S uicide, the deliberate taking of one’s own life, is the second leading cause of death among young people in Canada. Suicide and motor vehicle accidents account for almost sixty percent of youth deaths. This figure is not just relevant in Canada – globally, suicide is among the top three causes of death among young people (aged 15 to 34).
Suicide itself is not a mental disorder, but one of the most important causes of suicide is mental illness – most often Depression, Bipolar Disorder (Manic Depression), Schizophrenia, and Substance Use Disorders.
In Canada approximately 200 youth between the ages of 15 and 24 years die by suicide (Statistics Canada, CANISM, table 102-0551). The effects of youth suicide go beyond the deceased, impacting those who survive their death – their parents, friends, peers and communities. Suicide is understandably a tragic event and it elicits strong emotional responses.
Suicide in young people in Canada has been decreasing for the past decade. We do not really know why this is. As far as we can tell, rates are decreasing in areas that have no specific suicide prevention programs as well as in areas that do. Some researchers say this decrease in suicide rates is because depression is now better recognized and treated in young people. The latest figures for death by suicide among 15 to 24 year-olds in Canada show national incidence rates of 11.6 per 100,000 population. This means that for every 8,620 young people between the age of 15 and 24, there will be one death by suicide. Rates among males are nearly three times as high as those among females.
Suicide is found in every culture and may be the result of complex social, cultural, religious and socio-economic factors, in addition to mental disorders.
However, the rates vary substantially across the country, with youth suicide much higher in the Arctic North than in southern provinces. For example, the lowest rates for the years 2000 to 2004 were found in Nova Scotia (4.4 per 100,000), and highest rates – 90 times greater – were found in Nunavut (364.4 per 100,000). This large difference reflects a very high suicide rate that exists in some aboriginal communities. From this huge difference in rates, it is obvious that the reasons for suicide vary from place to place.
Not all self-harm behaviours are attempts to die by suicide. There may be many reasons for self-harm behaviours besides suicide, including a cry for help (e.g. a person may self-harm if they are stuck in a harmful situation from which they cannot escape, such as ongoing sexual abuse.)
MYTH: Someone who is smart and successful would never die by suicide
REALITY: In fact, people’s suicidal thoughts, intentions, plans and attempts are often kept secret. Suicide knows no cultural, ethnic, racial, education or income boundaries.
MYTH: People who attempt suicide are just looking for attention
REALITY: A suicide attempt is often the critical event that leads a deeply distressed person to a first contact with a helping professional such as physician or psychologist. An attempt at suicide is a desperate cry for help – this is not an action that should be classified as attention seeking behaviour.
MYTH: Suicide is a natural response to overwhelming stress.
REALITY: Suicide is an abnormal outcome of stress. While everybody experiences stress, the vast majority of people do not attempt suicide.
MYTH: Once a person decides to take his or her life, they will continue to feel strongly about suicide until they complete it.
REALITY: The intensity of suicidality waxes and wanes, and many people who attempt or complete suicide struggle with their conviction to die.
MYTH: When a person decides to take his or her life, there is nothing anyone can do to stop them.
REALITY: Individuals who attempt suicide may be suffering from a mental disorder which will respond to appropriate and effective treatment. Appropriate treatment of a mental disorder significantly reduces the risk of suicide. For example, suicidal thinking associated with Depression usually resolves with effective treatment of the Depressive Disorder.
MYTH: Antidepressants such as SSRIs (selective serotonin reuptake inhibitors) increase the risk for suicide among adolescents.
REALITY: In fact, contrary to much public opinion, treatment of depression with selective serotonin reuptake inhibitors does not increase but rather decreases youth suicide rates.
MYTH: Talking to someone about whether or not they are suicidal will make their suicidal symptoms worse.
REALITY: Asking someone if they have thoughts of suicide will not put the idea in their head if they are not suicidal. If they are having suicidal thoughts, knowing that you are concerned enough about them to ask may give them the courage to ask for help.
Suicidal ideation: Includes thoughts and fantasies about, or ruminations and preoccupations with, death in general, and self-inflicted death in particular.
Suicide attempt: Sometimes referred to as parasuicide, a suicide attempt is any purposeful action taken by a person associated with an implicit or explicit intent to die, regardless of the likelihood of the chosen method to actually cause death.
Suicide: The result of lethal intentional self-harm.
Self-harm: Any self-inflicted injury that is not associated with an implicit or explicit intent to die. Examples of self-harm behaviours include burning/cutting after an emotionally upsetting event or burning/cutting as a method of manipulation or threat.
*Data collection in some jurisdictions may not differentiate self-harm events from suicide attempts, although clinical approaches to patients with persistent self-harm behaviours may be different from those for patients after a suicide attempt.
Suicidal behaviour: Can include all behaviour from low-risk threats and suicidal ideation to suicide attempt and suicide. Also sometimes referred to as “suicidality”.
Suicidal Ideation. This includes ideas about death or dying, wishing they were dead or ideas about dying by suicide. These ideas are not usually persistent, but can be fairly common in people with mental disorders or those with difficult life circumstances. Most people with suicidal ideation do not go on to die by suicide but the ideation is a risk factor in suicide. Persistent and strong thoughts of suicide are of greater concern than occasional and mild thoughts about suicide.
Suicidal intent. The idea of dying by suicide is better formed and more consistently held than in suicidal ideation. A person with suicidal intent may think about dying by suicide most of the time, imagining what life would be like for friends and family without them around. The strongest intent occurs when a person decides they will choose suicide.
Suicidal plan. This is a clear plan on how the act of suicide will occur. Vague plans are considered part of intent. In a suicidal plan the means of suicide will be identified and obtained, and the place and time will be chosen. The presence of a suicidal plan constitutes a psychiatric emergency.
According to the American Association of Suicidology consensus panel, the following observable signs and symptoms indicate the need for immediate medical intervention:
- Someone threatening to hurt or kill himself or herself
- Someone looking for ways to kill himself or herself
- Someone seeking access to pills, weapons or other means for the purpose of suicide
- Someone talking or writing about death, dying, or suicide
“A suicide warning sign is the earliest detectable sign that indicates heightened risk for suicide in the near term (i.e., within minutes, hours, or days) A warning sign refers to some feature of the developing outcome of interest (suicide) rather than to a distinct construct (risk factor) that predicts or may be related to suicide.” (American Association of Suicidology)
The following may be warning signs for suicide and in clinical practice should be considered in relation to mental status (for example – Depression):
- Acting reckless or engaging in risky activities
- Feeling trapped (like there is no way out)
- Increasing alcohol or drug use
- Withdrawing from family friends/family/society
- Agitation or intense anxiety
- Dramatic mood changes
- No reasons for living / no sense of purpose in life
Although hopelessness, withdrawal from friends and family, and increased substance misuse are important predictors of suicide risk, it has not yet been clearly established that the other warning signs mentioned above will increase the risk of suicide in the absence of other factors. However, given our current understanding of this issue, these warning signs may help the clinician conducting a suicide assessment to better determine the degree of risk in the short term.
A risk factor is defined as some variable that increases the likelihood of an event occurring. A risk factor does not necessarily cause the event rather; the presence of the risk factor makes the event more likely than it would be if the risk factor was absent.
Strong risk factors for suicide are:
- Presence of current suicidal plan
- Previous suicide attempt
- History of mental disorder, including substance abuse (especially Bipolar Disorder and Depression)
- Availability of lethal means (access to methods)
- History of childhood sexual or physical assault
- Family history of completed suicide
- Family history of psychiatric illness
Aboriginal youth suicide risk factors may differ compared to those influencing non-aboriginals, however substantial scientifically valid data regarding these issues is lacking, and there is a great need for rigorous research in this area. Studies of risk factors for suicide and suicide attempt in Aboriginal youth point to male gender, substance use and abuse (especially alcohol and solvent use), psychiatric disorder, parental substance use, physical abuse, suicides or suicide attempts among friends, and stressful recent life events.
Suicide ideation and intent may benefit from support or cognitive-based counseling. The presence of a suicide plan should lead to placement of the person in a situation in which they are safe and secure. Often this can mean a hospital or a community treatment center. It should be therapeutic and not punishing and should be accompanied by supportive and cognitive counseling. The family or loved ones may also require support and help.
If you suspect someone is suicidal you should immediately contact someone else that can help out while you stay with the person. The helper can then seek professional assistance by calling 911, the mobile crisis hotline (in settings where that is available) or can take the suicidal person directly for medical evaluation in the nearest hospital emergency room.
Ask about ideation: Have you been thinking about dying, harming yourself or suicide?
Ask about intent: Have you decided that you would be better off dead or that you should kill yourself?
Ask about plans: What plans have you made to kill yourself? (and obtain details)
Ideally, suicide prevention strategies should target risk factors that have been demonstrated to be both causal (meaning that they have a direct link to suicide) and modifiable (that they can be altered). For example, mental disorders are risk factors for suicide (causal) and can be treated (modifiable) to reduce suicide risk. Other examples of risk factors that are likely causal and modifiable are: alcohol and drug abuse and access to lethal means. Examples of risk factors that are neither causal nor modifiable are: history of suicide attempt, history of sexual or physical abuse, and stressful life events.
In general, the scientific evidence for effective youth suicide prevention interventions is limited but some strategies show promise. Important questions to ask when implementing a school-based suicide prevention program.
Promising school-based programs include:
- Screening for and referral of students with mental health problems
- Gatekeeper training for education professionals with respect to the recognition of Depression and other mental illnesses and procedures for referral to mental health services.
School-based programs with inconclusive evidence:
- Suicide awareness curricula are widely employed, however there is little substantial evidence to support their implementation. Our recent reviews of these programs could not identify any that had demonstrated a decrease in suicide rates. There is some older evidence that they may be harmful. School and Community Based Suicide Prevention Interventions Study
- There is also limited evidence for the effectiveness of peer-helper programs.
School-based programs that should not be used:
- Psychological debriefing/critical incident stress debriefing interventions are not supported by sufficient positive evidence to substantiate widespread or unqualified use, and have actually been shown to have negative effects in adults.
Community-based suicide prevention strategies often target access to methods for self-harm. Examples of community-based strategies include:
- Construction of bridge safety barriers
- Detoxification of cooking gas and car exhaust
- Limiting access to pesticides
- Limiting of size of acetaminophen packets
- Restriction of firearms
- Media reporting guidelines
Some controversy exists about the effects of community-based strategies, since it is difficult to measure direct intervention effects in the presence of secular trends in suicide rate and the potential for method substitution. There is no substantive evidence that commonly applied and expensive community based suicide prevention programs such as “ASSIST” actually prevent suicide. To our knowledge the risks of these approaches have not be adequately studied.
One promising approach to suicide prevention using the healthcare system is the training of primary care physicians to recognize, treat, and if necessary, refer patients suffering from mental illness, especially Depression.
Because treatment of depression is associated with decreased suicide rates and suicide attempts in youth, effective early treatment of depression is an approach targeting a causal as well as modifiable risk factor. Although most youth report primary care physicians as the first choice point of contact in cases of distress, family physicians often feel uncomfortable in their ability to recognize and treat depressed youth. Since training can increase physician identification of suicidal patients, and improve treatment of Depression and decrease suicide rates, it should be more widely available.
Family & Friends
Suicide affects a web of individuals connected with the deceased including parents, siblings, friends and acquaintances, classmates, healthcare providers and others. A conservative estimate counts six “survivors” for every suicide death. While the grief experienced by survivors of suicide has many features similar to the grief experienced by other bereaved persons, it has a few unique characteristics including feelings of shame, self-recrimination, and a perpetual search for meaning.
Our research has found that since psychological debriefing (including such interventions as Critical Incident Stress Debriefing [CISD] and Critical Incident Stress Management [CISM]) is not recommended for routine use in adults, it is not possible to justify either on scientific, ethical, or legal grounds the endorsement or use of these interventions in children and adolescents.
So what should school mental health professionals and policy makers consider when faced with the question of what to do? Given our current state of knowledge, it is prudent to develop interventions based on the following five empirically-supported principles in post-trauma intervention and prevention:
- Promotion of a sense of safety
- Promotion of calm
- Promotion of a sense of self and community efficacy
- Promotion of connectedness
- Promotion of hope
One possibility would be to apply an evidence-supported program that was created upon these principles: Psychological First Aid (PFA). Alternatively, a cognitive behavioural intervention that has been empirically validated (supported by evidence) for use in school-aged youth, such as Cognitive Behavioural Intervention for Trauma in Schools (CBITS), could be provided to individuals demonstrating significant psychological distress weeks after the trauma has passed. This could be linked to screening strategies or training of school personnel who would be aware of behaviours and other indicators that would help them identify those youth most at risk. It is essential that school-based mental health interventions be based on best scientific evidence.
Dr. Sakinofsky (a Canadian suicide researcher) suggests the following protocol be used following a suicide in a clinical inpatient or partial hospitalization setting (2007). This approach has clinical utility but has not been adequately evaluated using appropriately designed intervention studies.
- Contact the family, offer a meeting and assistance.
- Call initial staff meeting immediately after the suicide to inform staff members and develop strategies to support patients
- Defer further admissions to unit until environment is stabilized.
- Review patient passes and levels of observation to ensure patient safety.
- Call meeting to inform patients of the suicide and address questions.
- Have key staff member document particulars of event in detail on the chart, noting entries that occurred after the suicide as “late notes” rather than dating retrospectively.
- Delegate staff members to attend the funeral if desired by the family.
- Consider holding a memorial service for staff and patients to attend.
Mental Health Providers
Mental health professionals who lose a patient to suicide may experience grief, anger, guilt, shock, self-doubt, and fear of blame. Subsequent to the initial reaction, they may experience a period of feeling profound loss, sadness, isolation, and shame. Trainees’ experiences are often especially traumatic, particularly if they feel they have not been adequately trained to deal with a patient suicide or feel they have not been sufficiently supported by their institution.
There may be a need for active support and outreach to mental health providers who are dealing with the suicide of a patient. Trainees should be guided through the experience by supervisors in a helpful, non-judgmental, and compassionate approach. Mental health professionals should be careful to thoroughly document the circumstances surrounding the patient’s suicide and ensure the chart/record is complete. If legal is anticipated, the mental health professional should contact his or her professional association. Institutional reviews (such as mortality rounds) should, whenever possible, be conducted by individuals not party to the suicide case.