Mental Health and Illness - Suicide

Suicide may be the ultimate expression or consequence of depression or other serious mental disorders. Not all people who suffer from depression contemplate suicide, nor do all those who attempt suicide suffer from depressive or other mental illnesses. However, with the exception of certain desperate medical situations, suicide in the United States generally is considered an unacceptable

TABLE 8.5
Death rates for suicide, according to sex, race, Hispanic origin, and age, selected years 1950–2001
[Data are based on death certificates]

Sex, race, Hispanic origin, and age	19501	19601	1970	1980	1990	1995	2000	2001
Allpersons	Deaths per 100,000resident population
All ages, age adjusted	13.2	12.5	13.1	12.2	12.5	11.8	10.4	10.7
All ages, crude	11.4	10.6	11.6	11.9	12.4	11.7	10.4	10.8
Under 1 year	…	…	…	…	…	…	…	…
1–4 years	…	…	…	…	…	…	…	…
5–14 years	0.2	0.3	0.3	0.4	0.8	0.9	0.7	0.7
15–24 years	4.5	5.2	8.8	12.3	13.2	13.0	10.2	9.9
15–19 years	2.7	3.6	5.9	8.5	11.1	10.3	8.0	7.9
20–24 years	6.2	7.1	12.2	16.1	15.1	15.8	12.5	12.0
25–44 years	11.6	12.2	15.4	15.6	15.2	15.1	13.4	13.8
25–34 years	9.1	10.0	14.1	16.0	15.2	15.0	12.0	12.8
35–44 years	14.3	14.2	16.9	15.4	15.3	15.1	14.5	14.7
45–64 years	23.5	22.0	20.6	15.9	15.3	13.9	13.5	14.4
45–54 years	20.9	20.7	20.0	15.9	14.8	14.4	14.4	15.2
55–64 years	26.8	23.7	21.4	15.9	16.0	13.2	12.1	13.1
65 years and over	30.0	24.5	20.8	17.6	20.5	17.9	15.2	15.3
65–74 years	29.6	23.0	20.8	16.9	17.9	15.7	12.5	13.3
75–84 years	31.1	27.9	21.2	19.1	24.9	20.6	17.6	17.4
85 years and over	28.8	26.0	19.0	19.2	22.2	21.3	19.6	17.5
Male
All ages, age adjusted	21.2	20.0	19.8	19.9	21.5	20.3	17.7	18.2
All ages, crude	17.8	16.5	16.8	18.6	20.4	19.5	17.1	17.6
Under 1 year	…	…	…	…	…	…	…	…
1–4 years	…	…	…	…	…	…	…	…
5–14 years	0.3	0.4	0.5	0.6	1.1	1.3	1.2	1.0
15–24 years	6.5	8.2	13.5	20.2	22.0	22.0	17.1	16.6
15–19 years	3.5	5.6	8.8	13.8	18.1	17.1	13.0	12.9
20–24 years	9.3	11.5	19.3	26.8	25.7	27.0	21.4	20.5
25–44 years.	17.2	17.9	20.9	24.0	24.4	24.4	21.3	22.1
25–34 years	13.4	14.7	19.8	25.0	24.8	24.8	19.6	21.0
35–44 years	21.3	21.0	22.1	22.5	23.9	24.0	22.8	23.1
45–64 years	37.1	34.4	30.0	23.7	24.3	22.2	21.3	22.5
45–54 years	32.0	31.6	27.9	22.9	23.2	22.5	22.4	23.4
55–64 years	43.6	38.1	32.7	24.5	25.7	21.8	19.4	21.1
65 years and over	52.8	44.0	38.4	35.0	41.6	36.2	31.1	31.5
65–74 years	50.5	39.6	36.0	30.4	32.2	28.5	22.7	24.6
75–84 years	58.3	52.5	42.8	42.3	56.1	44.9	38.6	37.8
85 years and over	58.3	57.4	42.4	50.6	65.9	62.7	57.5	51.1
Female
All ages, age adjusted	5.6	5.6	7.4	5.7	4.8	4.3	4.0	4.0
All ages, crude	5.1	4.9	6.6	5.5	4.8	4.3	4.0	4.1
Under 1 year	…	…	…	…	…	…	…	…
1–4 years	…	…	…	…	…	…	…	…
5–14 years	0.1	0.1	0.2	0.2	0.4	0.4	0.3	0.3
15–24 years	2.6	2.2	4.2	4.3	3.9	3.6	3.0	2.9
15–19 years	1.8	1.6	2.9	3.0	3.7	3.1	2.7	2.7
20–24 years	3.3	2.9	5.7	5.5	4.1	4.2	3.2	3.1
25–44 years	6.2	6.6	10.2	7.7	6.2	5.8	5.4	5.5
25–34 years	4.9	5.5	8.6	7.1	5.6	5.1	4.3	4.4
35–44 years	7.5	7.7	11.9	8.5	6.8	6.4	6.4	6.4
45–64 years.	9.9	10.2	12.0	8.9	7.1	6.1	6.2	6.6
45–54 years	9.9	10.2	12.6	9.4	6.9	6.6	6.7	7.2
55–64 years	9.9	10.2	11.4	8.4	7.3	5.3	5.4	5.7
65 years and over	9.4	8.4	8.1	6.1	6.4	5.4	4.0	3.9
65–74 years	10.1	8.4	9.0	6.5	6.7	5.4	4.0	3.9
75–84 years	8.1	8.9	7.0	5.5	6.3	5.4	4.0	4.0
85 years and over	8.2	6.0	5.9	5.5	5.4	5.4	4.2	3.4

act, the product of irrationality. It often is referred to as a "long-term solution to a short-term problem."

Since the 1980s the rate of suicide has decreased from approximately twelve suicides per 100,000 resident population to 10.6 deaths per 100,000 (0.01 percent), according to the NIMH. However, in 2000 there were more suicides than homicides—suicide outnumbered homicide by five to three. In 2001, suicide was the eleventh leading cause of death among all age groups, and ranked as the eighth leading cause of death among males in the United States, according to the NIMH. (See Table 8.5.)

Who Commits Suicide?

Suicide occurs among all age, sex, racial, occupational, religious, and social groups. Table 8.5 lists the suicide death rates by age, sex, and race/ethnicity from 1950 to 2000. Although the overall rate of suicide has remained

TABLE 8.5
Death rates for suicide, according to sex, race, Hispanic origin, and age, selected years 1950–2001
[Data are based on death certificates]

Sex, race, Hispanic origin, and age	19501	19601	1970	1980	1990	1995	2000	2001
White male2	Deaths per 100,000 resident population
All ages, age adjusted	22.3	21.1	20.8	20.9	22.8	21.6	19.1	19.6
All ages, crude	19.0	17.6	18.0	19.9	22.0	21.1	18.8	19.5
15–24 years	6.6	8.6	13.9	21.4	23.2	23.1	17.9	17.6
25–44 years	17.9	18.5	21.5	24.6	25.4	25.8	22.9	24.0
45–64 year	39.3	36.5	31.9	25.0	26.0	23.9	23.2	24.7
65 years and over	55.8	46.7	41.1	37.2	44.2	38.5	33.3	33.7
65–74 years	53.2	42.0	38.7	32.5	34.2	30.1	24.3	26.3
75–84 years	61.9	55.7	45.5	45.5	60.2	47.7	41.1	40.2
85 years and over	61.9	61.3	45.8	52.8	70.3	67.9	61.6	55.0
Black or African American male2
All ages, age adjusted	7.5	8.4	10.0	11.4	12.8	12.4	10.0	9.8
All ages, crude	6.3	6.4	8.0	10.3	12.0	11.7	9.4	9.2
15–24 years	4.9	4.1	10.5	12.3	15.1	17.8	14.2	13.0
25–44 years	9.8	12.6	16.1	19.2	19.6	18.3	14.3	14.4
45–64 years	12.7	13.0	12.4	11.8	13.1	11.5	9.9	9.7
65 years and over	9.0	9.9	8.7	11.4	14.9	14.6	11.5	11.5
65–74 years	10.0	11.3	8.7	11.1	14.7	13.8	11.1	10.7
75–84 years3	*	*	*	10.5	14.4	16.7	12.1	13.5
85 years and over	- - -	*	*	*	*	*	*	*
American Indian or Alaska Native male2
All ages, age adjusted	- - -	- - -	- - -	19.3	20.1	17.4	16.0	17.4
All ages, crude	- - -	- - -	- - -	20.9	20.9	18.0	15.9	17.0
15–24 years	- - -	- - -	- - -	45.3	49.1	30.8	26.2	24.7
25–44 years	- - -	- - -	- - -	31.2	27.8	29.1	24.5	27.6
45–64 years	- - -	- - -	- - -	*	*	13.6	15.4	17.0
65 years and over	- - -	- - -	- - -	*	*	*	*	*
Asian or Pacific Islander male2
All ages, age adjusted	- - -	- - -	- - -	10.7	9.6	9.6	8.6	8.4
All ages, crude	- - -	- - -	- - -	8.8	8.7	9.0	7.9	7.7
15–24 years	- - -	- - -	- - -	10.8	13.5	14.4	9.1	9.1
25–44 years	- - -	- - -	- - -	11.0	10.6	10.8	9.9	9.3
45–64 years	- - -	- - -	- - -	13.0	9.7	8.7	9.7	8.2
65 years and over	- - -	- - -	- - -	18.6	16.8	18.9	15.4	18.3
Hispanic or Latinomale2,4
All ages, age adjusted	- - -	- - -	- - -	- - -	13.7	12.7	10.3	10.1
All ages, crude	- - -	- - -	- - -	- - -	11.4	10.9	8.4	8.3
15–24 years	- - -	- - -	- - -	- - -	14.7	16.0	10.9	9.5
25–44 years	- - -	- - -	- - -	- - -	16.2	14.5	11.2	11.8
45–64 years	- - -	- - -	- - -	- - -	16.1	14.2	12.0	11.4
65 years and over	- - -	- - -	- - -	- - -	23.4	21.0	19.5	18.5
White, not Hispanic or Latinomale4
All ages, age adjusted	- - -	- - -	- - -	- - -	23.5	22.3	20.2	21.0
All ages, crude	- - -	- - -	- - -	- - -	23.1	22.2	20.4	21.4
15–24 years	- - -	- - -	- - -	- - -	24.4	24.0	19.5	19.6
25–44 years	- - -	- - -	- - -	- - -	26.4	27.1	25.1	26.4
45–64 years	- - -	- - -	- - -	- - -	26.8	24.5	24.0	25.9
65 years and over	- - -	- - -	- - -	- - -	45.4	39.0	33.9	34.4
White female2
All ages, age adjusted	6.0	5.9	7.9	6.1	5.2	4.7	4.3	4.5
All ages, crude	5.5	5.3	7.1	5.9	5.3	4.8	4.4	4.6
15–24 years	2.7	2.3	4.2	4.6	4.2	3.8	3.1	3.1
25–44 years	6.6	7.0	11.0	8.1	6.6	6.3	6.0	6.2
45–64 years	10.6	10.9	13.0	9.6	7.7	6.7	6.9	7.3
65 years and over	9.9	8.8	8.5	6.4	6.8	5.7	4.3	4.1

fairly stable, the rate nearly tripled from 1950 to 1995 among adolescents and young adults; however, the rates in this age group decreased from a high of 13.0 per 100,000 in 1995 to 10.2 in 2000 and 9.9 in 2001. In 1999 suicide was the third leading cause of death among people age fifteen to twenty-four years, meaning more teens and young adults died from suicide than from acquired immune deficiency syndrome (AIDS), birth defects, cancer, chronic lung disease, heart disease, pneumonia, influenza, and stroke combined.

TABLE 8.5
Death rates for suicide, according to sex, race, Hispanic origin, and age, selected years 1950–2001
[Data are based on death certificates]

Sex, race, Hispanic origin, and age	19501	19601	1970	1980	1990	1995	2000	2001
Black or African American female2	Deaths per 100,000 resident population
All ages, age adjusted	1.8	2.0	2.9	2.4	2.4	2.0	1.8	1.8
All ages, crude	1.5	1.6	2.6	2.2	2.3	2.0	1.7	1.7
15–24 years	1.8	*	3.8	2.3	2.3	2.2	2.2	1.3
25–44 years	2.3	3.0	4.8	4.3	3.8	3.3	2.6	2.6
45–64 years	2.7	3.1	2.9	2.5	2.9	2.0	2.1	2.6
65 years and over	*	*	2.6	*	1.9	2.1	1.3	1.6
American Indian or Alaska Native female2
All ages, age adjusted	- - -	- - -	- - -	4.7	3.6	3.9	3.8	4.0
All ages, crude	- - -	- - -	- - -	4.7	3.7	3.8	4.0	4.1
15–24 years	- - -	- - -	- - -	*	*	*	*	*
25–44 years	- - -	- - -	- - -	10.7	*	6.4	7.2	6.1
45–64 years	- - -	- - -	- - -	*	*	*	*	*
65 years and over	- - -	- - -	- - -	*	*	*	*	*
Asian or
Pacific Islander female2
All ages, age adjusted	- - -	- - -	- - -	5.5	4.1	4.1	2.8	2.9
All ages, crude	- - -	- - -	- - -	4.7	3.4	3.7	2.7	2.8
15–24 years	- - -	- - -	- - -	*	3.9	4.8	2.7	3.6
25–44 years	- - -	- - -	- - -	5.4	3.8	3.6	3.3
2.945–64 years	- - -	- - -	- - -	7.9	5.0	4.7	3.2	3.8
65 years and over	- - -	- - -	- - -	*	8.5	8.6	5.2	4.9
Hispanic or Latino female2,4
All ages, age adjusted	- - -	- - -	- - -	- - -	2.3	2.0	1.7	1.6
All ages, crude	- - -	- - -	- - -	- - -	2.2	1.8	1.5	1.5
15–24 years	- - -	- - -	- - -	- - -	3.1	2.4	2.0	2.3
25–44 years	- - -	- - -	- - -	- - -	3.1	2.5	2.1	2.0
45–64 years	- - -	- - -	- - -	- - -	2.5	2.8	2.5	2.3
65 years and over	- - -	- - -	- - -	- - -	*	*	*	*
White, not Hispanic or Latino female4
All ages, age adjusted	- - -	- - -	- - -	- - -	5.4	4.9	4.7	4.9
All ages, crude	- - -	- - -	- - -	- - -	5.6	5.1	4.9	5.0
15–24 years	- - -	- - -	- - -	- - -	4.3	4.0	3.3	3.3
25–44 years	- - -	- - -	- - -	- - -	7.0	6.6	6.7	6.9
45–64 years	- - -	- - -	- - -	- - -	8.0	6.9	7.3	7.8
65 years and over	- - -	- - -	- - -	- - -	7.0	5.8	4.4	4.3
… Category not applicable.
* Rates based on fewer than 20 deaths are considered unreliable and are not shown.
- - - Data not available.
1Includes deaths of persons who were not residents of the 50 states and the District of Columbia.
2The race groups, white, black, Asian or Pacific Islander, and American Indian or Alaska Native, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Death rates for the American Indian or Alaska Native and Asian or Pacific Islander populations are known to be underestimated.
3In 1950 rate is for the age group 75 years and over.
4Prior to 1997, excludes data from states lacking a Hispanic-origin item on the death certificate.
SOURCE: "Table 46. Death Rates for Suicide, According to Sex, Race, Hispanic Origin, and Age: United States, Selected Years 1950–2001," in Health, United States, 2003, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Hyattsville, MD, 2003

The number of completed suicides does not give a complete picture of the problem, because for every completed suicide there are many unsuccessful suicide attempts. For example, during the 1990s death rates for suicide declined, but in some age groups, the rate of suicide attempts actually increased. Usually suicide attempts outnumber completed suicides by about eight to one. Among teens, however, the ratio is twenty-five to thirty attempts for every successful suicide. According to the NIMH, approximately one million teens go through "suicide crises" each year. Depression, substance abuse, physical abuse, and sexual abuse are risk factors for attempted suicide by adolescents.

Approximately four times as many men die by suicide than women do. This is despite the fact that women attempt suicide three times as often as men. Men make up about three-fourths of total suicides, and white males account for most of that number. Men use more deadly weapons than women—more than half shoot themselves (80 percent of all suicide deaths by firearm are white males), but gun use is increasing rapidly among people of both genders. In the younger age brackets for women (ages fifteen to twenty-four), more than half of those who completed a suicide used a gun.

In 2001 the suicide rate for white non-Hispanic males in the "all ages" category (21 per 100,000 population) was higher than the rate for males of other races and ethnicities in that age category. It was more than double that for African-American males (9.8 per 100,000). American Indian/Alaska Native males had a suicide rate almost as high as that of white males (17.4 per 100,000). This reflects the high suicide rate (24.7 per 100,000) among young (fifteen to twenty-four years old) American Indian/Alaska Native males. Although still relatively high, this rate has decreased by half from its peak of 49.11 per 100,000 in 1990. Between 1950 and 1999, suicide rates among young (fifteen to twenty-four years old) white and African-American men increased dramatically—from 6.6 to 17.6 per 100,000 population for whites, and from 4.9 to 13.0 per 100,000 population for African-Americans. (See Table 8.5.)

Among older white males, the suicide rate in 2001 was far higher than for any other racial group. White males age sixty-five and older had death rates from suicide (33.7 per 100,000) nearly three times higher than the rates for African-American males (11.5 per 100,000). For white males, suicide rates increased dramatically from age sixty-five on. White men age eighty-five or older committed suicide at the highest rate for any combination of race, sex, and gender: 55.0 per 100,000 population. The rates for African-American men, however, showed virtually no increase in their later years. (See Table 8.5.)

For white and African-American women, the suicide rates were far lower than those for men in all age groups. The death rate from suicide for white women was 4.5 per 100,000 in 2001, and for African-American women the rate was less than half that at 1.8 per 100,000. Young white women age fifteen to twenty-four had a suicide rate (3.1 per 100,000) about one-sixth the rate for white men (17.6 per 100,000) in the same age group. For African-American women of all ages, the rate (1.8 per 100,000) was about one-sixth the African-American male rate (9.8 per 100,000). (See Table 8.5.)

Female suicide rates do not change as drastically as men's do as they age. African-American women sixty-five years and older had a suicide rate of 1.6 per 100,000, compared to 11.5 per 100,000 African-American men. For white women age sixty-five and older, the rate was 4.1 per 100,000 in 2001, compared to the white male rate of 33.7 per 100,000. (See Table 8.5.) One widely held theory about the high rates among white men older than age sixty-five years is that these men, who traditionally have been in positions of power, have great difficulty adjusting to lives they may consider useless or diminished.

Other minority groups showed similar disparities between the suicide rates of women and men in 2001. American Indian/Alaska Native males (17.4 per 100,000) had a suicide rate more than four times that of American Indian/Alaska Native females (4.0 per 100,000). The suicide rate for Asian/Pacific Islander men was 8.4 per 100,000, whereas the rate for Asian/Pacific Islander women was 2.9 per 100,000. Hispanic males had a rate of 10.1 per 100,000. Hispanic females (1.6 per 100,000) and African-American females (1.8 per 100,000), had the lowest suicide rates. (See Table 8.5.)

Why Do People Commit Suicide?

People commit suicide for various reasons. Notes left by people who have killed themselves usually tell of life crises that they believed were unbearable. Many describe enduring chronic pain, losing loved ones, being unable to pay bills, or finding themselves incapable of living independently. Other commonly cited reasons are as follows:

• To punish loved ones
• To gain attention
• To join a deceased loved one
• To avoid punishment
• To express love

Some suicides are committed on an irrational, impulsive whim. Researchers observe that even among those most determined to commit suicide, the desire is not as much to die as it is to escape the lives they are leading and to end the pain they are suffering. Whatever the cause of their despair, they are desperately crying out for help.

Follow-up studies on suicide survivors reveal their intense ambivalence about actually dying. Not all survivors are glad to be alive, but for most, the attempted suicide marked a definite turning point. It was an urgent and dramatic signal that their problems demanded serious and immediate attention. Most of the survivors said that what they really wanted was to change their lives.

Suicide among the Terminally Ill

Not all suicides are categorized as the acts of people who are mentally ill. Some people consider suicides committed by people who are terminally ill as rational choices. They argue that a person who is terminally ill has the right to die, that is, the right to control the manner of their death. Until the late 1990s, people with cancer and AIDS were, of the terminally ill, the most likely to commit suicide. Patients with terminal diseases often worry that they will suffer long and painful deaths and that they stand a good chance of losing everything—health, independence, jobs, insurance, homes, and contact with loved ones and friends.

Researchers have found that factors with significant impact on the quality of life include security, family, love, pleasurable activity, and freedom from pain and suffering. Sufferers of debilitating disease may lose all of these. For some, suicide is a last recourse to relieve pain, suffering, insecurity, dependence, or hopelessness.

Suicide's Warning Signs

Researchers believe that most suicidal people convey their intentions to someone among their friends and family, either openly or indirectly. The people they signal are those who know them well and are in the best position to recognize the signs and give help. Comments such as "You'd be better off without me," "No one will have to worry about me much longer," or even a casual "I've had it" may be signals of upcoming attempts. Some people who are suicidal put their affairs in order. They draw up wills, give away prized possessions, or act as if they are preparing for a long trip. They may even talk about going away.

Often the indicator is a distinct change in personality or behavior. A normally happy person may become increasingly depressed. A regular churchgoer may stop attending services, or an avid runner may quit exercising. These types of changes, if added to expressions of worthlessness or hopelessness, can indicate not only that the person is seriously depressed but also that he or she may have decided on trying suicide. Although the vast majority of people who are depressed are not suicidal, most of the suicide-prone are depressed. Researchers and health care practitioners caution that suicide threats and attempts should not be discounted as harmless bids for attention. Anyone thinking, talking about, or planning suicide should receive immediate professional evaluation and treatment.

People who have a record of previous suicide attempts are at the highest risk of actually killing themselves—more than 600 times likelier than the general population. Between 20 and 50 percent of those who complete suicide have tried it before.

The National Center for Injury Prevention and Control (NCIPC) of the Centers for Disease Control and Prevention sponsors initiatives to raise public awareness of suicide and institutes strategies to reduce suicide deaths. Along with support for research about risk factors for suicide in the general population, NCIPC also addresses high-risk populations with programs such as the American Indian/Alaska Native Community Suicide Prevention Center and the Surgeon General's Call to Action—a blueprint for addressing suicide.