Fuad Khan, MD, MBA

Our greatest challenge in psychiatry is preventing the suicide of a patient. News of the suicide of a patient, acquaintance, colleague, or friend elicits a deep feeling of dread, often accompanied by confusion, disbelief, and sadness. The 

Centers for Disease Control and Prevention

 (CDC) reported suicide as being the 10th leading cause of death in 2017 in the United States. Nationally, suicide rates have increased by approximately 33% from 1999 to 2017 among all age groups. Additionally, the annual increase in suicides has climbed from 1% per year during 1999 to 2006 to close to 2% per year from 2006 to 2017.

 For ages 10 to 34 suicide is now the second leading cause of death. The largest number of suicides occur between ages 35 and 55, where it is the fourth leading cause of death.

 Despite death by suicide being surpassed by 9 other causes, its aftermath leaves enduring feelings of guilt, loss, betrayal, confusion and sadness in those left behind, often never fully resolving.

Clinically, predicting suicide remains challenging at best. For each suicide there is often a complex web of life experiences, personality traits, psychiatric diagnoses, cultural beliefs, relationship issues, and acute stressors that ultimately converge on a person’s decision to take ones life. This article is the first in a 4-part series on suicide and will provide a general overview of the topic. Subsequent articles will examine the various factors that can increase the risk of suicide, provide an overview of the complexity and challenges in attempting to accurately screen for and identify a patient at high risk for suicide, and discuss appropriate intervention options.

, originates from the Latin terms sui “self” and caedere “the act of slaying.”

 Technically, the CDC describes suicide and suicide attempt as “. . . death caused by injuring oneself with the intent to die. A suicide attempt is when someone harms themselves with the intent to end their life, but they do not die as a result of their actions.”

The history of suicide among humans is a nebulous subject. Currently, we have no way of accurately determining when the first suicide occurred, what the motivating factors leading to the suicide were, or when the concept of suicide was conceived. According to 

 the cognitive revolution in humans started approximately 70,000 years BC, with significant advancement in thinking and language, which paved the way to abstract thought and the ability to plan ahead. In contrast to the preceding ancestors where a life was to be lived until death, the ability of imagining alternatives could create the possibility of making a choice between continuing to live, or to end one’s life by self-intent. Over the millennia a wide range of motivating factors could have affected a person’s decision attempt suicide, including:
1. Suicide as an alternative to enslavement by a hostile enemy. The choice to commit suicide at Masada by the Jewish people is an example of how liberty and freedom influenced the decision to die rather than be enslaved.


2. Suicide as a chosen end of pain and suffering from a chronic injury or illness. Because improvement in medical science provides more options to prolong life, the question of quality of life becomes all the more important. Euthanasia has become a prominent subject, and mental health experts and other medical professionals are expected to serve a role in solving the controversies, and in physician-assisted suicide.

3. Suicide associated with shame over failure to protect ones family/culture/country. Examples include Seppuku (AKA harakiri) “cutting the belly”often called an “honor suicide,” and suicide in Ancient Greece after military defeat.

4. Suicide for a cause such as Kamikaze fighters and suicide bombers. There may be close associations of thought process in such suicides to the same as those in euthanasia, honor-suicide, and suicide related to depression.

5. Suicide to end severe emotional distress which is the more common suicide that mental health professionals face and attempt to treat.

While study of archeology and human cultures may give us some idea of what happened, it is impossible to really understand what people thought. It was only around 4000 BC when the Sumerian writings started to give us a chance to probe into human thinking. The story of suicide is similar. The first ever note considered to be a 

Some of the earliest recorded attention to the subject of suicide in the western world can be traced to ancient Greece, where it was discussed more from a societal or state perspective, rather than an individual one. Plato viewed it as a negative behavior except in certain circumstances, whereas Aristotle considered it as a loss to society.

 Sometimes suicide was encouraged, such as sati (suttee) in ancient Hindu culture, or enforced

; for example, hemlock for Socrates, or in the service of honor or a noble cause.

The concept of suicide focused on the act of suicide without much distinction between “imposed” or “volitional” suicide. In Europe, it was the fifth century when suicide became a subject in religious thought with St Augustine declaring it as immoral.

 Suicide became taboo, and the act and the doer both at risk of being publicly abhorred extended from religion into the cultural realm. The underreporting of suicide even in present-day culture has its roots in these historical judgments.

As society progressed towards relative freedom of thought, the loosening of the concept of “sin” as the cause and effect of suicide allowed more inquiry into the act of suicide. 

 a French sociologist, proposed the idea of suicide as a societal problem with integration of the individual in the society as a central theme in a suicide. He felt that an overidentification, underidentification, or disconnection from society in an individual had an impact on the risk of suicide.

These developments led to the study of suicide from a perspective of influences extrinsic to an individual. Several theories tying industrialization, the movement of the female population into the mainstream workforce, and social status compatibility were brought forward as related to suicide.

 highlights the significant association of the sharp increase in suicide among Inuit Indians of Canada after their exposure to severe societal and cultural shifts imposed by the rapid and intense colonization and its long-term aftermath. Poor social integration has shown to have a strong correlation with suicide independent of the presence of psychiatric illness.

 Studies show that economics, particularly unemployment, can influence suicide rates over the long term in different societies.

Steady advances in knowledge and science linked suicide with the medical field as early as the 17th century.

 The role of mental illness in suicide became prominent in recent decades.

 Advancement in understanding neurobiology and behavior has led to the proposal of a stress-diathesis model in which a combination of genetic predisposition and exposure to stress can affect suicidal behavior. It separates risk factors into trait-dependent and state-dependent.

 All of these discoveries have led to increased efforts to understand and prevent suicide.

 clearly articulates its position that suicide is preventable and has put forth several proposals to reduce suicide.

 These efforts include:
• Development and clarification of accurate nomenclatures such as suicide ideation, intent, and suicide behavior

• Identification of risk and protective factors of suicide
• Developing systematic prevention strategies in various sectors such as health care, business, legal, political, cultural, educational, and media

Given that suicide is such a complex, multifaceted issue, it becomes extremely hard for a single sector to be effective in preventing suicide. Health care professionals often find themselves feeling and/or held responsible for failing to prevent a suicide. Thus, clinicians need to follow due diligence with all patients.

Future articles will explore in greater detail the numerous factors that can increase/decrease the risk of suicide, the complexity and challenges in attempting to accurately screen for and identify a patient at high risk for suicide, and appropriate intervention options.

 is Medical Director, Psychiatric Services, Wentworth-Douglass Hospital, Dover, NH; 

 is Master of Science candidate, Johns Hopkins University, Baltimore, MD.

1. Hedegaard H, Curtin SC, Warner M. ). Suicide mortality in the United States, 1999–2017. 

. 2018;330:1-8.
2. Suicide Prevention Resource Center. 

.
4. Centers for Disease Control and Prevention. 

. New York, NY: Random House; 2014.
6. Schwartz M, Kaplan KJ.. Judaism, Masada, and suicide: a critical analysis. 

. 1992;25:127-132.
7. Ricou M, Wainwright T. The psychology of euthanasia: why there are no easy answers. 

. 2019;24:243-256.
8. Thurston A. Physician-assisted death: a selected annotated bibliography. 

. 2019;111:31-69.
9. Roberts K, Miller M, Azrael D. Honor-related suicide in the United States: a study of national violent death reporting system data. 

. 2019;23:34-46.
10. Greenland A, Proulx D, Savage DA. Dying for the cause: the rationality of martyrs, suicide bombers and self-immolators. 

The Ancient Egyptians: A Source Book of Their Writings

. New York, NY: Harper Torchbooks; 1966.
12. Cholbi M. Suicide. In Zalta EN, Ed. 

. Metaphysics Research Lab: Stanford University, CA; 2017.
13. Thakur P. A journey of Hindu women from Shakti to sati in ancient India. 

. 2017;4:383-385.
14. De Leo D. DSM-V and the future of suicidology. 

. 2011;32:233-239.
15. Durkheim É, Simpson G, Spaulding JA. 

. London, UK: Routledge; 2002.
16. Anderson O. Did suicide increase with industrialization in Victorian England? 

. 1980;86:149-173.
17. Newman JF, Whittemore KR, Newman HG. Women in the labor force and suicide. 

. 1973;21: 220-230.
18. Lester D. Economic factors and suicide. 

. 1988;128:245-248.
19. Morris M, Crooks C. Structural and cultural factors in suicide prevention: the contrast between mainstream and Inuit approaches to understanding and preventing suicide. 

. 2015;29:321-338.
20. Duberstein PR, Conwell Y, Conner KR, et al. Poor social integration and suicide: fact or artifact? A case-control study. 

. 2004;34:1331-1337.
21. Ceccherini-Nelli A, Priebe S. Economic factors and suicide rates: associations over time in four countries. 

. 2011;46:975-982.
22. Anton J, Van Hoof L. 

A Historical Perspective on Suicide: Comprehensive Textbook of Suicidology

. New York: The Guilford Press. 2000: 96-123.
23. Silverman MM, Maris RW. The prevention of suicidal behaviors: an overview. 

. 1995;25:10-21.
24. Mann JJ, Arango V. Integration of neurobiology and psychopathology in a unified model of suicidal behavior. 

. 1992;12(Suppl):2S-7S.
25. World Health Organization. Preventing Suicide: A Global Imperative. 2014.
26. Crosby A, Ortega L, Melanson C. Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements.

Articles

Predicting suicide remains challenging at best. For each suicide there is often a complex web of life experiences, personality traits, psychiatric diagnoses, cultural beliefs, relationship issues, and acute stressors that ultimately converge on a person’s decision to take one’s life.

Fuad Khan, MD, MBA

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Suicide: A Biography