Suicide: A Global Perspective

The assessment and management of suicide risk are probably the most difficult tasks that clinicians encounter during their professional careers despite the abundant literature and guidelines now available. Each health professional should be able to perform an assessment of suicide risk, although such assessments are usually performed by psychiatrists. During such assessments, clinicians may be helped by psychometric instruments despite the fact that such instruments are not in many cases entirely reliable. The management of suicide risk is an art that must be based on science. Clinicians should evaluate the role of pharmacotherapy, psychotherapy and hospitalization in the reduction of suicide risk, while maintaining high levels of empathy with the patient. At the present time, only lithium and clozapine have shown promise for reducing suicidality, more so than antidepressants. Education of psychotherapists and medical staff remains one of the priorities for better assessing and managing suicide risk.

The impact of culture of suicide, both at the aggregate level and the individual level, is discussed. The deleterious impact of a changing culture, especially for native and aboriginal groups, is noted, and the assumption of the cultural invariability of suicidal phenomena questioned. The implications of cultural differences for counseling the suicidal client are explored.

As a result of the strong link between mental illness and suicide, the diagnosis and treatment of psychiatric disorders have been always considered a first-choice strategy in the prevention of suicide. However, prevention may take advantage from the study of other factors that may help to explain inequalities in the suicide rates between countries and fluctuations over time. The aim of the present chapter is to review empirical research which has investigated the impact of economic crises and recession on suicide. To this goal we performed careful MedLine and PsycINFO searches from 1980 to 2010. Our analysis of the literature indicates that there is no strong evidence that a recession in the economy is a causal factor for suicide.

Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. We reviewed evidence for the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. The results of our review indicate a clear link between alcohol use disorders and suicide but, to date, the causal nature of this relationship is speculative. The solution may be in research investigating the possible biological, social and psychological variables that mediate this link.

The phenomenon of suicide has been present throughout human history. It can be identified throughout the world as a consequence of factors pertaining to health, culture, and history. Cultural, ethnic and sociological aspects have been clarified by means of studies examining gender and age difference. In an ever more globalised world, migration and the formation of ethnic minorities within host countries, in conjunction with distinct socio-cultural features leads to new challenges regarding suicidal tendency. It is evident from past studies that the data that we have originates in various countries and when we refer to factors such as risk or protection in minorities we are referring to minorities which are not part of or related to our own cultural circle or our own country. The origin of data can limit the usefulness of our work. We can access limited scientific resources but are confronted with various methodological difficulties. The definition of minority, race and immigrant alone varies from country to country. Interaction between minority and host country, social integration and circumstance vary considerably. Despite these limitations chapter sets out to examine the ethnic aspect of suicide and provide an overall view however fragmented it may be.

Parallel to the growing interest in spiritual life in mainstream culture, in Western culture there has been an increasing distinction between religion and spirituality. This article defines the concept of spirituality and its constitutive elements and presents evidence from the literature to show that, in spite of its importance for mental health patients and suicidal people, it is still an overlooked area in Suicidology. Not only are there relatively few studies addressing this topic, but ‘religion/spirituality’ is usually just one of a series of variables, generally measured with a single question (mainly inquiring about church attendance/affiliation). Furthermore, studies on non-religious forms of spirituality are rare. Attention is also given to meaning and purpose in life, a central aspect of spirituality that has been generally neglected in suicide research. Some examples of instrument to measure spiritual constructs are provided, with a particular focus on meaning/purpose in life. The paper concludes with suggestions for future research and stressing the importance of considering spirituality in the clinical assessment and treatment of suicidal behavior.

The present chapter reviews research on suicide in prisons and jails. The characteristics of prisoners committing suicide are described, the role of screening discussed, and the need for adequate training and standards for care to be implemented noted.

Literature has widely documented the positive association of unemployment with suicide. Since 1997, the transition of suicide rate has been in line with the unemployment rate in Hong Kong. We aim to examine the suicide risk ratio between the unemployed and the employed during the period of 2003-2006 by age and gender, and explore such unknown suicide-related socioeconomic factors as living arrangement and marital status among the unemployed. Descriptive analysis and Chi-square Test are employed. Results show that not every member in the community can benefit from economic recovery, for the unemployed individuals tend to face heightened risks of completing suicide in times of economic recovery. For developing an effective strategy for suicide prevention, the government should put more effort to empower unemployed individuals.

Therapeutic research on suicide was virtually unknown a decade ago, but recently a great deal of clinically important information has emerged. A landmark event was approval by the US FDA of antisuicidal effects of clozapine in schizophrenia patients in 2003. Interest in effects of psychotropic drug treatments on suicidal behavior was strongly stimulated by recent regulatory warnings of increased risk of suicidal thoughts or behaviors in juveniles and young adults treated with modern antidepressants. This chapter reviews recent research findings pertaining to effects of psychoactive drugs on suicide risk. Antipsychotics other than clozapine are not known to reduce suicidal risk. Lithium has compelling evidence of long-term effectiveness in reducing risks of suicide and attempts by as much as 80% among patients with bipolar disorders, a mix of major affective disorders, and possibly also recurrent major depressive disorder. Its effects may be superior to those of some mood-stabilizing anticonvulsants. Several ecological studies, especially in the US and Nordic countries, find inverse associations between prescriptions for modern antidepressants and temporal or regional variance in suicide rates. However, suicide rates decreased in the same countries even before introduction of modern antidepressants, and other factors may be involved. Notably, lower regional suicide rates are associated with indices of greater access to clinical care. Many large cohort and case-control studies have found reduced suicidal risk with long-term antidepressant treatment; a minority found increased risk, which may be confounded by association of antidepressant treatment with more severe illness and selection of relatively nontoxic modern antidepressants for patients at increased suicidal risk. In many randomized, controlled trials in adults, antidepressants show reductions in suicidal ideation, along with other depressive symptoms, but without consistent effects on rates of suicidal acts. The FDA finds evidence of increased risk of suicidal thoughts and perhaps of attempts in juvenile and young adult patients treated with modern antidepressants vs. a placebo. It has long been recognized that some depressed patients experience increased agitation soon after exposure to antidepressants, and such reactions may increase suicidal risk. These effects usually can be anticipated and minimized by timely clinical interventions. The findings of beneficial effects of antidepressant treatment on suicidal ideation but not behavior, and of reduced risk of suicidal behaviors by lithium and clozapine, suggest differential pharmacologic effects on particular components of “suicidality,” in that reduction of anger, aggression and impulsivity evidently can limit progression from suicidal ideation to acts. Effective suicide prevention requires focused assessment and supervision, especially early in clinical management of patients with major mood disorders, with appropriate pharmacological and psychosocial interventions.

The villain for the would-be suicide attempter is pain; clinicians need something to fight that pain, an anodyne. Psychotherapy is such; yet, to assuage the pain, the clinician primarily needs to know what he/she is treating. This paper, thus, first offers an empirical, cross-cultural perspective on that ‘what,’ illustrated with the writings of William Styron. It is argued once one understands what we are treating, effective psychotherapy comes naturally. An outline of some common factors (or commonalities) in the field of psychotherapy with suicidal people is presented. The most essential common factor is the therapeutic relationship. What is effective and what is lethal are outlined, concluding that to treat the suicidal attempter effectively, the clinician has to be person-centred, not mental disorder centred. He/she has to know whom he/she is treating; this is quality care.

Suicide rates in Europe range from the very low to the highest in the world. For many years, Hungary had the highest suicide rate in the world but, in recent years, the newly independent Baltic States have risen to the top. Meanwhile, southern European nations, such as Greece and Spain, have very low suicide rates. The present chapter briefly reviews some of the intriguing trends and findings about suicide in Europe.

More than half of the world’s population lives in Asia1, and the region is diverse in ethnicity and religion, ranging from India where the major religion is Hinduism to Japan where the major religions are Buddhism and Shinto. The rates of suicide differ in the nations making up Asia, as do the methods used for suicide and trends in the suicide rates over the years. This chapter will briefly review some of the facts pertaining to suicide in Asia and identify similarities and differences from suicide elsewhere in the world.

Asia accounts for more than half of all suicides in the world. Suicide rates in Asia vary vastly across the continent. Most suicides occur in China, India and Japan contributing more than 300,000 fatalities every year – about 40% of all suicides in the world. Countries in West Asia including the Middle East report very low rates, whereas countries such as Japan and Korea report much higher rates of suicide. These rates seem to have increased since the Asian Economic crisis that began in 1997 and has not abated since. A major problem with the study of suicide in Asia is, apart from a number of exceptions, the relative paucity of accurate suicide statistics. A few countries provide reliable data but the majority do not, and some provide none at all.

While hanging is the most popular method of committing suicide in most countries the use of pesticides is of particular concern in Asia, especially in rural areas. Suicide prevention programs are strongly supported by the government in a few countries and are non-existent in some others. Socio-cultural and political factors contribute to this state of affairs.

The present chapter reviews epidemiological research on suicidal behavior in Australia, in the population as a whole and in Indigenous Australians and immigrants. Australia has proposed a National Suicide Prevention Strategy, and this is briefly described.

The epidemiology of completed suicide in Canada and the United States is described, and the differences in the results between the two countries are noted. For the United States, suicidal behavior in the various immigrants and native groups is explored while, for Canada, the efforts to develop a uniquely Canadian suicidology are discussed.

Suicide rates in Latin America are lower than in other regions of the world. The suicide behaviour is known starting with the pre Colombian culture and right now it is associated with specific factors such as poverty, violence and displacement.

The suicide rates are increasing in countries such Brazil, Chile, Costa Rica, Ecuador, México, Nicaragua, Paraguay y Uruguay as especially among teenagers and old people.

With the exception of Mexico, suicides are more frequent in men and the well known method is the mechanical asphyxia.

The few epidemiological studies have identified as factors of risk in family background, the presence of depressive and anxiety disorders, the abuse of psychoactive substances and alcohol, family dysfunction and school abuse (buying).

In some countries in Latin América there are programs of suicide prevention than consist in the epidemiological surveillance early detection of mental pathologies, psycho education and family attendance, nevertheless in countries with higher signs of poverty, suicide is not considered as a public health problem.

Austria ranked among the countries with highest suicide rates for decades. The suicide rate increased until 1986, but decreased continuously since then. At present, Austria’s suicide rate is about the European average. The most common method for both sexes is hanging, followed by shooting (for men) or jumping from heights (for women). This chapter presents epidemiological data as well as a study concerning the acceptance of suicide motives. Furthermore, the Austrian National Suicide Prevention Plan is outlined. It comprises activities to increase awareness of suicide risk, support and treatment after suicide attempts, treatment of mental illness, education of health care staff, restriction of access to means of suicide, and responsible media reporting. Although the plan has not yet been approved by the Austrian parliament, many of the activities have already been implemented on a regional level.

The present chapter reviews the existing evidence regarding the link between physical activity, active and passive involvement in sports, and suicidal behavior, and presents possible explanations regarding this relationship as well as their application for suicide prevention.

The review explores the association between completed suicide and neoplasms. Several studies demonstrated that the risk of suicide in cancer patients is higher than that for the general population. The risk of suicide increases with disease severity; the severity of the cancer increases the suicide risk. The risk is highest shortly after the diagnosis has been made, but for some cancer types, the risk remains increased for more than 5 years after diagnosis. Men have a higher suicide risk than women. Mood disorders, pain, and poor physical functioning are important clinical correlates. Screens for depression and suicide in people with cancer should be done after diagnosis and redone during the first 6 months regularly, particularly in the primary-care setting. More attention to cancer patients' psychological and care situation and public education are needed to decrease the stigma associated with having a cancer diagnosis. Assessment and treatment of depression could improve the prognosis for cancer patients who suffer from unrecognized depressions and in turn reduce their risk of suicide.

Lester [1] introduced self-mutilation into mainstream psychology with a review of relevant research in a leading journal of the American Psychological Association (Psychological Bulletin) and discusses the relationship between self-mutilation and suicidal behavior. The present chapter compares our current understanding of self-mutilation with that of attempted suicide to explore similarities and differences.

Hypothalamic Pituitary Adrenal (HPA) axis hyperactivity measured with the dexamethasonesuppression test and the dexamethesone/CRH test may be found to have some predictive power for suicidal behavior in mood disorders. Increased prolactin (PRL) levels may be related both to physiological and pathological conditions. HPA axis abnormalities and increased levels of PRL may coexist and common neuroendocrine changes may activate both HPA axis and PRL release. HPA axis hyperactivity is presumably present in a large subpopulation of depressed subjects. Suicidal behavior is considered to be a form of inward directed aggression and aggressive behavior has been connected to high androgen levels. However, lower plasma total testosterone levels have also been reported in subjects with depression and higher suicidality. Lipid/immune dysregulations, the increased ratio of blood fatty acids and increased PRL levels may be associated with the increased production of pro-inflammatory cytokines, which were reported both in major depression and suicidal behavior. Although no studies have been done to determine whether antemortem physical stress may be detected by raised post-mortem PRL, this would be of great interest for physicians.

Murder - suicide is an event where a person kills another and then suicide. Murder - suicide is more rare than other forms of violent deaths, but it is certainly mostly tragic and usually more shocking than homicide or suicide when taken individually, especially when the event involves a mass murder.

This chapter will present an overview of the main types of murder-suicide, outlining the most common features of the crime and providing some guidelines on prevention. Thematic context of homicide followed by suicide, including victim - perpetrator relationship, age, sex, race, ethnicity, and occupation in addition to precipitating factors, motivation, type of fatal injury, and location of event, is discussed.

For each different category of crime the incidence of the phenomenon in the Italian context is given. The Italian data were collected in a span of 24 years (from 1 January 1985 to December 31, 2008), using the information disclosed by the state press agency and the four national newspapers of greater circulation.

Suicide among older adults is a critical public health problem. International statistics indicate an average of one suicide in the world every 90 minutes among those 65 years of age and older. The assessment of suicide risk in older people should include the assessment of risk factors such as the presence of physical illness, functional limitations, the severity of depression and hopelessness, a lack of reasons for living, social isolation and the occurrence of stressful life events. In addition, greater emphasis should be placed in medical education on the recognition and effective treatment of depressive disorders and suicidal states in older people.