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Wikipedia

Suicide

January 10, 2023

For information on prevention, see suicide prevention. For other uses, see suicide (disambiguation).

Suicide is the act of intentionally causing one's own death.[9] Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and substance abuse (including alcoholism and the use of and withdrawal from benzodiazepines) are risk factors.[2][3][5][10] Some suicides are impulsive acts due to stress (such as from financial or academic difficulties), relationship problems (such as breakups or divorces), or harassment and bullying.[2][11][12] Those who have previously attempted suicide are at a higher risk for future attempts.[2] Effective suicide prevention efforts include limiting access to methods of suicide such as firearms, drugs, and poisons; treating mental disorders and substance abuse; careful media reporting about suicide; and improving economic conditions.[2][13] Although crisis hotlines are common resources, their effectiveness has not been well studied.[14][15]

Suicide
The Suicide by Édouard Manet
SpecialtyPsychiatry, clinical psychology, clinical social work
Usual onset15–30 and 70+ years old[1]
Risk factorsDepression, bipolar disorder, autism, schizophrenia, personality disorders, anxiety disorders, alcoholism, substance abuse[2][3][4][5]
PreventionLimiting access to methods of suicide, treating mental disorders and substance misuse, careful media reporting about suicide, improving social and economic conditions[2]
Frequency12 per 100,000 per year[6]
Deaths793,000 / 1.5% of deaths (2016)[7][8]

The most commonly adopted method of suicide varies from country to country and is partly related to the availability of effective means.[16] Common methods of suicide include hanging, pesticide poisoning, and firearms.[2][17] Suicides resulted in 828,000 deaths globally in 2015, an increase from 712,000 deaths in 1990.[18][19][inconsistent] This makes suicide the 10th leading cause of death worldwide.[3][6]

Approximately 1.5% of all deaths worldwide are by suicide.[8] In a given year, this is roughly 12 per 100,000 people.[6] Rates of suicide are generally higher among men than women, ranging from 1.5 times higher in the developing world to 3.5 times higher in the developed world.[1] Suicide is generally most common among those over the age of 70; however, in certain countries, those aged between 15 and 30 are at the highest risk.[1] Europe had the highest rates of suicide by region in 2015.[20] There are an estimated 10 to 20 million non-fatal attempted suicides every year.[21] Non-fatal suicide attempts may lead to injury and long-term disabilities.[22] In the Western world, attempts are more common among young people and women.[22]

Views on suicide have been influenced by broad existential themes such as religion, honor, and the meaning of life.[23][24] The Abrahamic religions traditionally consider suicide as an offense towards God due to the belief in the sanctity of life.[25] During the samurai era in Japan, a form of suicide known as seppuku (腹切り, harakiri) was respected as a means of making up for failure or as a form of protest.[26] Sati, a practice outlawed by the British in India, expected a Hindu widow to immolate herself on her husband's funeral pyre, either willingly or under pressure from her family and society.[27] Suicide and attempted suicide, while previously illegal, are no longer so in most Western countries.[28] It remains a criminal offense in some countries.[29] In the 20th and 21st centuries, suicide has been used on rare occasions as a form of protest, and kamikaze and suicide bombings have been used as a military or terrorist tactic.[30] Suicide is often seen as a major catastrophe for families, relatives, and other nearby supporters, and it is viewed negatively almost everywhere around the world.[31][32][33]

Definitions

Main article: Suicide terminology

Suicide, derived from Latin suicidium, is "the act of taking one's own life".[9][34] Attempted suicide or non-fatal suicidal behavior amounts to self-injury with at least some desire to end one's life that does not result in death.[35][36] Assisted suicide occurs when one individual helps another bring about their own death indirectly via providing either advice or the means to the end.[37] This is in contrast to euthanasia, where another person takes a more active role in bringing about a person's death.[37] Suicidal ideation is thoughts of ending one's life but not taking any active efforts to do so.[35] It may or may not involve exact planning or intent.[36] In a murder–suicide (or homicide–suicide), the individual aims at taking the lives of others at the same time. A special case of this is extended suicide, where the murder is motivated by seeing the murdered persons as an extension of their self.[38] Suicide in which the reason is that the person feels that they are not part of society is known as egoistic suicide.[39]

In 2011, the Centre for Suicide Prevention in Canada found that the normal verb in scholarly research and journalism for the act of suicide was commit.[40][41] On the other hand, the American Psychological Association lists "committed suicide" as a term to avoid because it "frame[s] suicide as a crime".[42] Some advocacy groups recommend using the terms took his/her own life, died by suicide, or killed him/herself instead of committed suicide.[43][44][45] The Associated Press Stylebook recommends avoiding "committed suicide" except in direct quotes from authorities.[46] The Guardian and Observer style guides deprecate the use of "committed",[47] as does CNN.[48] Opponents of commit argue that it implies that suicide is criminal, sinful, or morally wrong.[49]

Risk factors

Precipitating circumstances in the US, 2017[50]
Categories Percentage
Diagnosed mental problem
 
 50%
Recent or upcoming crisis
 
 31%
Intimate partner problem
 
 27%
Physical health problem
 
 21%
Alcohol problem
 
 18%
Substance abuse (excluding alcohol)
 
 18%
Argument
 
 16%
Family problem
 
 10%
Job problem
 
 10%
Financial problem
 
 9%
Legal problem
 
 8%
Death of loved one
 
 7%
Suicide is multi-factorial. Multiple precipitating circumstances and risk factors can apply to the same person.

Factors that affect the risk of suicide include mental disorders, drug misuse, psychological states, cultural, family and social situations, genetics, experiences of trauma or loss, and nihilism.[51][52][15] Mental disorders and substance misuse frequently co-exist.[53] Other risk factors include having previously attempted suicide,[22] the ready availability of a means to take one's life, a family history of suicide, or the presence of traumatic brain injury.[54] For example, suicide rates have been found to be greater in households with firearms than those without them.[55]

Socio-economic problems such as unemployment, poverty, homelessness, and discrimination may trigger suicidal thoughts.[56][57] Suicide might be rarer in societies with high social cohesion and moral objections against suicide.[36] About 15–40% of people leave a suicide note.[58] War veterans have a higher risk of suicide due in part to higher rates of mental illness, such as post-traumatic stress disorder, and physical health problems related to war.[59] Genetics appears to account for between 38% and 55% of suicidal behaviors.[60] Suicides may also occur as a local cluster of cases.[61]

Most research does not distinguish between risk factors that lead to thinking about suicide and risk factors that lead to suicide attempts.[62][63] Risks for suicide attempt rather than just thoughts of suicide include a high pain tolerance and a reduced fear of death.[64]

Mental illness

 
A picture of a woman with depression, who was suicidal

Mental illness is present at the time of suicide 27% to more than 90% of the time.[65][22][66][67] Of those who have been hospitalized for suicidal behavior, the lifetime risk of suicide is 8.6%.[22][68] Comparatively, non-suicidal people hospitalized for affective disorders have a 4% lifetime risk of suicide.[68] Half of all people who die by suicide may have major depressive disorder; having this or one of the other mood disorders such as bipolar disorder increases the risk of suicide 20-fold.[69] Other conditions implicated include schizophrenia (14%), personality disorders (8%),[70][71] obsessive–compulsive disorder,[72] and post-traumatic stress disorder.[22] Those with autism also attempt and consider suicide more frequently.[73]

Others estimate that about half of people who die by suicide could be diagnosed with a personality disorder, with borderline personality disorder being the most common.[74] About 5% of people with schizophrenia die of suicide.[75] Eating disorders are another high risk condition.[76] Around 22% to 50% of people suffering with gender dysphoria have attempted suicide, however this greatly varies by region.[77][78][79][80][81]

Among approximately 80% of suicides, the individual has seen a physician within the year before their death,[82] including 45% within the prior month.[83] Approximately 25–40% of those who died by suicide had contact with mental health services in the prior year.[65][82] Antidepressants of the SSRI class appear to increase the frequency of suicide among children but do not change the risk among adults.[84] An unwillingness to get help for mental health problems also increases the risk.[61]

Previous attempts

A previous history of suicide attempts is the most accurate predictor of suicide.[22] Approximately 20% of suicides have had a previous attempt, and of those who have attempted suicide, 1% die by suicide within a year[22] and more than 5% die by suicide within 10 years.[76]

Self-harm

Non-suicidal self-harm is common with 18% of people engaging in self-harm over the course of their life.[85]: 1  Acts of self-harm are not usually suicide attempts and most who self-harm are not at high risk of suicide.[86] Some who self-harm, however, do still end their life by suicide, and risk for self-harm and suicide may overlap.[86] Individuals who have been identified as self-harming after being admitted to hospital are 68% (38–105%) more likely to die by suicide.[87]: 279 

Psychosocial factors

A number of psychological factors increase the risk of suicide including: hopelessness, loss of pleasure in life, depression, anxiousness, agitation, rigid thinking, rumination, thought suppression, and poor coping skills.[69][88][89] A poor ability to solve problems, the loss of abilities one used to have, and poor impulse control also play a role.[69][90] In older adults, the perception of being a burden to others is important.[91] Those who have never married are also at greater risk.[22] Recent life stresses, such as a loss of a family member or friend or the loss of a job, might be a contributing factor.[69][61]

Certain personality factors, especially high levels of neuroticism and introvertedness, have been associated with suicide. This might lead to people who are isolated and sensitive to distress to be more likely to attempt suicide.[88] On the other hand, optimism has been shown to have a protective effect.[88] Other psychological risk factors include having few reasons for living and feeling trapped in a stressful situation.[88] Changes to the stress response system in the brain might be altered during suicidal states.[36] Specifically, changes in the polyamine system[92] and hypothalamic–pituitary–adrenal axis.[93]

Social isolation and the lack of social support has been associated with an increased risk of suicide.[88] Poverty is also a factor,[94] with heightened relative poverty compared to those around a person increasing suicide risk.[95] Over 200,000 farmers in India have died by suicide since 1997, partly due to issues of debt.[96] In China, suicide is three times as likely in rural regions as urban ones, partly, it is believed, due to financial difficulties in this area of the country.[97]

The time of year may also affect suicide rates. There appears to be a decrease around Christmas,[98] but an increase in rates during spring and summer, which might be related to exposure to sunshine.[36] Another study found that the risk may be greater for males on their birthday.[99]

Being religious may reduce one's risk of suicide while beliefs that suicide is noble may increase it.[100][61][101] This has been attributed to the negative stance many religions take against suicide and to the greater connectedness religion may give.[100] Muslims, among religious people, appear to have a lower rate of suicide; however, the data supporting this is not strong.[29] There does not appear to be a difference in rates of attempted suicide.[29] Young women in the Middle East may have higher rates.[102]

Substance misuse

 
"The Drunkard's Progress", 1846 demonstrating how alcoholism can lead to poverty, crime, and eventually suicide

Substance misuse is the second most common risk factor for suicide after major depression and bipolar disorder.[103] Both chronic substance misuse as well as acute intoxication are associated.[53][104] When combined with personal grief, such as bereavement, the risk is further increased.[104] Substance misuse is also associated with mental health disorders.[53]

Most people are under the influence of sedative-hypnotic drugs (such as alcohol or benzodiazepines) when they die by suicide,[105] with alcoholism present in between 15% and 61% of cases.[53] Use of prescribed benzodiazepines is associated with an increased rate of suicide and attempted suicide. The pro-suicidal effects of benzodiazepines are suspected to be due to a psychiatric disturbance caused by side effects, such as disinhibition, or withdrawal symptoms.[10] Countries that have higher rates of alcohol use and a greater density of bars generally also have higher rates of suicide.[106] About 2.2–3.4% of those who have been treated for alcoholism at some point in their life die by suicide.[106] Alcoholics who attempt suicide are usually male, older, and have tried to take their own lives in the past.[53] Between 3 and 35% of deaths among those who use heroin are due to suicide (approximately fourteenfold greater than those who do not use).[107] In adolescents who misuse alcohol, neurological and psychological dysfunctions may contribute to the increased risk of suicide.[108]

The misuse of cocaine and methamphetamine has a high correlation with suicide.[53][109] In those who use cocaine, the risk is greatest during the withdrawal phase.[110] Those who used inhalants are also at significant risk with around 20% attempting suicide at some point and more than 65% considering it.[53] Smoking cigarettes is associated with risk of suicide.[111] There is little evidence as to why this association exists; however, it has been hypothesized that those who are predisposed to smoking are also predisposed to suicide, that smoking causes health problems which subsequently make people want to end their life, and that smoking affects brain chemistry causing a propensity for suicide.[111] Cannabis, however, does not appear to independently increase the risk.[53]

Medical conditions

There is an association between suicidality and physical health problems such as[76] chronic pain,[112] traumatic brain injury,[113] cancer,[114] chronic fatigue syndrome,[115] kidney failure (requiring hemodialysis), HIV, and systemic lupus erythematosus.[76] The diagnosis of cancer approximately doubles the subsequent frequency of suicide.[114] The prevalence of increased suicidality persisted after adjusting for depressive illness and alcohol abuse. Among people with more than one medical condition the frequency was particularly high. In Japan, health problems are listed as the primary justification for suicide.[116]

Sleep disturbances, such as insomnia[117] and sleep apnea, are risk factors for depression and suicide. In some instances, the sleep disturbances may be a risk factor independent of depression.[118] A number of other medical conditions may present with symptoms similar to mood disorders, including hypothyroidism, Alzheimer's, brain tumors, systemic lupus erythematosus, and adverse effects from a number of medications (such as beta blockers and steroids).[22]

Occupational factors

See also: Suicide in the military

Certain occupations carry an elevated risk of self-harm and suicide, such as military careers. Research in several countries has found that the rate of suicide among former armed forces personnel in particular,[119][120][121][122] and young veterans especially,[123][124][119] is markedly higher than that found in the general population.

Media

See also: Copycat suicide and Social media and suicide
 
In Goethe's The Sorrows of Young Werther, the title character kills himself due to a love triangle involving Charlotte (pictured at his grave). Some admirers of the story were triggered into copycat suicide, known as the "Werther effect".

The media, including the Internet, plays an important role.[51][88] Certain depictions of suicide may increase its occurrence, with high-volume, prominent, repetitive coverage glorifying or romanticizing suicide having the most impact.[125] When detailed descriptions of how to kill oneself by a specific means are portrayed, this method of suicide can be imitated in vulnerable people.[16] This phenomenon has been observed in several cases after press coverage.[126][127] In a bid to reduce the adverse effect of media portrayals concerning suicide report, one of the effective methods is to educate journalists on how to report suicide news in a manner that might reduce that possibility of imitation and encourage those at risk to seek for help. When journalists follow certain reporting guidelines the risk of suicides can be decreased.[125] Getting buy-in from the media industry, however, can be difficult, especially in the long term.[125]

This trigger of suicide contagion or copycat suicide is known as the "Werther effect", named after the protagonist in Goethe's The Sorrows of Young Werther who killed himself and then was emulated by many admirers of the book.[128] This risk is greater in adolescents who may romanticize death.[129] It appears that while news media has a significant effect, that of the entertainment media is equivocal.[130][131] It is unclear if searching for information about suicide on the Internet relates to the risk of suicide.[132] The opposite of the Werther effect is the proposed "Papageno effect", in which coverage of effective coping mechanisms may have a protective effect. The term is based upon a character in Mozart's opera The Magic Flute—fearing the loss of a loved one, he had planned to kill himself until his friends helped him out.[128] As a consequence, fictional portrayals of suicide, showing alternative consequences or negative consequences, might have a preventive effect,[133] for instance fiction might normalize mental health problems and encourage help-seeking.[134]

Other factors

Trauma is a risk factor for suicidality in both children[135] and adults.[88] Some may take their own lives to escape bullying or prejudice.[136] A history of childhood sexual abuse[137] and time spent in foster care are also risk factors.[138] Sexual abuse is believed to contribute to approximately 20% of the overall risk.[60] Significant adversity early in life has a negative effect on problem-solving skills and memory, both of which are implicated in suicidality.[36]

Problem gambling is associated with increased suicidal ideation and attempts compared to the general population.[139] Between 12 and 24% of pathological gamblers attempt suicide.[140] The rate of suicide among their spouses is three times greater than that of the general population.[140] Other factors that increase the risk in problem gamblers include concomitant mental illness, alcohol, and drug misuse.[141]

Genetics might influence rates of suicide. A family history of suicide, especially in the mother, affects children more than adolescents or adults.[88] Adoption studies have shown that this is the case for biological relatives, but not adopted relatives. This makes familial risk factors unlikely to be due to imitation.[36] Once mental disorders are accounted for, the estimated heritability rate is 36% for suicidal ideation and 17% for suicide attempts.[36] An evolutionary explanation for suicide is that it may improve inclusive fitness. This may occur if the person dying by suicide cannot have more children and takes resources away from relatives by staying alive. An objection is that deaths by healthy adolescents likely does not increase inclusive fitness. Adaptation to a very different ancestral environment may be maladaptive in the current one.[90][142]

Infection by the parasite Toxoplasma gondii, more commonly known as toxoplasmosis, has been linked with suicide risk. One explanation states that this is caused by altered neurotransmitter activity due to the immunological response.[36]

There appears to be a link between air pollution and depression and suicide.[143]

Rational

 
Teenage recruits for Japanese Kamikaze suicide pilots in May 1945

Rational suicide is the reasoned taking of one's own life.[144] However, some consider suicide as never being rational.[144]

Euthanasia and assisted suicide are accepted practices in a number of countries among those who have a poor quality of life without the possibility of getting better.[145][146] They are supported by the legal arguments for a right to die.[146]

The act of taking one's life for the benefit of others is known as altruistic suicide.[147] An example of this is an elder ending his or her life to leave greater amounts of food for the younger people in the community.[147] Suicide in some Inuit cultures has been seen as an act of respect, courage, or wisdom.[148]

A suicide attack is a political or religious action where an attacker carries out violence against others which they understand will result in their own death.[149] Some suicide bombers are motivated by a desire to obtain martyrdoms or are religiously motivated.[59] Kamikaze missions were carried out as a duty to a higher cause or moral obligation.[148] Murder–suicide is an act of homicide followed within a week by suicide of the person who carried out the act.[150]

Mass suicides are often performed under social pressure where members give up autonomy to a leader.[151] Mass suicides can take place with as few as two people, often referred to as a suicide pact.[152] In extenuating situations where continuing to live would be intolerable, some people use suicide as a means of escape.[153][154] Some inmates in Nazi concentration camps are known to have killed themselves during the Holocaust by deliberately touching the electrified fences.[155]

Methods

 
Deaths by gun-related suicide versus non-gun-related suicide rates per 100,000 in high-income countries in 2010[156]
Main article: Suicide methods

The leading method of suicide varies among countries. The leading methods in different regions include hanging, pesticide poisoning, and firearms.[17] These differences are believed to be in part due to availability of the different methods.[16] A review of 56 countries found that hanging was the most common method in most of the countries,[17] accounting for 53% of male suicides and 39% of female suicides.[157]

Worldwide, 30% of suicides are estimated to occur from pesticide poisoning, most of which occur in the developing world.[2] The use of this method varies markedly from 4% in Europe to more than 50% in the Pacific region.[158] It is also common in Latin America due to the ease of access within the farming populations.[16] In many countries, drug overdoses account for approximately 60% of suicides among women and 30% among men.[159] Many are unplanned and occur during an acute period of ambivalence.[16] The death rate varies by method: firearms 80–90%, drowning 65–80%, hanging 60–85%, jumping 35–60%, charcoal burning 40–50%, pesticides 60–75%, and medication overdose 1.5–4.0%.[16] The most common attempted methods of suicide differ from the most common methods of completion; up to 85% of attempts are via drug overdose in the developed world.[76]

In China, the consumption of pesticides is the most common method.[160] In Japan, self-disembowelment known as seppuku (harakiri) still occurs;[160] however, hanging and jumping are the most common.[161] Jumping to one's death is common in both Hong Kong and Singapore at 50% and 80% respectively.[16] In Switzerland, firearms are the most frequent suicide method in young males, although this method has decreased since guns have become less common.[162][163] In the United States, 50% of suicides involve the use of firearms, with this method being somewhat more common in men (56%) than women (31%).[164] The next most common cause was hanging in males (28%) and self-poisoning in females (31%).[164] Together, hanging and poisoning constituted about 42% of U.S. suicides (as of 2017).[164]

Pathophysiology

There is no known unifying underlying pathophysiology for suicide;[22] it is believed to result from an interplay of behavioral, socio-economic and psychological factors.[16]

Low levels of brain-derived neurotrophic factor (BDNF) are both directly associated with suicide[165] and indirectly associated through its role in major depression, posttraumatic stress disorder, schizophrenia and obsessive–compulsive disorder.[166] Post-mortem studies have found reduced levels of BDNF in the hippocampus and prefrontal cortex, in those with and without psychiatric conditions.[167] Serotonin, a brain neurotransmitter, is believed to be low in those who die by suicide.[168] This is partly based on evidence of increased levels of 5-HT2A receptors found after death.[169] Other evidence includes reduced levels of a breakdown product of serotonin, 5-hydroxyindoleacetic acid, in the cerebral spinal fluid.[170] However, direct evidence is hard to obtain.[169] Epigenetics, the study of changes in genetic expression in response to environmental factors which do not alter the underlying DNA, is also believed to play a role in determining suicide risk.[171]

Prevention

Main article: Suicide prevention
 
 
As a suicide prevention initiative, these signs on the Golden Gate Bridge promote a special telephone that connects to a crisis hotline, as well as a 24/7 crisis text line.
 
A suicide prevention fence on a bridge

Suicide prevention is a term used for the collective efforts to reduce the incidence of suicide through preventive measures. Protective factors for suicide include support, and access to therapy.[52] About 60% of people with suicidal thoughts do not seek help.[172] Reasons for not doing so include low perceived need, and wanting to deal with the problem alone.[172] Despite these high rates, there are few established treatments available for suicidal behavior.[88]

Reducing access to certain methods, such as firearms or toxins such as opioids and pesticides, can reduce risk of suicide by that method.[16][173][15][36] This may be in part because suicide is often an impulsive decision, with up to 70% of near-fatal suicide attempts made after less than one hour of deliberation—thus, reducing access to easily-accessible methods of suicide may make impulsive attempts less likely to succeed.[174] Other measures include reducing access to charcoal (for burning) and adding barriers on bridges and subway platforms.[16][175][15] Treatment of drug and alcohol addiction, depression, and those who have attempted suicide in the past, may also be effective.[173][15] Some have proposed reducing access to alcohol as a preventive strategy (such as reducing the number of bars).[53]

In young adults who have recently thought about suicide, cognitive behavioral therapy appears to improve outcomes.[176][88] School-based programs that increase mental health literacy and train staff have shown mixed results on suicide rates.[15] Economic development through its ability to reduce poverty may be able to decrease suicide rates.[94] Efforts to increase social connection, especially in elderly males, may be effective.[177] In people who have attempted suicide, following up on them might prevent repeat attempts.[178] Although crisis hotlines are common, there is little evidence to support or refute their effectiveness.[14][15] Preventing childhood trauma provides an opportunity for suicide prevention.[135] The World Suicide Prevention Day is observed annually on 10 September with the support of the International Association for Suicide Prevention and the World Health Organization.[179]

Screening

IS PATH WARM [...] is an acronym [...] to assess [...] a potentially suicidal individual, (i.e., ideation, substance abuse, purposelessness, anger, feeling trapped, hopelessness, withdrawal, anxiety, recklessness, and mood).[180]

— American Association of Suicidology (2019)

There is little data on the effects of screening the general population on the ultimate rate of suicide.[181][182] Screening those who come to the emergency departments with injuries from self-harm have been shown to help identify suicide ideation and suicide intention. Psychometric tests such as the Beck Depression Inventory or the Geriatric Depression Scale for older people are being used.[183] As there is a high rate of people who test positive via these tools that are not at risk of suicide, there are concerns that screening may significantly increase mental health care resource utilization.[184] Assessing those at high risk, though, is recommended.[22] Asking about suicidality does not appear to increase the risk.[22]

Mental illness

See also: Antidepressants and suicide risk

In those with mental health problems, a number of treatments may reduce the risk of suicide. Those who are actively suicidal may be admitted to psychiatric care either voluntarily or involuntarily.[22] Possessions that may be used to harm oneself are typically removed.[76] Some clinicians get patients to sign suicide prevention contracts where they agree to not harm themselves if released.[22] However, evidence does not support a significant effect from this practice.[22] If a person is at low risk, outpatient mental health treatment may be arranged.[76] Short-term hospitalization has not been found to be more effective than community care for improving outcomes in those with borderline personality disorder who are chronically suicidal.[185][186]

There is tentative evidence that psychotherapy, specifically dialectical behaviour therapy, reduces suicidality in adolescents[187] as well as in those with borderline personality disorder.[188] It may also be useful in decreasing suicide attempts in adults at high risk.[189] However, a decrease in suicide has not been observed.[187]

There is controversy around the benefit-versus-harm of antidepressants.[51] In young persons, some antidepressants, such as SSRIs, appear to increase the risk of suicidality from 25 per 1000 to 40 per 1000.[190] In older persons, however, they may decrease the risk.[22] Lithium appears effective at lowering the risk in those with bipolar disorder and major depression to nearly the same levels as that of the general population.[191][192] Clozapine may decrease the thoughts of suicide in some people with schizophrenia.[193] Ketamine, which is a dissociative anaesthetic, seems to lower the rate of suicidal ideation.[194] In the United States, health professionals are legally required to take reasonable steps to try to prevent suicide.[195][196]

Epidemiology

Main articles: Epidemiology of suicide and List of countries by suicide rate
See also: Seasonal effects on suicide rates

Approximately 1.4% of people die by suicide, a mortality rate of 11.6 per 100,000 persons per year.[6][22] Suicide resulted in 842,000 deaths in 2013 up from 712,000 deaths in 1990.[19] Rates of suicide have increased by 60% from the 1960s to 2012, with these increases seen primarily in the developing world.[3] Globally, as of 2008/2009, suicide is the tenth leading cause of death.[3] For every suicide that results in death there are between 10 and 40 attempted suicides.[22]

Suicide rates differ significantly between countries and over time.[6] As a percentage of deaths in 2008 it was: Africa 0.5%, South-East Asia 1.9%, Americas 1.2% and Europe 1.4%.[6] Rates per 100,000 were: Australia 8.6, Canada 11.1, China 12.7, India 23.2, United Kingdom 7.6, United States 11.4 and South Korea 28.9.[197][198] It was ranked as the 10th leading cause of death in the United States in 2016 with about 45,000 cases that year.[199] Rates have increased in the United States in the last few years,[199] with the highest value being in 2017 (the most recent data).[200] In the United States, about 650,000 people are seen in emergency departments yearly due to attempting suicide.[22] The United States rate among men in their 50s rose by nearly half in the decade 1999–2010.[201] Greenland, Lithuania, Japan, and Hungary have the highest rates of suicide.[6] Around 75% of suicides occur in the developing world.[2] The countries with the greatest absolute numbers of suicides are China and India, partly due to their large population size, accounting for over half the total.[6] In China, suicide is the 5th leading cause of death.[202]

  •  

    Death rate from suicide per 100,000 as of 2017[203]

  •  

    Share of deaths from suicide, 2017[204]

Sex and gender

Main article: Gender differences in suicide
 
 
Suicide rates per 100,000 males (left) and females (right).

Globally as of 2012, death by suicide occurs about 1.8 times more often in males than females.[6][205] In the Western world, males die three to four times more often by means of suicide than do females.[6] This difference is even more pronounced in those over the age of 65, with tenfold more males than females dying by suicide.[206] Suicide attempts and self-harm are between two and four times more frequent among females.[22][207][208] Researchers have attributed the difference between suicide and attempted suicide among the sexes to males using more lethal means to end their lives.[206][209][210] However, separating intentional suicide attempts from non-suicidal self-harm is not currently done in places like the United States when gathering statistics at the national level.[211]

China has one of the highest female suicide rates in the world and is the only country where it is higher than that of men (ratio of 0.9).[6][202] In the Eastern Mediterranean, suicide rates are nearly equivalent between males and females.[6] The highest rate of female suicide is found in South Korea at 22 per 100,000, with high rates in South-East Asia and the Western Pacific generally.[6]

A number of reviews have found an increased risk of suicide among lesbian, gay, bisexual, and transgender people.[212][213] Among transgender persons, rates of attempted suicide are about 40% compared to a general population rate of 5%.[214][215] This is believed to in part be due to social stigmatisation.[216]

Age

 
Suicide rates by age[217]

In many countries, the rate of suicide is highest in the middle-aged[218] or elderly.[16] The absolute number of suicides, however, is greatest in those between 15 and 29 years old, due to the number of people in this age group.[6] Worldwide, the average age of suicide is between age 30 and 49 for both men and women.[219] This means that half of people who died by suicide were approximately age 40 or younger, and half were older.[219] Suicidality is rare in children, but increases during the transition to adolescence.[220]

In the United States, the suicide death rate is greatest in Caucasian men older than 80 years, even though younger people more frequently attempt suicide.[22] It is the second most common cause of death in adolescents[51] and in young males is second only to accidental death.[218] In young males in the developed world, it is the cause of nearly 30% of mortality.[218] In the developing world rates are similar, but it makes up a smaller proportion of overall deaths due to higher rates of death from other types of trauma.[218] In South-East Asia, in contrast to other areas of the world, deaths from suicide occur at a greater rate in young females than elderly females.[6]

History

Main article: History of suicide
 
The Ludovisi Gaul killing himself and his wife, Roman copy after the Hellenistic original, Palazzo Massimo alle Terme

In ancient Athens, a person who died by suicide without the approval of the state was denied the honors of a normal burial. The person would be buried alone, on the outskirts of the city, without a headstone or marker.[221] However, it was deemed to be an acceptable method to deal with military defeat.[222] In Ancient Rome, while suicide was initially permitted, it was later deemed a crime against the state due to its economic costs.[223] Aristotle condemned all forms of suicide while Plato was ambivalent.[224] In Rome, some reasons for suicide included volunteering death in a gladiator combat, guilt over murdering someone, to save the life of another, as a result of mourning, from shame from being raped, and as an escape from intolerable situations like physical suffering, military defeat, or criminal pursuit.[224]

 
The Death of Seneca (1684), painting by Luca Giordano, depicting the suicide of Seneca the Younger in Ancient Rome

Suicide came to be regarded as a sin in Christian Europe and was condemned at the Council of Arles (452) as the work of the Devil. In the Middle Ages, the Church had drawn-out discussions as to when the desire for martyrdom was suicidal, as in the case of martyrs of Córdoba. Despite these disputes and occasional official rulings, Catholic doctrine was not entirely settled on the subject of suicide until the later 17th century. A criminal ordinance issued by Louis XIV of France in 1670 was extremely severe, even for the times: the dead person's body was drawn through the streets, face down, and then hung or thrown on a garbage heap. Additionally, all of the person's property was confiscated.[225][226]

Attitudes towards suicide slowly began to shift during the Renaissance. John Donne's work Biathanatos contained one of the first modern defences of suicide, bringing proof from the conduct of Biblical figures, such as Jesus, Samson and Saul, and presenting arguments on grounds of reason and nature to sanction suicide in certain circumstances.[227]

The secularization of society that began during the Enlightenment questioned traditional religious attitudes (such as Christian views on suicide) toward suicide and brought a more modern perspective to the issue. David Hume denied that suicide was a crime as it affected no one and was potentially to the advantage of the individual. In his 1777 Essays on Suicide and the Immortality of the Soul he rhetorically asked, "Why should I prolong a miserable existence, because of some frivolous advantage which the public may perhaps receive from me?"[227] Hume's analysis was criticized by philosopher Philip Reed as being "uncharacteristically (for him) bad", since Hume took an unusually narrow conception of duty and his conclusion depended upon the suicide producing no harm to others – including causing no grief, feelings of guilt, or emotional pain to any surviving friends and family – which is almost never the case.[228] A shift in public opinion at large can also be discerned; The Times in 1786 initiated a spirited debate on the motion "Is suicide an act of courage?".[229]

By the 19th century, the act of suicide had shifted from being viewed as caused by sin to being caused by insanity in Europe.[226] Although suicide remained illegal during this period, it increasingly became the target of satirical comments, such as the Gilbert and Sullivan comic opera The Mikado, which satirized the idea of executing someone who had already killed himself.

By 1879, English law began to distinguish between suicide and homicide, although suicide still resulted in forfeiture of estate.[230] In 1882, the deceased were permitted daylight burial in England[231] and by the middle of the 20th century, suicide had become legal in much of the Western world. The term suicide first emerged shortly before 1700 to replace expressions on self-death which were often characterized as a form of self-murder in the West.[224]

Social and culture

Legislation

Main article: Suicide legislation
 
A tantō knife prepared for seppuku (abdomen-cutting)
 
Samurai about to perform seppuku

No country in Europe currently considers suicide or attempted suicide to be a crime.[232] It was, however, in most Western European countries from the Middle Ages until at least the 19th century.[230] The Netherlands was the first country to legalize both physician-assisted suicide and euthanasia, which took effect in 2002, although only doctors are allowed to assist in either of them, and have to follow a protocol prescribed by Dutch law.[233] If such protocol is not followed, it is an offence punishable by law. In Germany, active euthanasia is illegal and anyone present during suicide may be prosecuted for failure to render aid in an emergency.[234] Switzerland has taken steps to legalize assisted suicide for the chronically mentally ill. The high court in Lausanne, Switzerland, in a 2006 ruling, granted an anonymous individual with longstanding psychiatric difficulties the right to end his own life.[235] England and Wales decriminalized suicide via the Suicide Act 1961 and the Republic of Ireland in 1993.[232] The word "commit" was used in reference to its being illegal, but many organisations have stopped it because of the negative connotation.[236][237]

In the United States, suicide is not illegal, but may be associated with penalties for those who attempt it.[232] Physician-assisted suicide is legal in the state of Washington for people with terminal diseases.[238] In Oregon, people with terminal diseases may request medications to help end their life.[239] Canadians who have attempted suicide may be barred from entering the United States. U.S. laws allow border guards to deny access to people who have a mental illness, including those with previous suicide attempts.[240][241]

In Australia, suicide is not a crime.[242] However, it is a crime to counsel, incite, or aid and abet another in attempting to die by suicide, and the law explicitly allows any person to use "such force as may reasonably be necessary" to prevent another from taking their own life.[243] The Northern Territory of Australia briefly had legal physician-assisted suicide from 1996 to 1997.[244]

In India, suicide was illegal until 2014, and surviving family members used to face legal difficulties.[245][246] It remains a criminal offense in most Muslim-majority nations.[29]

Religious views

Main article: Religious views on suicide

Christianity

Most forms of Christianity consider suicide sinful, based mainly on the writings of influential Christian thinkers of the Middle Ages, such as St. Augustine and St. Thomas Aquinas, but suicide was not considered a sin under the Byzantine Christian code of Justinian, for instance.[247][248] In Catholic and Orthodox doctrine, suicide is considered to be murder, violating the commandment "Thou shalt not kill," and historically neither church would even hold a burial service for a member that died by suicide, deeming it an act that condemned the person to hell, since they died in a state of mortal sin.[249] The basic idea being that life is a gift given by God which should not be spurned, and that suicide is against the "natural order" and thus interferes with God's master plan for the world.[250] However, it is believed that mental illness or grave fear of suffering diminishes the responsibility of the one completing suicide.[251]

Judaism

Judaism focuses on the importance of valuing this life, and as such, suicide is tantamount to denying God's goodness in the world. Despite this, under extreme circumstances when there has seemed no choice but to either be killed or forced to betray their religion, there are several accounts of Jews having died by suicide, either individually or in groups (see Holocaust, Masada, First French persecution of the Jews and York Castle for examples), and as a grim reminder there is even a prayer in the Jewish liturgy for "when the knife is at the throat", for those dying "to sanctify God's Name" (see Martyrdom). These acts have received mixed responses by Jewish authorities, regarded by some as examples of heroic martyrdom, while others state that it was wrong for them to take their own lives in anticipation of martyrdom.[252]

Islam

Islamic religious views are against suicide.[29] The Quran forbids it by stating "do not kill or destroy yourself".[253] The hadiths also state individual suicide to be unlawful and a sin.[29] Stigma is often associated with suicide in Islamic countries.[253]

Hinduism and Jainism

 
A Hindu widow burning herself with her husband's corpse, 1820s

In Hinduism, suicide is generally disdained and is considered equally sinful as murdering another in contemporary Hindu society. Hindu Scriptures state that one who dies by suicide will become part of the spirit world, wandering earth until the time one would have otherwise died, had one not taken one's own life.[254] However, Hinduism accepts a man's right to end one's life through the non-violent practice of fasting to death, termed Prayopavesa;[255] but Prayopavesa is strictly restricted to people who have no desire or ambition left, and no responsibilities remaining in this life.[255]

Jainism has a similar practice named Santhara. Sati, or self-immolation by widows, is a rare and illegal practice in Hindu society.[256]

Ainu

Within the Ainu religion, someone who dies by suicide is believed to become a ghost (tukap) who would haunt the living,[257] to come to fulfillment from which they were excluded during life.[258] Also, someone who insults another so they kill themselves is regarded as co-responsible for their death.[259] According to Norbert Richard Adami, this ethic exists due to the case that solidarity within the community is much more important to Ainu culture than it is to the Western world.[259]

Philosophy

Main article: Philosophy of suicide

A number of questions are raised within the philosophy of suicide, including what constitutes suicide, whether or not suicide can be a rational choice, and the moral permissibility of suicide.[260] Arguments as to acceptability of suicide in moral or social terms range from the position that the act is inherently immoral and unacceptable under any circumstances, to a regard for suicide as a sacrosanct right of anyone who believes they have rationally and conscientiously come to the decision to end their own lives, even if they are young and healthy.

Opponents to suicide include philosophers such as Augustine of Hippo, Thomas Aquinas,[260] Immanuel Kant[261] and, arguably, John Stuart Mill – Mill's focus on the importance of liberty and autonomy meant that he rejected choices which would prevent a person from making future autonomous decisions.[262] Others view suicide as a legitimate matter of personal choice. Supporters of this position maintain that no one should be forced to suffer against their will, particularly from conditions such as incurable disease, mental illness, and old age, with no possibility of improvement. They reject the belief that suicide is always irrational, arguing instead that it can be a valid last resort for those enduring major pain or trauma.[263] A stronger stance would argue that people should be allowed to autonomously choose to die regardless of whether they are suffering. Notable supporters of this school of thought include Scottish empiricist David Hume,[260] who accepted suicide so long as it did not harm or violate a duty to God, other people, or the self,[228] and American bioethicist Jacob Appel.[235][264]

Advocacy

See also: Advocacy of suicide
 
In this painting by Alexandre-Gabriel Decamps, the palette, pistol, and note lying on the floor suggest that the event has just taken place; an artist has taken his own life.[265]

Advocacy of suicide has occurred in many cultures and subcultures. The Japanese military during World War II encouraged and glorified kamikaze attacks, which were suicide attacks by military aviators from the Empire of Japan against Allied naval vessels in the closing stages of the Pacific Theater of World War II. Japanese society as a whole has been described as "suicide-tolerant"[266] (see Suicide in Japan).

Internet searches for information on suicide return webpages that 10–30% of the time encourage or facilitate suicide attempts. There is some concern that such sites may push those predisposed over the edge. Some people form suicide pacts online, either with pre-existing friends or people they have recently encountered in chat rooms or message boards. The Internet, however, may also help prevent suicide by providing a social group for those who are isolated.[267]

Locations

See also: List of suicide sites and Suicides at the Golden Gate Bridge

Some landmarks have become known for high levels of suicide attempts.[268] These include China's Nanjing Yangtze River Bridge,[269] San Francisco's Golden Gate Bridge, Japan's Aokigahara Forest,[270] England's Beachy Head,[268] and Toronto's Bloor Street Viaduct.[271] As of 2010, the Golden Gate Bridge has had more than 1,300 suicides by jumping since its construction in 1937.[272] Many locations where suicide is common have constructed barriers to prevent it;[273] this includes the Luminous Veil in Toronto,[271] the Eiffel Tower in Paris, the West Gate Bridge in Melbourne, and Empire State Building in New York City.[273] They generally appear to be effective.[274]

Notable cases

 
Japanese general Hideki Tojo, receiving treatment immediately after attempted suicide, 1945
Main article: List of suicides

An example of mass suicide is the 1978 Jonestown mass murder/suicide in which 909 members of the Peoples Temple, an American new religious movement led by Jim Jones, ended their lives by drinking grape Flavor Aid laced with cyanide and various prescription drugs.[275][276][277]

Thousands of Japanese civilians took their own lives in the last days of the Battle of Saipan in 1944, some jumping from "Suicide Cliff" and "Banzai Cliff".[278] The 1981 Irish hunger strikes, led by Bobby Sands, resulted in 10 deaths. The cause of death was recorded by the coroner as "starvation, self-imposed" rather than suicide; this was modified to simply "starvation" on the death certificates after protest from the dead strikers' families.[279] During World War II, Erwin Rommel was found to have foreknowledge of the 20 July plot on Hitler's life; he was threatened with public trial, execution, and reprisals on his family unless he killed himself.[280]

Other species

Main article: Animal suicide

As suicide requires a willful attempt to die, some feel it therefore cannot be said to occur in non-human animals.[222] Suicidal behavior has been observed in Salmonella seeking to overcome competing bacteria by triggering an immune system response against them.[281] Suicidal defenses by workers are also noted in the Brazilian ant Forelius pusillus, where a small group of ants leaves the security of the nest after sealing the entrance from the outside each evening.[282]

Pea aphids, when threatened by a ladybug, can explode themselves, scattering and protecting their brethren and sometimes even killing the ladybug; this form of suicidal altruism is known as autothysis.[283] Some species of termites (for example Globitermes sulphureus)[284] have soldiers that explode, covering their enemies with sticky goo.[285][284]

There have been anecdotal reports of dogs, horses, and dolphins killing themselves,[286] but little scientific study of animal suicide.[287] Animal suicide is usually put down to romantic human interpretation and is not generally thought to be intentional. Some of the reasons animals are thought to unintentionally kill themselves include: psychological stress, infection by certain parasites or fungi, or disruption of a long-held social tie, such as the ending of a long association with an owner and thus not accepting food from another individual.[288]

See also

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January 10, 2023
suicide, information, prevention, suicide, prevention, other, uses, suicide, disambiguation, intentionally, causing, death, mental, disorders, including, depression, bipolar, disorder, schizophrenia, personality, disorders, anxiety, disorders, physical, disord. For information on prevention see suicide prevention For other uses see suicide disambiguation Suicide is the act of intentionally causing one s own death 9 Mental disorders including depression bipolar disorder schizophrenia personality disorders anxiety disorders physical disorders such as chronic fatigue syndrome and substance abuse including alcoholism and the use of and withdrawal from benzodiazepines are risk factors 2 3 5 10 Some suicides are impulsive acts due to stress such as from financial or academic difficulties relationship problems such as breakups or divorces or harassment and bullying 2 11 12 Those who have previously attempted suicide are at a higher risk for future attempts 2 Effective suicide prevention efforts include limiting access to methods of suicide such as firearms drugs and poisons treating mental disorders and substance abuse careful media reporting about suicide and improving economic conditions 2 13 Although crisis hotlines are common resources their effectiveness has not been well studied 14 15 SuicideThe Suicide by Edouard ManetSpecialtyPsychiatry clinical psychology clinical social workUsual onset15 30 and 70 years old 1 Risk factorsDepression bipolar disorder autism schizophrenia personality disorders anxiety disorders alcoholism substance abuse 2 3 4 5 PreventionLimiting access to methods of suicide treating mental disorders and substance misuse careful media reporting about suicide improving social and economic conditions 2 Frequency12 per 100 000 per year 6 Deaths793 000 1 5 of deaths 2016 7 8 The most commonly adopted method of suicide varies from country to country and is partly related to the availability of effective means 16 Common methods of suicide include hanging pesticide poisoning and firearms 2 17 Suicides resulted in 828 000 deaths globally in 2015 an increase from 712 000 deaths in 1990 18 19 inconsistent This makes suicide the 10th leading cause of death worldwide 3 6 Approximately 1 5 of all deaths worldwide are by suicide 8 In a given year this is roughly 12 per 100 000 people 6 Rates of suicide are generally higher among men than women ranging from 1 5 times higher in the developing world to 3 5 times higher in the developed world 1 Suicide is generally most common among those over the age of 70 however in certain countries those aged between 15 and 30 are at the highest risk 1 Europe had the highest rates of suicide by region in 2015 20 There are an estimated 10 to 20 million non fatal attempted suicides every year 21 Non fatal suicide attempts may lead to injury and long term disabilities 22 In the Western world attempts are more common among young people and women 22 Views on suicide have been influenced by broad existential themes such as religion honor and the meaning of life 23 24 The Abrahamic religions traditionally consider suicide as an offense towards God due to the belief in the sanctity of life 25 During the samurai era in Japan a form of suicide known as seppuku 腹切り harakiri was respected as a means of making up for failure or as a form of protest 26 Sati a practice outlawed by the British in India expected a Hindu widow to immolate herself on her husband s funeral pyre either willingly or under pressure from her family and society 27 Suicide and attempted suicide while previously illegal are no longer so in most Western countries 28 It remains a criminal offense in some countries 29 In the 20th and 21st centuries suicide has been used on rare occasions as a form of protest and kamikaze and suicide bombings have been used as a military or terrorist tactic 30 Suicide is often seen as a major catastrophe for families relatives and other nearby supporters and it is viewed negatively almost everywhere around the world 31 32 33 Contents 1 Definitions 2 Risk factors 2 1 Mental illness 2 2 Previous attempts 2 3 Self harm 2 4 Psychosocial factors 2 5 Substance misuse 2 6 Medical conditions 2 7 Occupational factors 2 8 Media 2 9 Other factors 2 10 Rational 3 Methods 4 Pathophysiology 5 Prevention 5 1 Screening 5 2 Mental illness 6 Epidemiology 6 1 Sex and gender 6 2 Age 7 History 8 Social and culture 8 1 Legislation 8 2 Religious views 8 2 1 Christianity 8 2 2 Judaism 8 2 3 Islam 8 2 4 Hinduism and Jainism 8 2 5 Ainu 8 3 Philosophy 8 4 Advocacy 8 5 Locations 8 6 Notable cases 9 Other species 10 See also 11 References 12 Further reading 13 External linksDefinitionsMain article Suicide terminology Suicide derived from Latin suicidium is the act of taking one s own life 9 34 Attempted suicide or non fatal suicidal behavior amounts to self injury with at least some desire to end one s life that does not result in death 35 36 Assisted suicide occurs when one individual helps another bring about their own death indirectly via providing either advice or the means to the end 37 This is in contrast to euthanasia where another person takes a more active role in bringing about a person s death 37 Suicidal ideation is thoughts of ending one s life but not taking any active efforts to do so 35 It may or may not involve exact planning or intent 36 In a murder suicide or homicide suicide the individual aims at taking the lives of others at the same time A special case of this is extended suicide where the murder is motivated by seeing the murdered persons as an extension of their self 38 Suicide in which the reason is that the person feels that they are not part of society is known as egoistic suicide 39 In 2011 the Centre for Suicide Prevention in Canada found that the normal verb in scholarly research and journalism for the act of suicide was commit 40 41 On the other hand the American Psychological Association lists committed suicide as a term to avoid because it frame s suicide as a crime 42 Some advocacy groups recommend using the terms took his her own life died by suicide or killed him herself instead of committed suicide 43 44 45 The Associated Press Stylebook recommends avoiding committed suicide except in direct quotes from authorities 46 The Guardian and Observer style guides deprecate the use of committed 47 as does CNN 48 Opponents of commit argue that it implies that suicide is criminal sinful or morally wrong 49 Risk factorsPrecipitating circumstances in the US 2017 50 Categories PercentageDiagnosed mental problem 50 Recent or upcoming crisis 31 Intimate partner problem 27 Physical health problem 21 Alcohol problem 18 Substance abuse excluding alcohol 18 Argument 16 Family problem 10 Job problem 10 Financial problem 9 Legal problem 8 Death of loved one 7 Suicide is multi factorial Multiple precipitating circumstances and risk factors can apply to the same person Factors that affect the risk of suicide include mental disorders drug misuse psychological states cultural family and social situations genetics experiences of trauma or loss and nihilism 51 52 15 Mental disorders and substance misuse frequently co exist 53 Other risk factors include having previously attempted suicide 22 the ready availability of a means to take one s life a family history of suicide or the presence of traumatic brain injury 54 For example suicide rates have been found to be greater in households with firearms than those without them 55 Socio economic problems such as unemployment poverty homelessness and discrimination may trigger suicidal thoughts 56 57 Suicide might be rarer in societies with high social cohesion and moral objections against suicide 36 About 15 40 of people leave a suicide note 58 War veterans have a higher risk of suicide due in part to higher rates of mental illness such as post traumatic stress disorder and physical health problems related to war 59 Genetics appears to account for between 38 and 55 of suicidal behaviors 60 Suicides may also occur as a local cluster of cases 61 Most research does not distinguish between risk factors that lead to thinking about suicide and risk factors that lead to suicide attempts 62 63 Risks for suicide attempt rather than just thoughts of suicide include a high pain tolerance and a reduced fear of death 64 Mental illness A picture of a woman with depression who was suicidal Mental illness is present at the time of suicide 27 to more than 90 of the time 65 22 66 67 Of those who have been hospitalized for suicidal behavior the lifetime risk of suicide is 8 6 22 68 Comparatively non suicidal people hospitalized for affective disorders have a 4 lifetime risk of suicide 68 Half of all people who die by suicide may have major depressive disorder having this or one of the other mood disorders such as bipolar disorder increases the risk of suicide 20 fold 69 Other conditions implicated include schizophrenia 14 personality disorders 8 70 71 obsessive compulsive disorder 72 and post traumatic stress disorder 22 Those with autism also attempt and consider suicide more frequently 73 Others estimate that about half of people who die by suicide could be diagnosed with a personality disorder with borderline personality disorder being the most common 74 About 5 of people with schizophrenia die of suicide 75 Eating disorders are another high risk condition 76 Around 22 to 50 of people suffering with gender dysphoria have attempted suicide however this greatly varies by region 77 78 79 80 81 Among approximately 80 of suicides the individual has seen a physician within the year before their death 82 including 45 within the prior month 83 Approximately 25 40 of those who died by suicide had contact with mental health services in the prior year 65 82 Antidepressants of the SSRI class appear to increase the frequency of suicide among children but do not change the risk among adults 84 An unwillingness to get help for mental health problems also increases the risk 61 Previous attempts A previous history of suicide attempts is the most accurate predictor of suicide 22 Approximately 20 of suicides have had a previous attempt and of those who have attempted suicide 1 die by suicide within a year 22 and more than 5 die by suicide within 10 years 76 Self harm Non suicidal self harm is common with 18 of people engaging in self harm over the course of their life 85 1 Acts of self harm are not usually suicide attempts and most who self harm are not at high risk of suicide 86 Some who self harm however do still end their life by suicide and risk for self harm and suicide may overlap 86 Individuals who have been identified as self harming after being admitted to hospital are 68 38 105 more likely to die by suicide 87 279 Psychosocial factors A number of psychological factors increase the risk of suicide including hopelessness loss of pleasure in life depression anxiousness agitation rigid thinking rumination thought suppression and poor coping skills 69 88 89 A poor ability to solve problems the loss of abilities one used to have and poor impulse control also play a role 69 90 In older adults the perception of being a burden to others is important 91 Those who have never married are also at greater risk 22 Recent life stresses such as a loss of a family member or friend or the loss of a job might be a contributing factor 69 61 Certain personality factors especially high levels of neuroticism and introvertedness have been associated with suicide This might lead to people who are isolated and sensitive to distress to be more likely to attempt suicide 88 On the other hand optimism has been shown to have a protective effect 88 Other psychological risk factors include having few reasons for living and feeling trapped in a stressful situation 88 Changes to the stress response system in the brain might be altered during suicidal states 36 Specifically changes in the polyamine system 92 and hypothalamic pituitary adrenal axis 93 Social isolation and the lack of social support has been associated with an increased risk of suicide 88 Poverty is also a factor 94 with heightened relative poverty compared to those around a person increasing suicide risk 95 Over 200 000 farmers in India have died by suicide since 1997 partly due to issues of debt 96 In China suicide is three times as likely in rural regions as urban ones partly it is believed due to financial difficulties in this area of the country 97 The time of year may also affect suicide rates There appears to be a decrease around Christmas 98 but an increase in rates during spring and summer which might be related to exposure to sunshine 36 Another study found that the risk may be greater for males on their birthday 99 Being religious may reduce one s risk of suicide while beliefs that suicide is noble may increase it 100 61 101 This has been attributed to the negative stance many religions take against suicide and to the greater connectedness religion may give 100 Muslims among religious people appear to have a lower rate of suicide however the data supporting this is not strong 29 There does not appear to be a difference in rates of attempted suicide 29 Young women in the Middle East may have higher rates 102 Substance misuse The Drunkard s Progress 1846 demonstrating how alcoholism can lead to poverty crime and eventually suicide Substance misuse is the second most common risk factor for suicide after major depression and bipolar disorder 103 Both chronic substance misuse as well as acute intoxication are associated 53 104 When combined with personal grief such as bereavement the risk is further increased 104 Substance misuse is also associated with mental health disorders 53 Most people are under the influence of sedative hypnotic drugs such as alcohol or benzodiazepines when they die by suicide 105 with alcoholism present in between 15 and 61 of cases 53 Use of prescribed benzodiazepines is associated with an increased rate of suicide and attempted suicide The pro suicidal effects of benzodiazepines are suspected to be due to a psychiatric disturbance caused by side effects such as disinhibition or withdrawal symptoms 10 Countries that have higher rates of alcohol use and a greater density of bars generally also have higher rates of suicide 106 About 2 2 3 4 of those who have been treated for alcoholism at some point in their life die by suicide 106 Alcoholics who attempt suicide are usually male older and have tried to take their own lives in the past 53 Between 3 and 35 of deaths among those who use heroin are due to suicide approximately fourteenfold greater than those who do not use 107 In adolescents who misuse alcohol neurological and psychological dysfunctions may contribute to the increased risk of suicide 108 The misuse of cocaine and methamphetamine has a high correlation with suicide 53 109 In those who use cocaine the risk is greatest during the withdrawal phase 110 Those who used inhalants are also at significant risk with around 20 attempting suicide at some point and more than 65 considering it 53 Smoking cigarettes is associated with risk of suicide 111 There is little evidence as to why this association exists however it has been hypothesized that those who are predisposed to smoking are also predisposed to suicide that smoking causes health problems which subsequently make people want to end their life and that smoking affects brain chemistry causing a propensity for suicide 111 Cannabis however does not appear to independently increase the risk 53 Medical conditions There is an association between suicidality and physical health problems such as 76 chronic pain 112 traumatic brain injury 113 cancer 114 chronic fatigue syndrome 115 kidney failure requiring hemodialysis HIV and systemic lupus erythematosus 76 The diagnosis of cancer approximately doubles the subsequent frequency of suicide 114 The prevalence of increased suicidality persisted after adjusting for depressive illness and alcohol abuse Among people with more than one medical condition the frequency was particularly high In Japan health problems are listed as the primary justification for suicide 116 Sleep disturbances such as insomnia 117 and sleep apnea are risk factors for depression and suicide In some instances the sleep disturbances may be a risk factor independent of depression 118 A number of other medical conditions may present with symptoms similar to mood disorders including hypothyroidism Alzheimer s brain tumors systemic lupus erythematosus and adverse effects from a number of medications such as beta blockers and steroids 22 Occupational factors See also Suicide in the military Certain occupations carry an elevated risk of self harm and suicide such as military careers Research in several countries has found that the rate of suicide among former armed forces personnel in particular 119 120 121 122 and young veterans especially 123 124 119 is markedly higher than that found in the general population Media See also Copycat suicide and Social media and suicide In Goethe s The Sorrows of Young Werther the title character kills himself due to a love triangle involving Charlotte pictured at his grave Some admirers of the story were triggered into copycat suicide known as the Werther effect The media including the Internet plays an important role 51 88 Certain depictions of suicide may increase its occurrence with high volume prominent repetitive coverage glorifying or romanticizing suicide having the most impact 125 When detailed descriptions of how to kill oneself by a specific means are portrayed this method of suicide can be imitated in vulnerable people 16 This phenomenon has been observed in several cases after press coverage 126 127 In a bid to reduce the adverse effect of media portrayals concerning suicide report one of the effective methods is to educate journalists on how to report suicide news in a manner that might reduce that possibility of imitation and encourage those at risk to seek for help When journalists follow certain reporting guidelines the risk of suicides can be decreased 125 Getting buy in from the media industry however can be difficult especially in the long term 125 This trigger of suicide contagion or copycat suicide is known as the Werther effect named after the protagonist in Goethe s The Sorrows of Young Werther who killed himself and then was emulated by many admirers of the book 128 This risk is greater in adolescents who may romanticize death 129 It appears that while news media has a significant effect that of the entertainment media is equivocal 130 131 It is unclear if searching for information about suicide on the Internet relates to the risk of suicide 132 The opposite of the Werther effect is the proposed Papageno effect in which coverage of effective coping mechanisms may have a protective effect The term is based upon a character in Mozart s opera The Magic Flute fearing the loss of a loved one he had planned to kill himself until his friends helped him out 128 As a consequence fictional portrayals of suicide showing alternative consequences or negative consequences might have a preventive effect 133 for instance fiction might normalize mental health problems and encourage help seeking 134 Other factors Trauma is a risk factor for suicidality in both children 135 and adults 88 Some may take their own lives to escape bullying or prejudice 136 A history of childhood sexual abuse 137 and time spent in foster care are also risk factors 138 Sexual abuse is believed to contribute to approximately 20 of the overall risk 60 Significant adversity early in life has a negative effect on problem solving skills and memory both of which are implicated in suicidality 36 Problem gambling is associated with increased suicidal ideation and attempts compared to the general population 139 Between 12 and 24 of pathological gamblers attempt suicide 140 The rate of suicide among their spouses is three times greater than that of the general population 140 Other factors that increase the risk in problem gamblers include concomitant mental illness alcohol and drug misuse 141 Genetics might influence rates of suicide A family history of suicide especially in the mother affects children more than adolescents or adults 88 Adoption studies have shown that this is the case for biological relatives but not adopted relatives This makes familial risk factors unlikely to be due to imitation 36 Once mental disorders are accounted for the estimated heritability rate is 36 for suicidal ideation and 17 for suicide attempts 36 An evolutionary explanation for suicide is that it may improve inclusive fitness This may occur if the person dying by suicide cannot have more children and takes resources away from relatives by staying alive An objection is that deaths by healthy adolescents likely does not increase inclusive fitness Adaptation to a very different ancestral environment may be maladaptive in the current one 90 142 Infection by the parasite Toxoplasma gondii more commonly known as toxoplasmosis has been linked with suicide risk One explanation states that this is caused by altered neurotransmitter activity due to the immunological response 36 There appears to be a link between air pollution and depression and suicide 143 Rational Teenage recruits for Japanese Kamikaze suicide pilots in May 1945 Rational suicide is the reasoned taking of one s own life 144 However some consider suicide as never being rational 144 Euthanasia and assisted suicide are accepted practices in a number of countries among those who have a poor quality of life without the possibility of getting better 145 146 They are supported by the legal arguments for a right to die 146 The act of taking one s life for the benefit of others is known as altruistic suicide 147 An example of this is an elder ending his or her life to leave greater amounts of food for the younger people in the community 147 Suicide in some Inuit cultures has been seen as an act of respect courage or wisdom 148 A suicide attack is a political or religious action where an attacker carries out violence against others which they understand will result in their own death 149 Some suicide bombers are motivated by a desire to obtain martyrdoms or are religiously motivated 59 Kamikaze missions were carried out as a duty to a higher cause or moral obligation 148 Murder suicide is an act of homicide followed within a week by suicide of the person who carried out the act 150 Mass suicides are often performed under social pressure where members give up autonomy to a leader 151 Mass suicides can take place with as few as two people often referred to as a suicide pact 152 In extenuating situations where continuing to live would be intolerable some people use suicide as a means of escape 153 154 Some inmates in Nazi concentration camps are known to have killed themselves during the Holocaust by deliberately touching the electrified fences 155 Methods Deaths by gun related suicide versus non gun related suicide rates per 100 000 in high income countries in 2010 156 Main article Suicide methods The leading method of suicide varies among countries The leading methods in different regions include hanging pesticide poisoning and firearms 17 These differences are believed to be in part due to availability of the different methods 16 A review of 56 countries found that hanging was the most common method in most of the countries 17 accounting for 53 of male suicides and 39 of female suicides 157 Worldwide 30 of suicides are estimated to occur from pesticide poisoning most of which occur in the developing world 2 The use of this method varies markedly from 4 in Europe to more than 50 in the Pacific region 158 It is also common in Latin America due to the ease of access within the farming populations 16 In many countries drug overdoses account for approximately 60 of suicides among women and 30 among men 159 Many are unplanned and occur during an acute period of ambivalence 16 The death rate varies by method firearms 80 90 drowning 65 80 hanging 60 85 jumping 35 60 charcoal burning 40 50 pesticides 60 75 and medication overdose 1 5 4 0 16 The most common attempted methods of suicide differ from the most common methods of completion up to 85 of attempts are via drug overdose in the developed world 76 In China the consumption of pesticides is the most common method 160 In Japan self disembowelment known as seppuku harakiri still occurs 160 however hanging and jumping are the most common 161 Jumping to one s death is common in both Hong Kong and Singapore at 50 and 80 respectively 16 In Switzerland firearms are the most frequent suicide method in young males although this method has decreased since guns have become less common 162 163 In the United States 50 of suicides involve the use of firearms with this method being somewhat more common in men 56 than women 31 164 The next most common cause was hanging in males 28 and self poisoning in females 31 164 Together hanging and poisoning constituted about 42 of U S suicides as of 2017 update 164 PathophysiologyThere is no known unifying underlying pathophysiology for suicide 22 it is believed to result from an interplay of behavioral socio economic and psychological factors 16 Low levels of brain derived neurotrophic factor BDNF are both directly associated with suicide 165 and indirectly associated through its role in major depression posttraumatic stress disorder schizophrenia and obsessive compulsive disorder 166 Post mortem studies have found reduced levels of BDNF in the hippocampus and prefrontal cortex in those with and without psychiatric conditions 167 Serotonin a brain neurotransmitter is believed to be low in those who die by suicide 168 This is partly based on evidence of increased levels of 5 HT2A receptors found after death 169 Other evidence includes reduced levels of a breakdown product of serotonin 5 hydroxyindoleacetic acid in the cerebral spinal fluid 170 However direct evidence is hard to obtain 169 Epigenetics the study of changes in genetic expression in response to environmental factors which do not alter the underlying DNA is also believed to play a role in determining suicide risk 171 PreventionMain article Suicide prevention As a suicide prevention initiative these signs on the Golden Gate Bridge promote a special telephone that connects to a crisis hotline as well as a 24 7 crisis text line A suicide prevention fence on a bridge Suicide prevention is a term used for the collective efforts to reduce the incidence of suicide through preventive measures Protective factors for suicide include support and access to therapy 52 About 60 of people with suicidal thoughts do not seek help 172 Reasons for not doing so include low perceived need and wanting to deal with the problem alone 172 Despite these high rates there are few established treatments available for suicidal behavior 88 Reducing access to certain methods such as firearms or toxins such as opioids and pesticides can reduce risk of suicide by that method 16 173 15 36 This may be in part because suicide is often an impulsive decision with up to 70 of near fatal suicide attempts made after less than one hour of deliberation thus reducing access to easily accessible methods of suicide may make impulsive attempts less likely to succeed 174 Other measures include reducing access to charcoal for burning and adding barriers on bridges and subway platforms 16 175 15 Treatment of drug and alcohol addiction depression and those who have attempted suicide in the past may also be effective 173 15 Some have proposed reducing access to alcohol as a preventive strategy such as reducing the number of bars 53 In young adults who have recently thought about suicide cognitive behavioral therapy appears to improve outcomes 176 88 School based programs that increase mental health literacy and train staff have shown mixed results on suicide rates 15 Economic development through its ability to reduce poverty may be able to decrease suicide rates 94 Efforts to increase social connection especially in elderly males may be effective 177 In people who have attempted suicide following up on them might prevent repeat attempts 178 Although crisis hotlines are common there is little evidence to support or refute their effectiveness 14 15 Preventing childhood trauma provides an opportunity for suicide prevention 135 The World Suicide Prevention Day is observed annually on 10 September with the support of the International Association for Suicide Prevention and the World Health Organization 179 Screening IS PATH WARM is an acronym to assess a potentially suicidal individual i e ideation substance abuse purposelessness anger feeling trapped hopelessness withdrawal anxiety recklessness and mood 180 American Association of Suicidology 2019 There is little data on the effects of screening the general population on the ultimate rate of suicide 181 182 Screening those who come to the emergency departments with injuries from self harm have been shown to help identify suicide ideation and suicide intention Psychometric tests such as the Beck Depression Inventory or the Geriatric Depression Scale for older people are being used 183 As there is a high rate of people who test positive via these tools that are not at risk of suicide there are concerns that screening may significantly increase mental health care resource utilization 184 Assessing those at high risk though is recommended 22 Asking about suicidality does not appear to increase the risk 22 Mental illness See also Antidepressants and suicide risk In those with mental health problems a number of treatments may reduce the risk of suicide Those who are actively suicidal may be admitted to psychiatric care either voluntarily or involuntarily 22 Possessions that may be used to harm oneself are typically removed 76 Some clinicians get patients to sign suicide prevention contracts where they agree to not harm themselves if released 22 However evidence does not support a significant effect from this practice 22 If a person is at low risk outpatient mental health treatment may be arranged 76 Short term hospitalization has not been found to be more effective than community care for improving outcomes in those with borderline personality disorder who are chronically suicidal 185 186 There is tentative evidence that psychotherapy specifically dialectical behaviour therapy reduces suicidality in adolescents 187 as well as in those with borderline personality disorder 188 It may also be useful in decreasing suicide attempts in adults at high risk 189 However a decrease in suicide has not been observed 187 There is controversy around the benefit versus harm of antidepressants 51 In young persons some antidepressants such as SSRIs appear to increase the risk of suicidality from 25 per 1000 to 40 per 1000 190 In older persons however they may decrease the risk 22 Lithium appears effective at lowering the risk in those with bipolar disorder and major depression to nearly the same levels as that of the general population 191 192 Clozapine may decrease the thoughts of suicide in some people with schizophrenia 193 Ketamine which is a dissociative anaesthetic seems to lower the rate of suicidal ideation 194 In the United States health professionals are legally required to take reasonable steps to try to prevent suicide 195 196 EpidemiologyMain articles Epidemiology of suicide and List of countries by suicide rate See also Seasonal effects on suicide rates Approximately 1 4 of people die by suicide a mortality rate of 11 6 per 100 000 persons per year 6 22 Suicide resulted in 842 000 deaths in 2013 up from 712 000 deaths in 1990 19 Rates of suicide have increased by 60 from the 1960s to 2012 with these increases seen primarily in the developing world 3 Globally as of 2008 update 2009 suicide is the tenth leading cause of death 3 For every suicide that results in death there are between 10 and 40 attempted suicides 22 Suicide rates differ significantly between countries and over time 6 As a percentage of deaths in 2008 it was Africa 0 5 South East Asia 1 9 Americas 1 2 and Europe 1 4 6 Rates per 100 000 were Australia 8 6 Canada 11 1 China 12 7 India 23 2 United Kingdom 7 6 United States 11 4 and South Korea 28 9 197 198 It was ranked as the 10th leading cause of death in the United States in 2016 with about 45 000 cases that year 199 Rates have increased in the United States in the last few years 199 with the highest value being in 2017 the most recent data 200 In the United States about 650 000 people are seen in emergency departments yearly due to attempting suicide 22 The United States rate among men in their 50s rose by nearly half in the decade 1999 2010 201 Greenland Lithuania Japan and Hungary have the highest rates of suicide 6 Around 75 of suicides occur in the developing world 2 The countries with the greatest absolute numbers of suicides are China and India partly due to their large population size accounting for over half the total 6 In China suicide is the 5th leading cause of death 202 Death rate from suicide per 100 000 as of 2017 203 Share of deaths from suicide 2017 204 Sex and gender Main article Gender differences in suicide Suicide rates per 100 000 males left and females right 0 5 5 10 10 15 15 25 25 35 Above 35 No data Globally as of 2012 update death by suicide occurs about 1 8 times more often in males than females 6 205 In the Western world males die three to four times more often by means of suicide than do females 6 This difference is even more pronounced in those over the age of 65 with tenfold more males than females dying by suicide 206 Suicide attempts and self harm are between two and four times more frequent among females 22 207 208 Researchers have attributed the difference between suicide and attempted suicide among the sexes to males using more lethal means to end their lives 206 209 210 However separating intentional suicide attempts from non suicidal self harm is not currently done in places like the United States when gathering statistics at the national level 211 China has one of the highest female suicide rates in the world and is the only country where it is higher than that of men ratio of 0 9 6 202 In the Eastern Mediterranean suicide rates are nearly equivalent between males and females 6 The highest rate of female suicide is found in South Korea at 22 per 100 000 with high rates in South East Asia and the Western Pacific generally 6 A number of reviews have found an increased risk of suicide among lesbian gay bisexual and transgender people 212 213 Among transgender persons rates of attempted suicide are about 40 compared to a general population rate of 5 214 215 This is believed to in part be due to social stigmatisation 216 Age Suicide rates by age 217 In many countries the rate of suicide is highest in the middle aged 218 or elderly 16 The absolute number of suicides however is greatest in those between 15 and 29 years old due to the number of people in this age group 6 Worldwide the average age of suicide is between age 30 and 49 for both men and women 219 This means that half of people who died by suicide were approximately age 40 or younger and half were older 219 Suicidality is rare in children but increases during the transition to adolescence 220 In the United States the suicide death rate is greatest in Caucasian men older than 80 years even though younger people more frequently attempt suicide 22 It is the second most common cause of death in adolescents 51 and in young males is second only to accidental death 218 In young males in the developed world it is the cause of nearly 30 of mortality 218 In the developing world rates are similar but it makes up a smaller proportion of overall deaths due to higher rates of death from other types of trauma 218 In South East Asia in contrast to other areas of the world deaths from suicide occur at a greater rate in young females than elderly females 6 HistoryMain article History of suicide The Ludovisi Gaul killing himself and his wife Roman copy after the Hellenistic original Palazzo Massimo alle Terme In ancient Athens a person who died by suicide without the approval of the state was denied the honors of a normal burial The person would be buried alone on the outskirts of the city without a headstone or marker 221 However it was deemed to be an acceptable method to deal with military defeat 222 In Ancient Rome while suicide was initially permitted it was later deemed a crime against the state due to its economic costs 223 Aristotle condemned all forms of suicide while Plato was ambivalent 224 In Rome some reasons for suicide included volunteering death in a gladiator combat guilt over murdering someone to save the life of another as a result of mourning from shame from being raped and as an escape from intolerable situations like physical suffering military defeat or criminal pursuit 224 The Death of Seneca 1684 painting by Luca Giordano depicting the suicide of Seneca the Younger in Ancient Rome Suicide came to be regarded as a sin in Christian Europe and was condemned at the Council of Arles 452 as the work of the Devil In the Middle Ages the Church had drawn out discussions as to when the desire for martyrdom was suicidal as in the case of martyrs of Cordoba Despite these disputes and occasional official rulings Catholic doctrine was not entirely settled on the subject of suicide until the later 17th century A criminal ordinance issued by Louis XIV of France in 1670 was extremely severe even for the times the dead person s body was drawn through the streets face down and then hung or thrown on a garbage heap Additionally all of the person s property was confiscated 225 226 Attitudes towards suicide slowly began to shift during the Renaissance John Donne s work Biathanatos contained one of the first modern defences of suicide bringing proof from the conduct of Biblical figures such as Jesus Samson and Saul and presenting arguments on grounds of reason and nature to sanction suicide in certain circumstances 227 The secularization of society that began during the Enlightenment questioned traditional religious attitudes such as Christian views on suicide toward suicide and brought a more modern perspective to the issue David Hume denied that suicide was a crime as it affected no one and was potentially to the advantage of the individual In his 1777 Essays on Suicide and the Immortality of the Soul he rhetorically asked Why should I prolong a miserable existence because of some frivolous advantage which the public may perhaps receive from me 227 Hume s analysis was criticized by philosopher Philip Reed as being uncharacteristically for him bad since Hume took an unusually narrow conception of duty and his conclusion depended upon the suicide producing no harm to others including causing no grief feelings of guilt or emotional pain to any surviving friends and family which is almost never the case 228 A shift in public opinion at large can also be discerned The Times in 1786 initiated a spirited debate on the motion Is suicide an act of courage 229 By the 19th century the act of suicide had shifted from being viewed as caused by sin to being caused by insanity in Europe 226 Although suicide remained illegal during this period it increasingly became the target of satirical comments such as the Gilbert and Sullivan comic opera The Mikado which satirized the idea of executing someone who had already killed himself By 1879 English law began to distinguish between suicide and homicide although suicide still resulted in forfeiture of estate 230 In 1882 the deceased were permitted daylight burial in England 231 and by the middle of the 20th century suicide had become legal in much of the Western world The term suicide first emerged shortly before 1700 to replace expressions on self death which were often characterized as a form of self murder in the West 224 Social and cultureLegislation Main article Suicide legislation A tantō knife prepared for seppuku abdomen cutting Samurai about to perform seppuku No country in Europe currently considers suicide or attempted suicide to be a crime 232 It was however in most Western European countries from the Middle Ages until at least the 19th century 230 The Netherlands was the first country to legalize both physician assisted suicide and euthanasia which took effect in 2002 although only doctors are allowed to assist in either of them and have to follow a protocol prescribed by Dutch law 233 If such protocol is not followed it is an offence punishable by law In Germany active euthanasia is illegal and anyone present during suicide may be prosecuted for failure to render aid in an emergency 234 Switzerland has taken steps to legalize assisted suicide for the chronically mentally ill The high court in Lausanne Switzerland in a 2006 ruling granted an anonymous individual with longstanding psychiatric difficulties the right to end his own life 235 England and Wales decriminalized suicide via the Suicide Act 1961 and the Republic of Ireland in 1993 232 The word commit was used in reference to its being illegal but many organisations have stopped it because of the negative connotation 236 237 In the United States suicide is not illegal but may be associated with penalties for those who attempt it 232 Physician assisted suicide is legal in the state of Washington for people with terminal diseases 238 In Oregon people with terminal diseases may request medications to help end their life 239 Canadians who have attempted suicide may be barred from entering the United States U S laws allow border guards to deny access to people who have a mental illness including those with previous suicide attempts 240 241 In Australia suicide is not a crime 242 However it is a crime to counsel incite or aid and abet another in attempting to die by suicide and the law explicitly allows any person to use such force as may reasonably be necessary to prevent another from taking their own life 243 The Northern Territory of Australia briefly had legal physician assisted suicide from 1996 to 1997 244 In India suicide was illegal until 2014 and surviving family members used to face legal difficulties 245 246 It remains a criminal offense in most Muslim majority nations 29 Religious views Main article Religious views on suicide Christianity Most forms of Christianity consider suicide sinful based mainly on the writings of influential Christian thinkers of the Middle Ages such as St Augustine and St Thomas Aquinas but suicide was not considered a sin under the Byzantine Christian code of Justinian for instance 247 248 In Catholic and Orthodox doctrine suicide is considered to be murder violating the commandment Thou shalt not kill and historically neither church would even hold a burial service for a member that died by suicide deeming it an act that condemned the person to hell since they died in a state of mortal sin 249 The basic idea being that life is a gift given by God which should not be spurned and that suicide is against the natural order and thus interferes with God s master plan for the world 250 However it is believed that mental illness or grave fear of suffering diminishes the responsibility of the one completing suicide 251 Judaism Judaism focuses on the importance of valuing this life and as such suicide is tantamount to denying God s goodness in the world Despite this under extreme circumstances when there has seemed no choice but to either be killed or forced to betray their religion there are several accounts of Jews having died by suicide either individually or in groups see Holocaust Masada First French persecution of the Jews and York Castle for examples and as a grim reminder there is even a prayer in the Jewish liturgy for when the knife is at the throat for those dying to sanctify God s Name see Martyrdom These acts have received mixed responses by Jewish authorities regarded by some as examples of heroic martyrdom while others state that it was wrong for them to take their own lives in anticipation of martyrdom 252 Islam Islamic religious views are against suicide 29 The Quran forbids it by stating do not kill or destroy yourself 253 The hadiths also state individual suicide to be unlawful and a sin 29 Stigma is often associated with suicide in Islamic countries 253 Hinduism and Jainism A Hindu widow burning herself with her husband s corpse 1820s In Hinduism suicide is generally disdained and is considered equally sinful as murdering another in contemporary Hindu society Hindu Scriptures state that one who dies by suicide will become part of the spirit world wandering earth until the time one would have otherwise died had one not taken one s own life 254 However Hinduism accepts a man s right to end one s life through the non violent practice of fasting to death termed Prayopavesa 255 but Prayopavesa is strictly restricted to people who have no desire or ambition left and no responsibilities remaining in this life 255 Jainism has a similar practice named Santhara Sati or self immolation by widows is a rare and illegal practice in Hindu society 256 Ainu Within the Ainu religion someone who dies by suicide is believed to become a ghost tukap who would haunt the living 257 to come to fulfillment from which they were excluded during life 258 Also someone who insults another so they kill themselves is regarded as co responsible for their death 259 According to Norbert Richard Adami this ethic exists due to the case that solidarity within the community is much more important to Ainu culture than it is to the Western world 259 Philosophy Main article Philosophy of suicide A number of questions are raised within the philosophy of suicide including what constitutes suicide whether or not suicide can be a rational choice and the moral permissibility of suicide 260 Arguments as to acceptability of suicide in moral or social terms range from the position that the act is inherently immoral and unacceptable under any circumstances to a regard for suicide as a sacrosanct right of anyone who believes they have rationally and conscientiously come to the decision to end their own lives even if they are young and healthy Opponents to suicide include philosophers such as Augustine of Hippo Thomas Aquinas 260 Immanuel Kant 261 and arguably John Stuart Mill Mill s focus on the importance of liberty and autonomy meant that he rejected choices which would prevent a person from making future autonomous decisions 262 Others view suicide as a legitimate matter of personal choice Supporters of this position maintain that no one should be forced to suffer against their will particularly from conditions such as incurable disease mental illness and old age with no possibility of improvement They reject the belief that suicide is always irrational arguing instead that it can be a valid last resort for those enduring major pain or trauma 263 A stronger stance would argue that people should be allowed to autonomously choose to die regardless of whether they are suffering Notable supporters of this school of thought include Scottish empiricist David Hume 260 who accepted suicide so long as it did not harm or violate a duty to God other people or the self 228 and American bioethicist Jacob Appel 235 264 Advocacy See also Advocacy of suicide In this painting by Alexandre Gabriel Decamps the palette pistol and note lying on the floor suggest that the event has just taken place an artist has taken his own life 265 Advocacy of suicide has occurred in many cultures and subcultures The Japanese military during World War II encouraged and glorified kamikaze attacks which were suicide attacks by military aviators from the Empire of Japan against Allied naval vessels in the closing stages of the Pacific Theater of World War II Japanese society as a whole has been described as suicide tolerant 266 see Suicide in Japan Internet searches for information on suicide return webpages that 10 30 of the time encourage or facilitate suicide attempts There is some concern that such sites may push those predisposed over the edge Some people form suicide pacts online either with pre existing friends or people they have recently encountered in chat rooms or message boards The Internet however may also help prevent suicide by providing a social group for those who are isolated 267 Locations See also List of suicide sites and Suicides at the Golden Gate Bridge Some landmarks have become known for high levels of suicide attempts 268 These include China s Nanjing Yangtze River Bridge 269 San Francisco s Golden Gate Bridge Japan s Aokigahara Forest 270 England s Beachy Head 268 and Toronto s Bloor Street Viaduct 271 As of 2010 update the Golden Gate Bridge has had more than 1 300 suicides by jumping since its construction in 1937 272 Many locations where suicide is common have constructed barriers to prevent it 273 this includes the Luminous Veil in Toronto 271 the Eiffel Tower in Paris the West Gate Bridge in Melbourne and Empire State Building in New York City 273 They generally appear to be effective 274 Notable cases Japanese general Hideki Tojo receiving treatment immediately after attempted suicide 1945 Main article List of suicides An example of mass suicide is the 1978 Jonestown mass murder suicide in which 909 members of the Peoples Temple an American new religious movement led by Jim Jones ended their lives by drinking grape Flavor Aid laced with cyanide and various prescription drugs 275 276 277 Thousands of Japanese civilians took their own lives in the last days of the Battle of Saipan in 1944 some jumping from Suicide Cliff and Banzai Cliff 278 The 1981 Irish hunger strikes led by Bobby Sands resulted in 10 deaths The cause of death was recorded by the coroner as starvation self imposed rather than suicide this was modified to simply starvation on the death certificates after protest from the dead strikers families 279 During World War II Erwin Rommel was found to have foreknowledge of the 20 July plot on Hitler s life he was threatened with public trial execution and reprisals on his family unless he killed himself 280 Other speciesMain article Animal suicide As suicide requires a willful attempt to die some feel it therefore cannot be said to occur in non human animals 222 Suicidal behavior has been observed in Salmonella seeking to overcome competing bacteria by triggering an immune system response against them 281 Suicidal defenses by workers are also noted in the Brazilian ant Forelius pusillus where a small group of ants leaves the security of the nest after sealing the entrance from the outside each evening 282 Pea aphids when threatened by a ladybug can explode themselves scattering and protecting their brethren and sometimes even killing the ladybug this form of suicidal altruism is known as autothysis 283 Some species of termites for example Globitermes sulphureus 284 have soldiers that explode covering their enemies with sticky goo 285 284 There have been anecdotal reports of dogs horses and dolphins killing themselves 286 but little scientific study of animal suicide 287 Animal suicide is usually put down to romantic human interpretation and is not generally thought to be intentional Some of the reasons animals are thought to unintentionally kill themselves include psychological stress infection by certain parasites or fungi or disruption of a long held social tie such as the ending of a long association with an owner and thus not accepting food from another individual 288 See alsoList of suicide crisis lines List of countries by suicide rateReferences a b c Preventing suicide a global imperative WHO 2014 pp 7 20 40 ISBN 978 92 4 156477 9 a b c d e f g h i Suicide Fact sheet N 398 WHO April 2016 Archived from the original on 4 March 2016 Retrieved 3 March 2016 a b c d e Hawton K van Heeringen K April 2009 Suicide Lancet 373 9672 1372 81 doi 10 1016 S0140 6736 09 60372 X PMID 19376453 S2CID 208790312 De La Vega D Giner L Courtet P March 2018 Suicidality in 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Prescribed Benzodiazepines and Suicide Risk A Review of the Literature The Primary Care Companion for CNS Disorders 19 2 doi 10 4088 PCC 16r02037 PMID 28257172 Bottino SM Bottino CM Regina CG Correia AV Ribeiro WS March 2015 Cyberbullying and adolescent mental health systematic review Cadernos de Saude Publica 31 3 463 75 doi 10 1590 0102 311x00036114 PMID 25859714 Suicide rates rising across the U S CDC Online Newsroom CDC www cdc gov 11 April 2019 Retrieved 19 September 2019 Relationship problems or loss substance misuse physical health problems and job money legal or housing stress often contributed to risk for suicide Preventing Suicide A Resource for Media Professionals PDF 2008 ISBN 978 92 4 159707 4 a b Sakinofsky I June 2007 The current evidence base for the clinical care of suicidal patients strengths and weaknesses Canadian Journal of Psychiatry 52 6 Suppl 1 7S 20S PMID 17824349 Other suicide prevention strategies that have been considered are crisis centres and hotlines 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