Suicide (Latin suicidium, from sui caedere, to kill oneself) is the intentional killing of one's self. Suicide may occur for a number of reasons, including depression, desperation, emotional pressure, physical pain, shame, guilt, anxiety, financial difficulties, or other undesirable situations. The World Health Organization noted that over one million people commit suicide every year, and that it is one of the leading causes of death among teenagers and adults under 35. There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide.

Views on suicide have been influenced by cultural views on existential themes such as religion, honor, and the meaning of life. The Abrahamic religions consider suicide an offense towards God due to religious belief in the sanctity of life. In the West it was often regarded as a serious crime. Japanese views on honor and religion led to seppuku, one of the most painful methods of suicide, to be respected as a means to atone for mistakes or failure, or as a form of protest during the samurai era. In the 20th century, suicide in the form of self-immolation has been used as a form of protest, and in the form of kamikaze and suicide bombing as a military or terrorist tactic. Sati is a Hindu funeral practice in which the widow would immolate herself on her husband's funeral pyre, either willingly, or under pressure from the family and in-laws.

Medically assisted suicide (euthanasia, or the right to die) is currently a controversial ethical issue involving people who are terminally ill, in extreme pain, and/or have minimal quality of life through injury or illness. Self-sacrifice for others is not usually considered suicide, as the goal is not to kill oneself but to save another.

The predominant view of modern medicine is that suicide is a mental health concern, associated with psychological factors such as the difficulty of coping with depression, inescapable suffering or fear, or other mental disorder and pressures. A suicide attempt is sometimes interpreted as a "cry for help" and attention, or to express despair and the wish to escape, rather than a genuine intent to die. Most people who attempt suicide do not complete suicide on a first attempt; those who later gain a history of repetitions have a significantly higher probability of eventual completion of suicide.

Classification

Euthanasia and assisted suicide

Individuals who wish to end their own life may enlist the assistance of another person to achieve death. The other person, usually a family member or physician, may help carry out the act if the individual lacks the physical capacity to do so even with the supplied means. Assisted suicide is a contentious moral and political issue in many countries, as seen in the scandal surrounding Dr. Jack Kevorkian, a medical practitioner who supported euthanasia, was found to have helped patients end their own lives, and was sentenced to prison time.

Murder-suicide

A murder-suicide is an act in which an individual kills one or more other persons immediately before or at the same time as him or herself.

The combination of murder and suicide can take various forms, including:

• Suicide to facilitate murder, as in suicide bombing
• Suicide after murder to escape punishment
• Suicide after murder as a form of self-injury due to guilt
• Having a combined objective of suicide and murder
• Considering one's suicide as the main act, but murdering one's children first, to avoid them becoming orphans, to be together in an expected afterlife, in the context of severe depression where the person feels he is sparing his loved ones from a horrible life, or simply just to experience the act
• Joint suicide in the form of killing the other with consent, and then killing oneself
• Punishment - taking revenge on those deemed responsible and escaping the world seen as a terrible place, as in many school shootings
• Committing suicide using a method that results in the deaths of others such as crashing an aeroplane, such a suicide was famously attempted in FedEx Flight 705
• Some cases of cult suicide may also involve murder. Conversely, many spree killings have ended in suicide.

The motivation for the murder in murder-suicide can be purely criminal in nature or be perceived by the perpetrator as an act of care for loved ones in the context of severe depression.

Suicide attack

A suicide attack is when an attacker perpetrates an act of violence against others, typically to achieve a military or political goal, that results in his or her own death as well. Suicide bombings are often regarded as an act of terrorism. Historical examples include the assassination of Czar Alexander II and the in part successful kamikaze attacks by Japanese air pilots during the Second World War.

Self-injury

Self-injury is not a suicide attempt; however, initially self-injury was erroneously classified as a suicide attempt. There is a non-causal correlation between self-harm and suicide; both are most commonly a joint effect of depression.

Mass suicide

Some suicides are done under peer pressure or as a group. Mass suicides can take place with as few as two people, in a "suicide pact", or with a larger number of people. An example is the mass suicide that took place by members of the Peoples Temple, an American cult led by Jim Jones in Guyana in 1978.

Metaphorical suicide

The metaphorical sense of "willful destruction of one's self-interest", for example political suicide.

Impact of suicide

It is estimated that each suicide in the United States leaves an average of six people intimately affected by the death, either as a spouse, parent, significant other, sibling, or child of the deceased person. These people are referred to as survivors.

Causes

There is no single cause for which suicide can be directly attributed. Environmental factors, childhood upbringing, and mental illness each play a large role. Sociologists today consider external circumstances, such as a traumatic event, as a trigger instead of an actual independent cause. Suicides are more likely to occur during periods of socioeconomic, family and individual crisis. Most people with suicidal tendencies tend to suffer from some mental illness such as depression, bipolar disorder, or some degree of anxiety disorder. These diagnosable mental disorders are associated with more than 90% of suicide victims. As a result, many researchers study the causes of depression to understand the causes of suicide.

Many theories have been developed to explain the causes of suicide. Psychiatric theories emphasize mental illness. Psychological theories emphasise personality and poor coping skills, while sociological theories stress the influence of social and environmental pressures.

Biological

Genetic and biological factors play a large role in suicide likelihood. Research has shown that suicidal behaviour runs in families. A notable example are the suicides of the Hemingway family in which five members committed suicide. In 1985, the American Journal of Medical Genetics studied an Amish community in Pennsylvania. The studies revealed that four families, representing only 16 percent of the total Amish population, accounted for 73 percent of all Amish suicides. Some scientists claim 10 to 15 genes account for triggering suicide attempts. Similarly how depression is linked genetically, family ties may also have a large effect on one's suicide risk.

Mental illness

Studies show a high incidence of mental disorders in suicide victims at the time of their death with the total figure ranging from 98%to 87.3% with mood disorders and substance abuse being the two most common. A person diagnosed with schizophrenia may commit suicide for a number of reasons, including because of depression. Suicide among people suffering from bipolar disorder is often an impulse, which is due to the sufferer's extreme mood swings (one of the main symptoms of bipolar disorder), or also possibly an outcome of delusions occurring during an episode of mania or psychotic depression. Major depressive disorder is associated with a higher than average rate of suicide, especially in men.

Many studies measuring incidence of psychiatric disorder in suicides employ after-the-fact diagnosis. Such studies are often criticized for lack of objectivity. The main argument is that a decision of the psychiatrist is biased if he believes that suicidal people must be mentally ill. This bias is indirectly confirmed by statistics: "the highest estimate of mental illness when a sample had been diagnosed before suicide was 22 percent. Afterward the highest estimate was90 percent."



Use of after-the-fact diagnosis may lead to a kind of tautology. In simple words, "We say, in essence, 'All people who attempt suicide are mentally ill.' If someone asks, 'How do you know they are mentally ill?' the implied answer is, 'Because only mentally ill persons would try to commit suicide.'

Substance use

Substance misuse is the second most common cause of suicide, behind depression which is the most common cause for suicide. Both chronic substance misuse as well as acute substance abuse is associated with an increased risk of suicide. This is because of intoxicating and disinhibiting effects of psychoactive substances; when combined with personal grief such as bereavement the risk of suicide is greatly increased. More than 50 percent of suicides are related to alcohol or drug dependence. Up to 25 percent of drug addicts and alcoholics commit suicide. In adolescents the figure is higher with alcohol or drug misuse playing a role in up to 70 percent of suicides. It has been recommended that all drug addicts or alcoholics are investigated for suicidal thoughts due to the high risk of suicide. Misuse of drugs such as cocaine have a high correlation with suicide. Polysubstance misuse has been found to more often result in suicide in younger adults whereas suicide from alcoholism is more common in older adults. It has been found that drinking 6 drinks or more per day results in a six-fold increased risk of suicide. Alcohol misuse is associated with a number of mental health disorders and alcoholics have a very high suicide rate. High rates of major depressive disorder occur in heavy drinkers and those who abuse alcohol. Controversy has previously surrounded whether those who abused alcohol who developed major depressive disorder were self medicating (which may be true in some cases) but recent research has now concluded that chronic excessive alcohol intake itself directly causes the development of major depressive disorder in a significant number of alcohol abusers.

Chronic prescribed benzodiazepine use or chronic misuse is associated with depression as well as suicide. Care should be taken when prescribing especially to at risk patients. Depressed adolescents who were taking benzodiazepines were found to have a greatly increased risk of self harm or suicide, although the sample size was small. The effects of benzodiazepines in individuals under the age of 18 requires further research. Additional caution is required in using benzodiazepines in depressed adolescents. Benzodiazepine dependence often results in an increasingly deteriorating clinical picture which includes social deterioration leading to comorbid alcoholism and drug abuse. Suicide is a common outcome of chronic benzodiazepine dependence. Benzodiazepine misuse or misuse of other CNS depressants increases the risk of suicide in drug misusers. 11% of males and 23% of females with a sedative hypnotic misuse habit commit suicide.

Suicide as a form of defiance and protest

In the 1960s, Buddhist monks, most notably Thích Quảng Đức in South Vietnam, drew Western attention to their protests against President Ngô Đình Diệm by burning themselves to death. Also in the 1960s, Quaker Norman Morrison committed suicide by self-immolation to protest the United States involvement in the Vietnam War.

In Ireland protesting via hunger strike to the death has been used as a tactic in recent times for political causes. During The Troubles in Northern Ireland a hunger strike was launched by the provisional IRA to demand that their prisoners be reclassified as prisoners of war rather than as terrorists, during the infamous 1981 hunger strikes, led by Bobby Sands; this protest resulted in 10 deaths. The cause of death was recorded as "starvation, self-imposed" rather than suicide by the coroner, modified to simply "starvation" on the death certificates after protests from the striker's families.

Judicial suicide

A person who has committed a crime may commit suicide to avoid prosecution and disgrace:

• Hermann Göring, high-ranked Nazi and head of the Luftwaffe, committed suicide with cyanide capsules rather than be hanged after his conviction at the Nuremberg Trials.
• Irish revolutionary Theobald Wolfe Tone cut his throat rather than be hanged, after his request for a firing squad (a death worthy of a soldier) was denied.
• Colonel Alfred Redl was presented with the evidence of his espionage and shot himself to avoid a trial.
• Budd Dwyer, a Treasurer of Pennsylvania, killed himself on January 22, 1987 while on live television after being convicted (wrongly, he claimed) of financial crimes, in order to draw attention to his case and to enable his widow to draw survivor benefits (since he died before being removed from office).
• More recently, Deborah Jeane Palfrey, dubbed the DC Madam by the media, was convicted on April 15, 2008 of racketeering, using the mail for illegal purposes, and money laundering. On May 1, 2008 she was found dead by hanging, an apparent suicide.

Military suicide

In the final days of World War II, some Japanese pilots volunteered for kamikaze missions in an attempt to forestall defeat for the Empire. Near the end of WW2 the Japanese designed a small aircraft whose only purpose was kamikaze missions.In Nazi Germany, many soldiers and government officials (including Adolf Hitler) killed themselves rather than surrender to Allied forces. The Japanese also built one-man "human torpedo" suicide submarines called Kaitens.

Dutiful suicide

Dutiful suicide is an act, or non-fatal attempt at the act, of fatal self-violence at one's own hands done in the belief that it will secure a greater good, rather than to escape harsh or impossible conditions. It can be voluntary, to relieve some dishonor or punishment, or imposed by threats of death or reprisals on one's family or reputation (a kind of murder by remote control). It can be culturally traditional or generally abhorred; it can be heavily ritualized as in seppuku or purely functional. Dutiful suicide can be distinguished from a kamikaze or suicide bomb attack, in which a fighter consumes his own life in delivering a weapon to the enemy. An example of dutiful suicide is a soldier in a foxhole throwing his body on a live grenade to save the lives of his comrades.

Disgraced Roman aristocrats were sometimes allowed to commit suicide to spare themselves a trial and penalties against their families. An example of this was Emperor Nero who reportedly committed forced suicide following a large fire that burned through much of Rome. A more modern case is Erwin Rommel, who was found to have foreknowledge of the July 20 Plot on Hitler's life. Rommel was threatened with public trial, execution and reprisals on his family unless he killed himself, which he did.

Suicide as an escape

In situation where continuing to live is intolerable, some people use suicide as a means of escape. Some inmates in Nazi concentration camps are known to have killed themselves by delibertely touching the electrified fences.

Captain Thomas Phillips of the notorious slaver Hannibal stated that during his 1694 voyage twelve slaves "willfully drowned themselves" and several others persistently refused food, starving themselves to death, "for it is their Belief that when they die they return to their own Country and Friends again."

Other factors

Socio-economic factors such as unemployment, poverty, homelessness, and even discrimination trigger such suicidal thoughts. It is also noted that poverty may not be a direct cause but it can increase the risk of suicide, as it is a major risk group for depression.

Suicide methods

The leading method of suicide varies dramatically between countries. The leading methods in different regions include: hanging, pesticide poisoning, and firearms. Worldwide 30% of suicides are from pesticides. The use of this method however varies markedly from 4% in Europe to more than 50% in the Pacific region.In the United States suicides often involve the use of firearms (52%). Asphyxiation methods (including hanging) and toxification (poisoning and overdose) are fairly common as well. Together they comprised about 40% of U.S. suicides during the same time period. Other methods of suicide include blunt force trauma (jumping from a building or bridge, self-defenestrating, stepping in front of a train, or car collision, for example). Exsanguination or bloodletting (slitting one's wrist or throat), intentional drowning, self-immolation, electrocution, and intentional starvation are other suicide methods. Individuals may also intentionally provoke another person into administering lethal action against them, as in suicide by cop.

Whether or not exposure to suicide is a risk factor for suicide is controversial. A 1996 study was unable to find a relationship between suicides among friends. While a 1986 study found increased rates of suicide following the televisation of news stories regarding suicide.

Epidemiology

According to official statistics, about a million people die by suicide annually, more than those murdered or killed in war. According to 2005 data, suicides in the U.S. outnumber homicides by nearly 2 to 1 and ranks as the 11th leading cause of death in the country, ahead of liver disease and Parkinson's disease. Worldwide suicide rates have increased by 60% in the past 50 years, mainly in the developing countries. Most suicides in the world occur in Asia, which is estimated to account for up to 60% of all suicides. According to the World Health Organization, China, India and Japan may account for 40% of all world suicides. In the United States, for example, the rate of suicide is increasing for the first time in a decade. The increase in the overall suicide rate between 1999 and 2005 has been due primarily to an increase in suicides among whites aged 40–64, with white middle-aged women experiencing the largest annual increase.

Gender

[[File:Suicide world map - 2009 Male.svg|thumb|Suicide rate per 100,000 males (data from 1978–2008) ]]

[[File:Suicide world map - 2009 Female,2.svg|thumb|Suicide rate per 100,000 females (data from 1978–2008) ]]

In the Western world, males die much more often by means of suicide than do females, although females attempt suicide more often. Some medical professionals believe this stems from the fact that males are more likely to end their lives through effective violent means (guns, knives, hanging, etc.), while women primarily use less severe methods such as overdosing on medications.

Alcohol and drug use

Alcoholics are 5-20 times more likely to kill themselves and similarly drug misusers are 10-20 times more likely to die by suicide than those who do not misuse alcohol or drugs. About 15 percent of alcoholics commit suicide and about 33 percent of suicides in the under 35's have a primary diagnosis of alcohol or other substance misuse; over fifty percent of all suicides are related to alcohol or drug dependence. In adolescents alcohol or drug misuse plays a role in up to 70 percent of suicides.

National suicide rates

National suicide rates differ significantly between countries and amongst ethnic groups within countries. For example, in the USA, non-Hispanic Caucasians are nearly 2.5 times more likely to kill themselves than are African Americans or Hispanics. In the United Kingdom suicide rates vary significantly between different parts of the country. In Scotland, for example the suicide rate is approximately double that of England.

Society and culture

Views on suicide

Medical

In the United States, individuals who express the intent to harm themselves may be automatically determined to lack the present mental capacity to refuse treatment, and can be transported to the emergency department against their will. An emergency physician will determine whether inpatient care at a mental health care facility is warranted. This is sometimes referred to as being "committed". A court hearing may be held to determine the individual's competence. In most states, a psychiatrist may hold the person for a specific time period without a judicial order. If the psychiatrist determines the person to be a threat to himself or others, the person may be admitted involuntarily to a psychiatric treatment facility. This period is usually of three days duration. After this time the person must be discharged or appear in front of a judge. As in any judicial proceeding this person has a right to legal counsel.

Switzerland has recently taken steps to legalize assisted suicide for the chronically mentally ill. The high court in Lausanne, in a 2006 ruling, granted an anonymous individual with longstanding psychiatric difficulties the right to end his own life. At least one leading American bioethicist, Jacob Appel of Brown University, has argued that the American medical community ought to condone suicide in certain individuals with mental illness.

Criminal

In some jurisdictions, an act or incomplete act of suicide is considered to be a crime. More commonly, a surviving party member who assisted in the suicide attempt will face criminal charges.

In Brazil, if the help is directed to a minor, the penalty is applied in its double and not considered as homicide. In Italy and Canada, instigating another to suicide is also a criminal offense. In Singapore, assisting in the suicide of a mentally handicapped person is a capital offense. In India, abetting suicide of a minor or a mentally challenged person can result in a maximum 1 year prison term with a possible fine.

In Germany, the following laws apply to cases of suicide:

• Active euthanasia (killing on request) is prohibited by article 216 of the StGB (Strafgesetzbuch, German Criminal Code), punishable with six months to five years in jail
• German law interprets suicide as an accident and anyone present during suicide may be prosecuted for failure to render aid in an emergency. A suicide legally becomes emergency when a suicidal person loses consciousness. Failure to render aid is punishable under article 323c of the StGB, with a maximum one year jail sentence.

Cultural

In the Warring States Period and the Edo period of Japan, samurai who disgraced their honor chose to end their own lives by seppuku, a method in which the samurai takes a sword and slices into his abdomen, causing a fatal injury. The cut is usually performed diagonally from the top corner of the samurai's writing hand, and has long been considered an honorable form of death (even when done to punish dishonor). Though such a wound would be fatal, seppuku was not always technically suicide, as the samurai's assistant (the kaishaku) would usually stand by to cut short any suffering by quickly administering a fatal cut to the back of the neck (just short of decapitation), sometimes as soon as the first tiny incision into the abdomen was made.

Religious

In most forms of Christianity, suicide is considered a sin, based mainly on the writings of influential Christian thinkers of the Middle Ages, such as St. Augustine and St. Thomas Aquinas; suicide was not considered a sin under the Byzantine Christian code of Justinian, for instance. In Catholic doctrine, the argument is based on the commandment "Thou shalt not kill" (made applicable under the New Covenant by Jesus in Matthew 19:18), as well as the idea 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. However, it is believed that mental illness or grave fear of suffering diminishes the responsibility of the one completing suicide. Counter-arguments include the following: that the sixth commandment is more accurately translated as "thou shalt not murder", not necessarily applying to the self; that taking one's own life no more violates God's law than does curing a disease; and that a number of suicides by followers of God are recorded in the Bible with no dire condemnation.

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, Jews have committed individual suicide or mass suicide (see 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 both as examples of heroic martyrdom, whilst others state that it was wrong for them to take their own lives in anticipation of martyrdom.

Suicide is not allowed in the religion of Islam; however, martyring oneself for Allah (during combat) is not the same as completing suicide. Suicide in Islam is seen as a sign of disbelief in God. The use of suicide is practised by Radical groups such as Hamas and Al-Qaeda in Iraq.

In Hinduism, suicide is frowned upon and is considered equally sinful as murdering another. Hindu Scriptures state that one who commits suicide will become part of the spirit world, wandering earth until the time one would have otherwise died, had one not committed suicide.

Philosophical

Some see suicide as a legitimate matter of personal choice and a human right (colloquially known as the right to die movement), and maintain that no one should be forced to suffer against their will, particularly from conditions such as incurable disease, mental illness, and old age that have no possibility of improvement. Proponents of this view 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. This perspective is most popular in continental Europe, where euthanasia and other such topics are commonly discussed in parliament and has a good deal of support.

A narrower segment of this group considers suicide something between a grave but condonable choice in some circumstances and a sacrosanct right for anyone (even a young and healthy person) who believes they have rationally and conscientiously come to the decision to end their own lives. Notable supporters of this school of thought include German pessimist philosopher Arthur Schopenhauer,, Friedrich Nietzsche, and Scottish empiricist David Hume. Adherents of this view often advocate the abrogation of statutes that restrict the liberties of people known to be suicidal, such as laws permitting their involuntary commitment to mental hospitals.

Suicide locations

Some landmarks have become known for high levels of suicide attempts. The four most popular locations in the world are reportedly San Francisco’s Golden Gate Bridge, Toronto's Bloor Street Viaduct (before the construction of the Luminous Veil), Japan's Aokigahara Forest and England's Beachy Head. In 2005 the Golden Gate Bridge had a count exceeding 1,200 jumpers since its construction in 1937, in 1997 the Bloor Street Viaduct had one suicide every 22 days, and in 2002 Aokigahara had a record of 78 bodies found within the forest, replacing the previous record of 73 in 1998. The suicide rate of these places is so high that numerous signs, urging potential victims of suicide to seek help, have been posted.

See also

Footnotes

Further reading

• Berrios G E & Mohanna M (1990) Durkheim and French Psychiatric Views on Suicide during the 19th century: a conceptual history. British Journal of Psychiatry 156: 1-9

External links

• American Foundation for Suicide Prevention
• Samaritans, charity in the United Kingdom for suicide prevention
• Befrienders, link for worldwide support for those considering suicide or coping with its impact.