR, but is important in abnormal psychology, and the suicidal person has clear psychiatric symptoms. Suicide and suicidal ideation (thinking about it) may be separate from depression. As a topic, suicide has been hidden, but as the eighth leading cause of death in the United States, it is now emerging as a focus of research and social discussion.
2. Correlates of suicide (p. 392) Those who complete suicide attempts cannot be asked their reasons. Patterned after medical autopsies, a psychological autopsy attempts to make psychological sense of suicide by examining the persons case history, interviewing family and friends, and analyzing suicide notes. However, these sources of information are often unavailable or unreliable.
   More than 31,000 people in the United States kill themselves each year, but the real number may be 25 to 30 percent higher. In addition, for each suicide completed, eight to ten people make an attempt. Suicides among the young have increased dramatically in the past decade. The suicide rate among college appears to be only half that of people the same age who are not in college. Recent research has helped clarify which college students are at greatest risk for suicide: They appear to be older students, foreign-born students, graduate students who had extremely good grades as undergraduates but who now are below the graduate grade point average. Reasons for suicide include hopelessness, loneliness, helplessness, relationship problems, unspecified depression, money problems, and problems with their parents. Men complete suicide three times as often as women, but women attempt suicide three times as often. Persons under age 25 accounted for 15 percent of suicides in 1997; suicides in the 15 to 24 year-old age group increased more than 40 percent during the past decade, and it is now the second leading cause of death for that age group. High-risk people are unmarried, divorced, and widowed individuals, professionals, and those living in countries where religious authority is weak. For example, the rate is 12.2 per 100,000 in the United States; Hungarys rate is highest at 40.7 per 100,000. Firearms in suicide are most often used by men although their use by women is increasing. Most people communicate their intent to kill themselves within three months of the suicide.
3. Correlates of suicide: Hopelessness, alcohol, and other factors (p. 397) Depression and suicide are strongly correlated. From half to two-thirds of all suicides are related to mood disorders. However, most depressives do not commit suicide, and the risk of suicide increases after a depression has lifted. Negative expectations about the futurehopelessnessmay be the major catalyst for suicide. Hopelessness predicts suicidal behavior better than depression and better than thoughts about suicide (suicidal ideation). There is a strong correlation between alcohol consumption and suicide: intoxication may lower inhibitions or constrict thought and make negative moods or thoughts more intense. Those who commit suicide are more likely than others to suffer from mood disorders, schizophrenia, or substance abuse. A variety of stressors are associated with suicide.
4. Theoretical perspectives (p. 399) Emile Durkheim, a sociologist, proposed that suicide was related to sociocultural influences. He concluded that three categories of suicide exist: egoistic (when the person is unable to integrate with society), altruistic (when self destruction is for the cultures greater good), and anomic (when a major life event leaves a person unable to cope). Psychodynamic explanations stress the idea of anger turned inward on the self. However, psychological autopsies show this to be a cause of suicide in only a minority of cases. The chemical 5HIAA, a metabolite of the neurotransmitter serotonin, is found to be at abnormally low levels in people who commit suicide. This raises the possibility that suicides have a biological basis. Low 5HIAA levels occur in suicidal individuals who are not depressed.
5. Victims of suicide (p. 402) Children and adolescents take their lives at an alarming rate. Those who attempt suicide tend to show clinical symptoms of psychological disturbance, to use drug overdose as the method, to make their attempt at home, and to come from families with high levels of stress as a result of economic instability, substance abuse, or other life events. Copycat suicides, in which adolescents imitate media portrayals of other adolescents' suicides, are less common than the media suggest and tend to occur among those already contemplating suicide. However, highly publicized suicides can increase the chances of attempts. Fortunately, 41 percent of schools report having programs aimed at suicide prevention. The many stresses of life among the elderly place them at high risk for suicide. Suicide rates are particularly high for white males and first-generation Asian Americans. Native Americans and African Americans show low rates of suicide among older adults, although both groups are at high risk during young adulthood.
6. Preventing suicide (p. 404) People who attempt suicide have a wish to live along with a wish to die. They usually leave verbal or behavioral clues of their intentions, although these may be subtle. A clinical approach to suicide intervention stresses that most individuals are ambivalent about ending their lives and that counselors must be comfortable discussing the subject. Crisis intervention strategies are used to assess lethality, and to abort suicide attempts by offering intensive counseling to the individual and stabilizing him or her, sometimes in a hospital environment, while clarifying ways to deal with the crisis. Suicide prevention centers usually use paraprofessionals to take telephone calls from potentially suicidal individuals. These paraprofessionals are trained to establish rapport with the caller, evaluate suicidal potential, clarify the nature of the problem and the callers ability to cope, and recommend a plan of action. There is no conclusive evidence for the effectiveness of suicide prevention centers. Little research has been conducted, and alternative explanations for results are possible. Community prevention efforts can involve going into a school where a suicide has occurred and educating and providing counseling to survivors. Such an institutional response serves to minimize the mental health problems of survivors and can prevent future suicides. In 1999, the Surgeon General proposed the AIM program with three areas for reducing suicide: awareness, intervention, and methodology.
7. The right to suicide: Moral, ethical, and legal implications (p. 412) The Catholic Church sees suicide as a sin. On the other hand, Thomas Szasz criticizes suicide prevention programs because they limit individual options and personal responsibility. Some people contend that the elderly have the right to end their lives when they suffer terminal illness or an incapacitating illness that causes others misery. The quality of life is a significant moral and ethical issue that has led to right-to-die legislation and living wills that are recognized in several states. Dr. Jack Kevorkian, a physician in Michigan, has assisted patients to commit suicide, an act that a new law states is illegal. In 1998, Oregon votes passed a bill to allow physicians to help terminally ill patients die. Mental health professionals, like their medical colleagues, must face the issue of treating people who want to die, dealing with issues of ethics and human values. Werth set out basic criteria for professional to help make a decision to assist in terminating someones life, including a hopeless condition, lack of coercion, the patient is rational, and the decision is consistent with the patients values. Practicing therapists must consider their responsibility to keep someone alive who wants to die and the legal consequences of allowing someone to die. The Constitution appears to provide a basis for the right to refuse treatment, but therapists who fail to prevent suicides can anticipate that they will be sued.