SUICIDE BASICS EPIDEMIOLOGY Danielle Saint-Laurent HISTORY Norman L. Farberow PREVENTION Brian L. Mishara WARNING SIGNS AND PREDICTIONS Brian L. Mishara

EPIDEMIOLOGY Suicide, voluntarily taking one's own life, occurs in every country in the world. In Western societies, suicide is recognized as a leading cause of early death, a major public health problem, and a tragedy for individuals and families.

Epidemiology of Suicide According to the World Health Organization (WHO) in 1999, suicide is among the top ten causes of death for all age groups in North America and the majority of northern and western European countries; it represents 1 to 2 percent of total mortality. Analysis of the mortality figures (see Tables 1 and 2) reveals important differences in the mortality rate between various countries and age groups. The suicide rate in industrialized countries has increased since the beginning of the twentieth century and reached very high levels in many European countries and North America. The rise in suicides parallels the gradual increase in urbanization and education. It is also known that a major part of the increase in the suicide rate can be attributed to those people under forty years old. Epidemiological knowledge about suicide in the world is limited to countries that report suicide statistics to WHO. The majority of countries in Africa, the central part of South America, and a number of Asian countries do not report data on suicides. What epidemiological data are available can often vary in quality. According to Ian Rockette and Thomas McKinley, the misclassification of suicide leads to underreporting. Classifying suicides as unintentional poisonings, drownings, or undetermined deaths is not unusual. Underreporting and misclassification can be explained by social attitudes toward suicide, religious disapproval, and recording procedures. Some countries have a system whereby coroners can investigate unnatural deaths. In other countries a certificate is simply signed by the doctor. Autopsies also vary from one country to the next. For example, the autopsy rate is very high in Australia but very low in Germany. When there is no stigma associated with suicide, those close to the deceased are more likely to reveal information and characteristics about the deceased that would lead to a more accurate classification.

Suicide and Gender In almost all countries for which statistics are available, suicide is more frequent among men than women (see Tables 1 and 2), a trend that prevails in most age groups. In a number of countries, a trend toward an increase in suicide has also been observed among men but not women. The gap in rates between men and women is smaller in Asian countries. Contrary to other countries, the suicide rate in China is higher among women than men in both rural and urban areas. However, the male-female suicide ratio is lower than in most countries. Women's resistance to committing suicide may be explained by the strong role they play in family life, even if they work outside the home; their tasks prevent them from becoming socially and emotionally isolated. Women also seek medical treatment more often than men, increasing their chances of having any psychiatric problems detected and treated early. Conversely, men seem more vulnerable to losing their professional identity, a calamity often aggravated by solitude and loss of contact. Certain harmful behaviors linked to suicide, such as alcoholism and drug addiction, are especially common among men. Suicide rates per 100,000 inhabitants, men and women of various countries Country Year Men Women Total Argentina 1996 12.4 3.3 7.5 Canada 1997 20.0 5.1 12.4 Costa Rica 1995 11.8 2.3 7.0 Cuba 1996 28.2 12.9 20.3 Mexico 1995 7.3 1.0 4.0 United States of America 1997 19.7 4.5 11.7 Hong Kong 1996 16.7 9.2 12.9 Israel 1996 9.9 3.0 6.3 Singapore 1997 17.1 8.6 12.6 Austria 1997 30.1 18.6 9.0 Belarus 1997 66.8 10.2 36.0 Bulgaria 1997 24.5 9.4 16.4 Estonia 1996 68.9 13.0 38.4 Finland 1995 44.0 11.8 27.4 France 1996 29.0 9.8 18.8 Germany 1997 21.7 6.8 13.7 Greece 1997 5.9 0.1 3.4 Hungary 1995 53.6 15.0 32.5 Ireland 1996 20.4 3.7 11.9 Italy 1995 11.6 3.3 7.2 Kazakstan 1997 62.8 10.7 35.0 Kirgyzstan 1997 18.0 3.7 10.8 Netherlands 1995 13.2 6.4 9.7 Norway 1995 19.2 6.4 12.7 Poland 1996 26.1 4.7 14.9 Portugal 1997 10.2 2.5 5.9 Romania 1997 23.2 4.2 13.4 Russian Federation 1997 69.9 11.7 38.4 Spain 1995 12.4 3.3 7.5 Sweden 1996 19.5 7.9 13.6 Ukraine 1997 54.6 9.4 29.7 United Kingdom 1997 11.2 3.1 7.1 Australia 1995 19.7 5.2 12.3 New Zealand 1996 24.2 6.0 14.8 SOURCE: World Health Organization, 1999.

Suicide and Age According to David Lester, the suicide rate increases with age among men and varies with age among women. In industrialized countries, the rate is higher for women in their middle ages. In poor countries, the suicide rate is higher among young women. In many industrialized countries and even in small communities, statistics show an increase in suicide among young people, especially among young men. In many areas, namely North America, suicide is the leading or second leading cause of death among young males. Suicide among children under the age of twelve is rare. The incidence of suicide rises sharply at puberty; the highest youth suicide rates occur during adolescence or early adulthood. The increase in suicide among youth dovetails with an overall rise in youthful depression. In addition, the earlier onset of puberty induces adult stresses and turmoil at an earlier age, including sexual activity and the abuse of alcohol, tobacco, and drugs.

Methods of Suicide Methods of suicide vary greatly among different countries, depending on cultural traditions and social and political conditions. According to Canetto and Lester, the use of firearms in suicide deaths is definitely higher for both men and women in the United States than in Canada. This is mainly due to the large number of firearms in circulation and the absence of restrictions on access to them. In many countries, the use of firearms in suicide deaths is higher in rural areas than in urban ones because there are more hunters in rural areas. Another interesting example of the link between methods and their availability is that of domestic gas in England used for exhaust poisoning. When England lowered the toxicity of domestic gas, suicide by this method was eliminated in the country and suicides decreased by one-third. Other countries such as Switzerland, Ireland, and Scotland have also reported changes in the suicide rate following the detoxification of gas. There are also major differences in how men and women in Western countries commit suicide. Many men shoot and hang themselves while women tend to poison or hang themselves. In industrialized and developing nations, women most frequently use chemical products intended for agriculture.

Theories Suicide has been the subject of many studies dating back to Émile Durkheim's Le Suicide (1897). At the dawn of the twenty-first century, however, no theory on suicide has been accepted by a majority of researchers. Suicide may be associated with various pathologies. In Western societies, for example, suicide is considered to be a reflection of the social ills associated with crises such as unemployment, insecurity, weakness, or the loss of income, all of which contribute to the breakdown of family ties and the mental and physical isolation of individuals. Suicide often leads to various forms of exclusion in Western societies, in particular social isolation. Although Durkheim's theory has been influential, it is has not gained universal acceptance as an Suicide rates per 100,000 inhabitants of various countries, men and women by age group Men (ages) Women (ages) Country Year 15–24 25–44 45–64 65 + 15–24 25–44 45–64 65 + Argentina 1996 8.8 9.8 18.5 28.7 3.4 2.9 5.0 6.2 Canada 1997 22.4 25.0 25.5 23.0 4.5 6.6 7.6 4.5 Costa Rica 1995 11.8 16.3 15.2 9.2 4.0 2.9 3.1 0.0 Cuba 1996 14.2 25.3 33.8 83.8 13.1 12.9 15.3 26.6 Mexico 1995 7.6 8.4 8.0 1.8 2.0 1.1 1.1 1.1 United States of America 1997 18.9 23.8 22.5 33.9 3.5 6.0 6.5 4.9 Hong Kong 1996 11.8 17.9 20.1 34.1 7.5 8.3 9.0 27.4 Israel 1996 8.6 9.7 10.4 26.9 1.8 2.6 3.9 8.4 Singapore 1997 9.1 17.8 17.8 44.9 8.5 2.4 8.1 21.8 Austria 1997 24.3 30.9 35.8 68.2 4.8 8.7 12.8 20.8 Belarus 1997 32.9 79.3 116.5 81.3 6.7 9.8 16.4 17.8 Bulgaria 1997 14.1 18.5 33.4 63.5 4.8 7.3 12.1 29.0 Estonia 1996 34.9 72.6 120.8 84.2 7.8 9.9 22.5 28.8 Finland 1995 36.6 60.1 56.5 51.9 8.4 16.4 17.0 11.0 France 1996 12.8 35.6 36.8 58.5 4.2 10.5 16.3 17.4 Germany 1997 12.9 22.4 29.2 45.3 3.2 6.3 10.7 16.7 Greece 1997 2.8 7.0 7.6 9.7 0.8 0.8 1.4 2.0 Hungary 1995 19.2 56.6 77.6 112.8 3.8 13.1 23.1 41.2 Ireland 1996 25.4 32.0 19.7 15.8 4.5 5.3 5.4 1.3 Italy 1995 7.3 11.2 14.5 29.8 1.6 3.1 5.2 7.7 Kazakstan 1997 46.5 74.8 96.1 80.4 12.6 11.0 13.1 18.5 Kirgyzstan 1997 20.6 26.2 42.6 35.9 4.0 4.8 7.6 11.1 Netherlands 1995 9.2 16.9 16.7 20.9 4.4 7.6 8.8 10.3 Norway 1995 22.6 22.0 22.9 28.8 5.5 7.6 8.9 7.4 Poland 1996 17.2 31.8 41.6 30.8 2.9 4.7 8.4 7.0 Portugal 1997 4.3 9.3 11.0 32.2 1.2 2.3 3.7 6.4 Romania 1997 10.7 28.1 37.1 28.5 2.6 3.6 7.3 7.4 Russian Federation 1997 53.5 87.2 97.0 97.7 9.0 11.6 15.8 24.8 Spain 1995 8.7 12.1 14.4 32.3 2.1 2.8 5.1 8.5 Sweden 1996 12.0 22.6 29.1 32.8 4.6 8.0 14.0 12.6 Ukraine 1997 26.6 63.3 89.3 80.3 4.8 8.6 15.4 20.4 United Kingdom 1997 11.1 16.2 12.9 12.5 4.9 4.4 4.0 0.0 Australia 1995 23.1 27.9 21.6 21.4 6.1 6.7 7.0 5.1 New Zealand 1996 37.8 33.3 21.5 28.6 13.9 6.0 5.9 5.3 SOURCE: World Health Organization, 1999. exhaustive framework. His theory contributes to the understanding of how social integration and cohesion influence suicide. Durkheim explained how individual pathology was a function of social dynamics and the underlying reason for suicide occurrence. The anomic suicide defined by Durkheim is associated with societal crises of economic or social nature. Suicide existed before the acculturation, exclusion, and complex changes characteristic of Western societies. In smaller communities, suicide is not associated with social alienation and urbanization, according to Tousignant. In some of these smaller communities, suicide is often a means of making amends or seeking redemption in the eyes of the community. In this context, suicide is a social regulator rather than an anomic gesture. People who commit suicide in these smaller communities appear not to live on the fringe of society, but are socially integrated in their society. In addition to social factors, individual and biological factors are also associated with suicide, notably the presence of psychiatric problems. People who suffer from depression or other mental problems are statistically more at risk of suicide than the rest of the population. However, though mental disease is a risk factor that increases the probability of suicide, it does not itself explain the occurrence of suicide. Other individual syndromes associated with suicide are antisocial behavior and the abuse of drugs and alcohol. More recent studies have also linked genetic and biological factors to suicide, such as gender and serotonin production problems. To counter the problem of suicide, many countries have set up prevention programs that focus on early detection of mental disease and more adequate treatment of potential victims. Other programs seek to purvey more accurate information about the problem through the media. Legislation restricting the use of firearms, the restriction and control of toxic substances, and the detoxification of domestic gas are the most common and successful preventive measures in advanced industrialized countries.

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DANIELLE SAINT-LAURENT

HISTORY Although suicide has been recorded in both written and oral records in the history of man from primitive times on, no word existed for the phenomenon until the seventeenth century. According to the Oxford English Dictionary, the word suicide was first used in 1651, but Alfred Alvarez reported in 1972 that it appeared in Sir Thomas Browne's Religio Medici in 1642. The Oxford English Dictionary states that the word suicidium was actually derived by combining the Latin pronoun for "self" and the verb "to kill." The word sounds deceptively Latin, but Henry Romilly Fedden, in his 1938 book Suicide, stated that the Romans described the act using Latin phrases, such as vim sibi inferre (to cause violence to oneself), sibi mortem consciscere (to procure one's own death), and sua manu cadere (to fall by one's own hand). Early English also used phrases, such as self-murder, self-destruction, and self-killer, all of which reflect the early association of the act with murder.

Primitive and Traditional Societies There is reliable evidence that suicide was present in most primitive tribes around the world, almost always associated with evil spirits, revenge, and unappeased anger. These attitudes in the form of superstitions and fears of magic found their way into Christianity as taboos that have persisted to this day. Attitudes toward suicide, however, have shown great variability depending on the culture and the part of the world. In primitive societies suicide was variously used as a means to exact vengeance, as a way of placing responsibility for the death on the person who had supposedly caused it, and as a way of embarrassing an adversary. In other cultures suicide was not only tolerated but actually encouraged. The Goths and the Celts believed that to die naturally was shameful. Vikings unlucky enough not to die in battle fell on their own swords or jumped off cliffs in order to be able to enter Valhalla (the great hall of Odin for slain heroes in Norse mythology). And some Eskimo tribes believed it was better to kill oneself before growing feeble because people entered the next life in the same condition they left this one. In a number of societies tradition demanded that wives, retainers, servants, and ministers kill themselves so that they could continue to administer to the needs of their master after he died. Sometimes there was competition among the wives to be the first to follow the husband in death because that privilege identified his favorite. In Hindu India, the practice of suttee, the suicide of a widow by self-immolation on the funeral pyre of her husband, is reported to continue in some rural parts of the country, although it has long since been outlawed. Generally, however, the Hindu attitude toward suicide is ambiguous, condemning it but calling it justified in special cases, such as when a person has lived a full life or has achieved a special level as an ascetic. In early Oriental sacred writings, suicide was viewed with contradictory attitudes that both encouraged and condemned it. In ancient China the ceremonial sacrifice of widows was almost as commonplace as it was in India; it was also reported to occur frequently because of the wretchedness of people's lives. In Japan, Buddhist tradition institutionalized suicide with several kinds of seppuku, a ritual form of disemboweling oneself that was used to admit failure, atone for a mistake, or avoid humiliation. Among the samurai, the professional warriors of feudal Japan, seppuku was incorporated into an ethical code known as Bushido, which required the warrior to follow his dead lord into the next life, to regain honor when revenge was not possible, and to avoid execution by the enemy in a lost battle. Brahmanism was sympathetic to suicide in that its philosophy incorporated denial of the body and the separation of the body from the soul in the intensive search for knowledge. Mohammedism condemned suicide with great severity, calling suicide a rejection of the divine will, which was expressed in many different ways and to which humans must submit themselves at all times.

The Jewish Tradition Suicide among the Jews is generally infrequent, mostly because the value of life itself was so highly emphasized in the Torah. In the Old Testament of the Bible, a Jew is allowed to transgress every religious commandment in order to save his life except in cases of murder, incest, and the denial of God. Suicide was wrong, but was acceptable in instances of imminent capture and torture, apostasy, and shame or dishonor. Neither the Hebrew Bible nor the New Testament condemns nor condones suicide—nor does either contain the word suicide. The occasions of such deaths are described simply, briefly, and factually: Samson brought the temple of the Philistines down upon himself in order to kill his captors (Judg. 16:28–31); Saul, facing capture, disgrace, and torture in a defeat by the Philistines, fell on his own sword (1 Sam, 31:1–6); and Abimelech, not wanting the disgrace of being killed by a woman, killed himself (Judg. 9:54); Ahitophel chose to hang himself after he supported Absolam's unsuccessful revolt against King David (2 Samuel 17:23); Judas Iscariot simply "went and hanged himself" (Colt, 1991 p.153). The Jews were involved in a number of mass suicides. In an early instance, Josephus, the Jewish general who later became a Roman historian, decided to surrender to the Romans when his army was defeated. His solders argued they should all kill themselves instead. They were able to over-come Josephus's arguments and proceeded to kill each other, but he was able to survive by persuading the last remaining soldier that the two of them should save themselves. The best-known occasion was the death in 74 C.E.of 960 Zealots who defended Masada through three years of siege by the Roman army and, facing capture, were persuaded by their leader, Eleazar Ben Zair, that death by their own hand was better than the slavery they faced when captured.

The Egyptians, Greeks, and Romans The first recorded reference to suicide comes from ancient Egypt (about 4,000 years ago) in The Dispute between a Man and His Ba, in which a man describes the injustice and greed of his times to his ba, or soul, which has threatened to leave him if he kills himself, thus depriving him of an afterlife. There was no dishonor associated with the act of suicide itself, for death was seen as a mere passage from this life to the next and as a convenient way to avoid excessive pain or dishonor. The dead were considered coequals with the gods and to have the same physical and emotional needs as the living. Suicide among the ancient Greeks and Roman varied widely with respect to tolerance and legal restrictions. The primitive attitudes of horror and condemnation for suicide were preserved in the lower classes, but the upper classes were more tolerant and accepting. Four motivations appeared most often: the preservation of honor, the avoidance of excessive pain and disgrace, bereavement, and patriotism. The major concern was honor, whatever the origin, such as patriotism, pride, or protecting one's virtue. Among those opposing suicide, the Pythagoreans disapproved because it interfered with the regular orderly process of transmigration of souls on Earth, skewing the process. Socrates (c. 470–399 B.C.E.), possibly the most famous of Greek suicides, actually opposed suicide, reasoning that humans belonged to God, so suicide was destruction of God's property. Both Aristotle (384–322 B.C.E.) and Plato (c. 428–348? B.C.E.) condemned suicide but made exceptions, such as intolerable disgrace, unavoidable misfortune, or extraordinary sorrow. Aristotle felt that people belonged to the state, which made suicide a punishable act against the state. Plato considered a person to be a soldier of God, so the suicide deserted God, not the state. Suicide to avoid suffering was considered cowardice and weakness of character; suicide was acceptable, however, in cases of incurable illness or when God had summoned the soul. The Epicureans and Stoics, on the other hand, considered suicide an appropriate escape from the sufferings of physical illness and emotional frustration. For them neither life nor death was as important as one's right to decide about both. The manner of death was important, and suicide was often a carefully chosen validation of the principles by which one had lived. Among the Romans, Pliny the Elder (23–79 C.E.) considered the existence of poisonous herbs as proof of a kindly Providence because they allowed a person to die painlessly and quickly. Suicide among the Romans became more and more economically oriented. The right to commit suicide was denied to a slave because it was considered a financial loss to the master. Likewise it was denied to a soldier because it weakened the armed forces. If a civilian committed suicide while under arrest, the state was deprived of taxes and services so punishment consisted of forfeiture of the estate. Suicide among the upper classes, however, was acceptable, in part because the attitude toward death had become so casual and public that death itself had little or no meaning. The records contain the names of many notables in Roman history who chose suicide to avoid defeat or dishonor or out of grief, including the poet Lucan (39–65 C.E.); the defeated general Cato (95–46 B.C.E.); Petronius (d. 66 C.E.), the gifted playwright and author; Paulina, the wife of Seneca (4 B.C.E.?–65 C.E.), who was allowed to kill himself when sentenced to death by the emperor Nero; and Nero (37–68 C.E.) himself.

Pre-Reformation Christianity Christianity has contained markedly opposing attitudes toward suicide over time. The early era found suicide not only tolerated but also embraced by the church. Life was difficult, and the objective in life became to avoid sin and gain entrance before God and live there forever. Martyrdom was a quick way of achieving this eternal salvation. It guaranteed redemption for all sins incurred before death and was a way to provide for the members of the martyr's family, who were then taken care of by the church for the rest of their lives. As a result, martyrdom was eagerly sought, oftentimes by deliberately provoking the Roman authorities. In the fourth century C.E., as Rome's influence declined, the attitude of the church underwent several changes. The church's attitude toward suicide became progressively more hostile, moving from tentative disapproval to severe denunciation. St. Augustine, writing in The City of God in the fourth century, declared that suicide was murder; that no private person could assume the right to kill anyone, including herself; that suffering is sent by God and is to be endured; and that suicide is the worst of sins because it precludes any possibility of absolution. A series of church councils in the next several centuries progressively increased the condemnation and punishments with pronouncements denying funeral rights, forbidding burial within church cemeteries, and denying the saying of mass for the deceased. The penalties and the denial of burial rights suggest a reemergence of some of the early pagan horror of such deaths and were the basis for many of the practices that appeared later in many countries, such as desecrating the corpse of a person who committed suicide, mutilating the body, and burying it in a crossroad with a stake through the heart. In the thirteenth century, Thomas Aquinas summarized the position of the church in Summa Theologica. He stated that suicide was absolutely wrong because self-destruction was contrary to a person's natural inclinations; because a person has no right to deprive society of his presence; and because people are God's property so it is up to God, not people, to decide on life and death. Dante's Inferno (part of The Divine Comedy, which was completed in 1321) depicted the attitude of the time by showing the suicides condemned to eternal unrest in the woods of self-destruction.

Renaissance, Reformation, Enlightenment With the Renaissance and the Reformation of the fifteenth through seventeenth centuries came a marked shift in the attitudes toward suicide. Values in religion began to change as German religious reformer Martin Luther's (1483–1546) arguments emphasized personal inquiry and responsibility and raised questions about the absolutism and obedience demanded by the church. Italy experienced a revival of learning, and a number of writings helped soften the absolute condemnation of suicide. Among these, English poet John Donne's Biothanatos (1644) is considered the first defense of suicide in English. Shakespeare incorporated fourteen suicides into his eight tragedies. Most of this change took place in the upper classes, with the lower classes remaining staunchly against suicide and continuing the custom of mutilation of the corpse all the way into the nineteenth century. The Industrial Revolution of the eighteenth century and the rise of commercialism resulted in a drastic change in the attitude of society toward the poor. Economic failure became a mark of sin, with the good being rewarded with prosperity and the poor becoming social and moral outcasts. In a 1732 incident, Richard and Bridget Smith killed their daughter and hanged themselves, leaving a bitter note blaming their fear of worsening poverty. Writers and philosophers in this period through the eighteenth and nineteenth centuries (later known as the Enlightenment) wrote learned discourses on suicide. Some of these were sympathetic and focused on the rights of the individual. Such works included the English clergyman Robert Burton's Anatomy of Melancholy (1621) and the Scottish philosopher and historian David Hume's An Essay on Suicide (1783). Others held to the familiar arguments of duty to the state, the virtue of suffering, responsibility to the family, and the preservation of life as a primary law of nature. Among this group of writings was the German philosopher Immanuel Kant's The Metaphysics of Ethics. The last half of the eighteenth century and the first half of the nineteenth became known as the Romantic Age because of the impact the Romantic poets of that era had on the concept of death. The suicide by poison of the English poet Thomas Chatterton (1752–1770) at age seventeen was taken as a model—premature death in blazing genius— in which youth, death, and poetry became synonymous. According to George Howe Colt, writing in his 1991 book The Enigma of Suicide, "The poetic sensibility was too good for this world; it was best to burn brightly and to die young, like a shooting star" (Colt 1991, p. 81). The greatest change in the nineteenth century was the association of the word disgrace, a social value, with suicide. Survivors felt disgraced and the status of the family in the community sank. As suicide became more and more associated with mental illness, it was more often hidden, especially among the upper classes. The family thus often had the dismal choice of identifying their suicidal beloved one as either a weak sinner or a disturbed lunatic. Debates about social responsibilities versus individual rights and about the relationship between civilization and mental illness became common. Studies appeared in two major domains— statistical (social) and medical (at first neurobiological and later psychological). Relationships between suicide and epidemiological factors, such as age, sex, marital status, socioeconomic class, occupation, and climate, were investigated. Some studies of suicide explored possible links of social factors with physiological symptoms (e.g., pulmonary conditions, cancer); others linked the social factors with behavioral and relational factors (e.g., trouble at home, intense worry, poverty, misery, alcoholism). French physician Jean-Étienne Esquirol, author of Mental Maladies (1838), maintained that suicide was almost always a symptom of insanity but was not a disease per se. Italian physician Henry Morselli, author of Suicide: An Essay on Comparative Moral Statistics (1881), held that suicide was primarily the result of the struggle for life and nature's evolutionary process. He concluded that suicide could be lessened only by reducing the number of people, and that could be accomplished only through birth control. Morselli blamed Protestantism, free discussion, and individualism for the increasing number of suicides. Near the end of the nineteenth century, Émile Durkheim's Suicide (1897) established the field of sociology by offering the first comprehensive theory of suicide. Durkheim's theory postulated that two basic social forces exist and interact within any society—regulation and integration. Societies that were chaotic and confused produced "anomic" suicides; societies characterized by excessive constraints were likely to develop "fatalistic" suicides; societies in which the individual felt alienated and separate would have "egoistic" suicides; and in societies in which there was overidentification with the values or causes of a person's group, the suicides would be "altruistic." Durkheim's theory stimulated a continuing array of sociologicalstatistical investigations. It has been modified in innumerable ways, none of which seriously challenged his basic underlying theory.

Twentieth Century and Beyond The early twentieth century was distinguished by the radical new innovations introduced into the field of psychiatry by psychoanalysis, especially in the study of the motivations and dynamics of suicide. The psychoanalytic approach of the Austrian neurologist Sigmund Freud delved into the individual searching for hidden conflicts, repressed memories, and complex defenses in a proposed new conceptual structuring of the personality into three layers: id, ego, and superego. Freud's first formulation of suicide, found in his essay "Mourning and Melancholia," developed from his studies of melancholia and depression. In this work, Freud contended that suicide resulted from rage originally directed against a loved one but now acted out on an image of that person that has been incorporated into the self. Not completely satisfied with this formulation, Freud later proposed, in his book Beyond the Pleasure Principle (1922), that suicide was an expression of the death instinct (Thanatos), which existed in continuous conflict with the life instinct (Eros), and which became more powerful in situations of extreme emotional distress. The American psychiatrist Karl Menninger, in his 1938 book Man against Himself, extended Freud's concept of the death instinct and hypothesized that three elements exist in constantly shifting patterns in all self-destructive behavior—the wish to kill, the wish to be killed, and the wish to die. Other psychoanalysts formulated theories consistent with their own concepts of the important elements in personality development. Investigations into the problems of suicide continued through the first half of the twentieth century with relatively little interest professionally or concern by the public, despite suicide as a mode of death appearing consistently in the list of the top ten causes of death in the United States. The establishment in 1958 of the Los Angeles Suicide Prevention Center, which provided a model for immediate consultation, guidance, and assistance to the suicidal person in the community by means of the telephone, initiated a belated reawakening of interest in the phenomenon. Since then, activity in the field has grown exponentially with the founding of various national professional associations, an international association, and several professional journals that publish articles primarily on suicide. Research is exploring various aspects of suicide with questions that sound strikingly similar to the questions raised in previous centuries. These questions are epidemiological, demographic, biological, constitutional, neurological, psychiatric, psychological, psychodynamic, and sociocultural in nature, and the questions explore such areas as mental illness, prevention, public health, individual rights, family obligations, treatment, and survivor relationships. The sinner/criminal suicide of yesterday is recognized today as a complex, multi-faceted biopsychosociocultural phenomenon.

Bibliography Adler, Alfred. "Suicide." Journal of Individual Psychology 14 (1958):57–61. Alvarez, Alfred. The Savage God: A Study of Suicide. New York: Random House, 1972. Colt, George Howe. The Enigma of Suicide. New York: Summit, 1991. Donne, John. Biothanatos. New York: Facsimile Text Society, 1930. Durkheim, Émile. Le Suicide, translated by George Simpson. Glencoe, NY: Free Press, 1951. Esquirol, Jean-Étienne. Mental Maladies: A Treatise on Insanity, translated by Ebenezer Kingsbury Hunt. New York: Hefner, 1965. Fedden, Henry Romilly. Suicide. London: Peter Davies, 1938. Hankoff, Leon D., ed. Suicide: Theory and Clinical Aspects. Littleton, MA: P. G. Publishing, 1979. Menninger, Karl. Man against Himself. New York: Harcourt, Brace, 1938. Morselli, Henry. Suicide: An Essay on Comparative Moral Statistics. New York: D. Appleton, 1975.

NORMAN L. FARBEROW

PREVENTION Suicide prevention involves actions to intervene in an individual's suicidal pattern or mindset as well as a variety of public health measures to reduce the incidence of suicidal behavior in a community. There are many ways to prevent suicides. Suicides are the result of a combination of multiple risk factors, including mental disorders, personal characteristics, inadequate coping skills, and environmental variables, such as recent losses, lack of social support, and availability of lethal means. Any activities that help reduce risk factors, such as treating mental disorders and psychiatric difficulties, increase one's ability to cope with stressful situations and problems. Preventing or treating alcoholism and drug abuse and ensuring that people develop good social support systems have some effect in preventing suicides. National strategies that focus upon decreasing the number of deaths by suicide in a country generally take a combined approach, in which various types of complementary programs and services are provided in order to decrease the incidence of suicide.

Primary Prevention of Suicide Suicide prevention may focus on primary prevention, which involves developing skills or reducing risk factors in order to prevent people from becoming suicidal. Primary prevention strategies can either focus on an entire population or specific high-risk groups. An example of a primary prevention program that focuses on the general population is National Suicide Prevention Week—a week of activities in which media reports and a publicity campaign focus on teaching the general population how to get help, give help, or identify suicide risk. Another example of primary prevention for a large population is a high school program, in which teachers, support staff, and students learn about suicide, particularly how to know when a student is at risk and how to find and use available resources for oneself and for others. Some primary prevention strategies focus on suicide, such as in the previous example of a high school suicide prevention program. However, many primary prevention strategies do not focus directly on suicide but are concerned more with general risk factors, such as poor coping skills or stress related to school examinations. For example, research studies indicate that adolescents who attempt suicide have fewer coping strategies than adolescents who do not attempt suicide. The Reaching Young Europe program, called "Zippy and Friends," is offered by the Partnership for Children in different European countries. As a twenty-four-week program, it focuses upon teaching coping skills to young children. Although suicide is not mentioned in this program, it is assumed that children who can better cope with everyday problems will eventually be at lower risk of suicide because problematic situations will not become so severe that they will consider detrimental behavior or engage in behavior to end their own lives. Primary prevention strategies that focus on high-risk groups try to identify people who are more likely to commit or attempt suicide. For example, high-risk groups include persons in custody, young gays and lesbians, persons who previously attempted suicide, and persons with mental health disorders, notably mood disorders such as depression, as well as schizophrenia, and alcoholism. Sometimes prevention programs for high-risk groups focus on all people in that risk group. For example, a program for Native people may focus upon the entire community and aim to develop better intergenerational cooperation and establish an identity using role models from traditional Native practices. Public education programs generally focus on reducing the stigma associated with seeking treatment and providing social support for those who are depressed and suicidal. They may involve a popular spokesperson who is open and frank and whose discussions of suicide may encourage others to seek professional help and talk about their problems with friends and loved ones.

Secondary Prevention Secondary prevention strategies involve interventions with people who are already suicidal or at high risk of suicide in order to reduce the probability that they will commit suicide. Suicide prevention hotlines and telephone crisis intervention services are regularly available in most developed countries and many less developed parts of the world. These centers vary from "active listening" services, where people can talk about any problem, to more specifically focused suicide prevention organizations that evaluate suicidal risk and urgency in all calls and focus their efforts on helping suicidal persons, friends and family members of suicidal persons, and sometimes persons bereaved by suicide. They are generally based upon the belief that suicide is a means of coping with a seemingly impossible and interminable situation or problem and suicidal people are ambivalent about using suicide as a solution. Ambivalence in the suicide-prone is expressed in their desire to seek some other means of diminishing their anguish or problems. This leads them to contact a telephone help line. Suicide prevention help lines generally begin by assessing the urgency of the situation, that is, whether or not the person is likely to commit or attempt suicide in the near future. If the urgency is high, trained personnel may then focus upon seeking short-term solutions, such as sending an ambulance during an attempt or getting immediate help in a crisis situation. If the urgency is less high, they may focus upon exploring alternative means to resolve the caller's problems, or they may simply offer compassionate empathic listening. It is assumed that being able to talk about one's problems with a compassionate stranger helps the callers better understand what is going on, feel better about themselves, and encourages them to learn about other services that are available in their community. There is evidence that hotlines do help many callers. Although it is difficult to prove, studies indicate that help lines prevent suicide attempts and completed suicides. There is substantial evidence that reducing the availability and lethality of means of suicide has a preventive effect. The risk of suicide in a home where there is a firearm is five or six times greater than in a home without guns. Countries that have adopted strict gun control regulations appear to have reduced suicide rates. Although someone who is determined to commit suicide can always find some means of completing the suicide, some people prefer certain methods and are less likely to kill themselves if those methods are not readily available. Furthermore, in a crisis situation, the availability of lethal means greatly increases the probability that a death by suicide will occur. Reducing the availability of means is not limited to gun control or making sure that firearms are taken out of the home of someone who is suicidal. Other prevention methods include constructing barriers on bridges to prevent people from jumping, constructing "suicide pits" beneath the rails of subway train lines so that people who jump in front of trains are less likely to be killed, and educating parents to dispose of potentially lethal medications in the homes of suicidal teenagers. One of the most promising methods of suicide prevention is what is called "gatekeeper" training. Gatekeepers are people who may come into contact with suicidal individuals in their daily work, such as clergy, police officers, custodial personnel, teachers and school personnel, and physicians. Very often, these individuals receive little or no specific training in the identification of suicide risk and how to help suicidal individuals. Gatekeeper training involves not only information about assessing risk and intervening with suicidal people, but generally provides information on referral and help available from other services within their community, including treatment of depression, alcoholism, and drug abuse. There has been much public health interest in training physicians to identify suicidal individuals and depression. This interest was enhanced by results from the Island of Gotland in Sweden, where a physician training program focusing upon the recognition and treatment of depression and suicide was evaluated. This training program resulted in increased identification and treatment of depression and a decrease in suicides on the island. Research has shown that as many as 50 percent of those who commit suicide consult a physician in the month before their deaths. For this reason, physician training is considered an important means of suicide prevention. People who attempt suicide are at least a hundred times at greater risk of a future suicide attempt and dying by suicide than persons who have never attempted suicide. Suicide attempters who are treated in hospitals often do not appear for their first or second outpatient appointment after they leave the hospital. There are few follow-up programs that focus upon changing the circumstances that contribute to the increased risk of suicide before an attempt. One of the problems with the follow-up of those who have attempted suicide is lack of coordination and collaboration between different community services and agencies. In many suicide prevention centers, over 50 percent of callers also receive professional mental health services, but there is often little communication or collaboration between the different agencies. National strategies for suicide prevention often focus upon coordination of all services within a community and the development of protocols for collaboration to facilitate referrals between agencies.

Suicide Prevention in a Place Where a Suicide Has Occurred When a suicide occurs in a school or at the workplace, there is an increased risk of another suicide or suicides occurring in the same environment. Public health officials have developed several programs to prevent the so-called contagion of suicide following such events. It is usually thought that the risk of more suicides increases because people who are bereaved by suicide are more vulnerable. Also, there is a tendency to identify with the suicide victim and fantasize about obtaining all the attention that the suicide provoked. For these reasons, several programs have been developed to prevent increased suicidal behavior in schools or workplaces where a suicide has occurred. These programs usually involve offering help to those who are troubled by the suicidal death and helping educate people about the nature of suicide and the resources for prevention. In any program following a suicide (often called "postvention programs") it is important to be aware that too much public attention to the event may help glorify the suicide in the eyes of vulnerable suicidal people. Successful programs do not have a fixed agenda about how to deal with a suicide event, but rather emphasize an understanding of the individual needs of people who were exposed to the suicide. They also focus on the need of family and friends to grieve in an appropriate manner.

Social Interventions Suicide is an intentional behavior whose expression is greatly influenced by the cultural milieu. In some cultures suicides are common; in others they are rare. Although in Western cultures men commit suicide more often than women, there are areas of the world, such as China, where a significant portion of suicides are by women who do not want to be a financial burden to their families. In some cultures, including the United States and Canada, some people have killed themselves in a copycat manner following the publicized suicide of a rock star. The option of killing oneself under specific circumstances is acquired at a young age. In each culture, children learn when and how people kill themselves. In most Western countries children's first experiences with suicide are from exposure to television and other media depictions of fictional suicides and suicide threats, including suicides in popular cartoons. One may ask if it is possible to prevent suicides within a society by modifying the way the option of suicide is transmitted from generation to generation and changing attitudes and knowledge about suicide within the society. A large body of research has shown that media depictions of suicides result in an increase in suicidal behavior by those who identify with the suicide victim. The emphasis in research on media and suicide has generally been negative: that is, it explores how media, such as television, newspapers, and the cinema, actually increase the incidence of suicide. There have been no studies of how the media may help prevent suicide. Researchers question if it is possible to reduce suicidal behavior in a society by developing media depictions and social campaigns that aim to change attitudes about the acceptability of suicide. These "positive" advertising campaigns are represented by National Suicide Prevention Days or Suicide Prevention Weeks, in which there is an objective of educating the population about the tragedy of suicide and how suicide may be prevented. Evaluations of the Quebec Suicide Prevention Week indicate that this national educational campaign's target population retained the positive messages the campaign conveyed. Although it is difficult to change attitudes and beliefs in a society, they can change over time. For example, the twentieth century has seen impressive changes in attitudes toward women's rights, women's participation in society, and sex role stereotypes. Similarly, one could imagine that attitudes toward suicide as an acceptable "way out" in certain circumstances could change if appropriate actions were taken to educate the population and influence how suicide is perceived.

Bibliography Government of Quebec. Help for Life: Quebec's Strategy for Preventing Suicide. Quebec: Ministère de la Santé et des Services sociaux, 1998. Hakanen, Jari, and Maila Upanne. "Evaluation Strategy for Finland's Suicide Prevention Project." Crisis 17, no. 4 (1996):167–174. Mishara, Brian L. "The Prevention of Suicide in Adulthood." In Martin Bloom and Thomas Gullotta eds., Encyclopedia of Primary Prevention and Health Promotion. New York: Kluwer Academic/Plenum Publications, 2002. Mishara, Brian L., and Marc Daigle. "Helplines and Crisis Intervention Services: Challenges for the Future." In David Lester ed., Suicide Prevention: Resources for the Millennium. Philadelphia: Brunner/Mazel, 2000. Mishara, Brian L., and Marc Daigle. "Effects of Different Telephone Intervention Styles with Suicidal Callers at Two Suicide Prevention Centers: An Empirical Investigation." American Journal of Community Psychology 25, no. 6 (1997):861–895. Mishara, Brian L., and Mette Ystgaard. "Exploring the Potential of Primary Prevention: Evaluation of the Befrienders International Reaching Young Europe Pilot Programme in Denmark." Crisis 21, no. 1 (2000):4–7. Murphy, George E. "The Physician's Responsibility for Suicide: Errors of Omission." Annals of Internal Medicine 82 (1975):305–309. Shaffer, David, and Madelyn Gould. "Suicide Prevention in Schools." In Keith Hawton and Kees van Heeringen eds., Suicide and Attempted Suicide. New York: John Wiley and Sons, 2000. Stack, Steven. "Media Impacts on Suicide: A Quantitative Review of 293 Findings." Social Sciences Quarterly 81, no. 4 (2000):975–988. World Health Organization. Preventing Suicide: A Resource for Primary Health Care Workers. Geneva: Author, 2001.

BRIAN L. MISHARA

WARNING SIGNS AND PREDICTIONS Suicide is a rare event. Most suicidal people find other solutions to their problems and do not attempt or commit suicide. Because of the large number of suicidal persons and small number of suicides, individual suicides are impossible to predict in a reliable manner. However, there are a number of warning signs that can help determine if a person is at risk. Many more people will always be identified as at risk than actually attempt or commit. Since the outcome is irreversible and tragic, it is best to take all indications of suicide risk seriously.

Who Is at Risk? Although people with any characteristics can commit suicide, some people are more at risk of suicide than others. People who can be identified as having the following characteristics are more likely to be suicidal than those of the general population. Persons with mental disorders or psychiatric problems are at great risk of suicide, particularly those suffering from clinical depression. Alcoholics and drug abusers are another category of individuals at great risk. Suicide risk may be greater for persons who discontinue medication they are taking for mental health problems. People who have previously attempted suicide are at greater risk of attempting suicide again than those persons who have never attempted suicide, primarily because the problems that led to the first attempt may not have been resolved. People who have experienced a recent major loss, such as death of a close friend or relative, divorce, or separation or loss of a job, are at greater risk that the general populace. Also, people whose close friends have committed suicide or have a family history of suicide are at great risk, as are people who are in physical ill health.

Warning Signs It is rare that a person who attempts or completes a suicide does not give prior indications of his or her suicidal intentions. This is because relatively few persons who commit suicide do so impulsively without having thought about ending their own lives beforehand for days, weeks, or months. Suicides rarely occur because of a sudden traumatic event. However, people at risk of suicide who experience a sudden traumatic event are at much greater risk of ending their lives at that time. People who are suicidal are often seen as having changed their personality or humor recently. Changes include depression or apathy, pessimism, irritability, or "not seeming to be themselves." There may be changes in eating patterns (eating much more or stopping eating) and sleeping habits (sleeping much more or being unable to sleep, particularly waking up early and not being able to get back to sleep). Suicidal people often feel lonely, misunderstood, helpless, hopeless, worthless or ashamed, guilty, and/or full of hate for themselves. These feelings are not normal, even for a person who has a mental disorder or psychiatric illness. They are indications that something is desperately wrong. Any behavior that may be interpreted as "preparing" for death may be an indication of suicidal intent. For example, suicidal persons may put their personal affairs in order and update or write a will. Even more direct preparations include giving away important objects (particularly if the person makes statements like, "I won't need them anymore" or "I don't care about them anymore"). Sometimes people say good-bye or express feelings in a way they never did before (e.g., "I never really told you how much I care about you; I just wanted you to know"). Another danger sign of suicide is a preoccupation or interest in obtaining means for killing oneself. The purchase of a gun or getting hold of potentially lethal medications may be an indication of suicidal intent. Tying nooses in a rope or occupying dangerously high places are other possible indicators. Some people review web sites that provide information about how to kill oneself, or investigate what constitutes a lethal dose of medication. These and other dangerous behaviors are important indications that a suicide might be imminent. Some suicidal people write suicide notes that they may leave around where others might see them. Leaving a suicide note where it can be found beforehand or making "obvious" preparations may be interpreted as an expression of the suicidal person's ambivalence. Although the person intends to die, there is also some hope that someone will find the note or identify the risk and help find a solution to his or her problems before a suicide attempt. Most suicidal persons express their suicidal intentions to others beforehand. These expressions may be in the form of direct suicide threats ("I can't stand it and I'm going to kill myself") or they may be much less direct ("Sometimes I think it's not worth going on"). Suicidal persons may be indirect in the communication of their intent because they are afraid of how a friend or family member will react. Depending upon the reaction, they may continue to confide their thoughts and plans or they may change the subject.

What To Do If There Are Warning Signs Whenever a person gives some of the above indications that he or she may be suicidal, others may be of great help if they talk to the person about how he or she is feeling. Unfortunately, most people hesitate to ask questions or talk about suicide because they are afraid that they will say or do the wrong thing. Often they feel that they may make things worse or even cause someone who is vulnerable to get the idea to commit suicide. However, mental health practitioners maintain that this does not happen. Suicide is not something someone can suggest by asking questions about what a person is thinking and feeling and whether or not a person is thinking about suicide. Conversations about suicide serve the purpose of communicating to a person who is considering whether or not he or she should end life that someone else is interested in helping—despite the fact that the suicidal person is thinking of doing something that most people find unable to speak about. Most people feel quite relieved that they are able to talk openly about suicide and the problems they are having. Discussions about suicide should focus on resources the person already has available. Does the person have a confident or friends with whom he/she can talk about the problem or get help? Is the suicidal individual seeing a mental health professional or other health care provider who can be of help? Conversations can be helpful if they explore alternative ways to help with the situation. When confronted with a suicidal person, mental health practitioners uphold that it is important to stay calm and listen empathically to what the person is saying. Despite the possibility that the attempt may not be serious or the person may be manipulative, it is important to take the situation seriously and to ask questions to find out how serious the intentions really are. Friends and helpers should ask specific questions about risk factors such as previous attempts and mental health problems. Generally, people who know when and how they are going to commit suicide are at much greater risk than people whose plans are vague and uncertain. For this reason it is useful to ask if the person has considered how and when he or she plans to commit suicide. Asking such a direct question can do no harm and can provide important information. If the person knows how and has the means at hand, the risk is great and immediate help is needed. If a person has a means of suicide available, such as a firearm or lethal medication, it is important to remove the means from the home. Concerned parties should consult a suicide prevention service or agency or skilled health or mental health care provider who is knowledgeable about suicide. If a person is at high risk, that is, the person appears to be ready to take his or her own life soon, it is best to stay with the person or have someone else stay with the person during this crisis period. It is not useful to get angry or panic. Nor is it useful to be falsely encouraging by saying things like, "I'm sure that everything will be all right." Also, it is best not to belittle or trivialize the problem by saying, for example, "I'm sure other people have been in much worse situations and they never thought of killing themselves." No matter how unimportant the problems may seem to an outsider, they may be sufficiently serious in the mind of the suicidal person for the person to consider taking his or her own life. A mature listener should not make promises he or she cannot keep or insist that things will change if he or she is not certain. One should not swear to keep secret a person's suicidal intentions. Saving a person's life is more important than betraying a confidence. Not all suicides are preventable. However, people who give indications that they are suicidal usually experience great ambivalence about whether they should kill themselves or not. If a person wants to commit suicide without telling anyone or indicating what he or she intends to do, there is nothing anyone can do to prevent it. However, people who do give indications that they are suicidal, despite their insistence that they must complete this act, are generally experiencing ambivalence about whether or not this is the only way to stop their anguish or painful situation. In these circumstances it is important to talk with the person and offer help so that the ambivalence against committing suicide may be strengthened in the short term by the presence of a caring friend. However, in the long run suicidal persons need to take steps to resolve underlying problems. This may involve starting or continuing help from a mental health professional, trying to resolve a drinking or drug problem, or learning to expand coping skills. Identifying suicide risk and offering help is the first step in the process of helping suicidal individuals decrease their risk of suicidal behavior.

Bibliography Hawton, Keith, and Kees van Heeringen, eds. The International Handbook of Suicide and Attempted Suicide. Chichester, England: John Wiley & Sons, 2000. Jacobs, Douglas G., ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass Publishers, 1999. Maris, Ronald W., Alan L. Berman, John T. Maltsberger, and Robert I. Yufit, eds. Assessment and Prediction of Suicide. New York: Guilford Press, 1992. Maris, Ronald W., Alan L. Berman, and Morton M. Silverman, eds. Comprehensive Textbook of Suicidology. New York: Guilford Press, 2000.