Suicide Awareness Facts

LivingWorks and Suicide First Aid

Many caregivers trained in ASIST have used their skills to benefit others.
Caregivers are more prepared to help a person at risk after participating in ASIST. Intervention stories from workshops around the world, some of which have appeared in the public and popular press, are common. Caregivers from all walks of life have used their ASIST skills in suicide situations ranging from a university student’s mother getting her son to a life-saving emergency resource, a city police officer on a domestic call helping a non-custodial father obtain needed health care services, a drive-by citizen deciding to stop and help a disoriented woman walking on the centre line of a busy street, a regular coffee time meeting between friends that surfaced the need for suicide first aid, to a passer-by helping a person decide not to jump from a bridge. In one study of ASIST participants, 80% reported using their knowledge in direct helping activities compared with 47% prior to taking the workshop.
- Turley and Tanney, LivingWorks Australian Field Trial Evaluation Report, Lifeline Australia, 1998

You are participating in the most widely used suicide intervention program in the world.
Beginning in 1982 with the first pilot workshop in a rural Alberta community and province-wide implementation in 1985, the ASIST workshop has spread to other parts of Canada and several countries around the world. As of November 2006, over 750,000 participants have taken the workshop in Canada, Australia, Norway and the United States, as well in other places such as Guam, Singapore, Hong Kong, Northern Ireland, Shetland Islands, and northern Russia. The common approach to suicide first aid by many different caregivers in a community has been shown to aid networking and to improve continuity of care for persons at risk. As a basic program suitable for all caregivers at all levels of expertise, the number of people who could benefit from ASIST in every community is very large.
- LivingWorks Education, 2006

Caregivers’ attitudes, knowledge and skills all change after ASIST training.
ASIST has been evaluated over the years in post-graduate research, including two doctoral studies, independent evaluations and funded project evaluations. All studies have shown participants becoming more comfortable, competent and confident in helping a person at risk of suicide. ASIST participants are more likely to use identified suicide intervention skills. They are also are more likely to show an increased clarification of attitudes about suicide, greater readiness to intervene, increased knowledge of suicide assessment and an understanding of the intervention model, and increased willingness to intervene accompanied by greater optimism that their intervention may prevent a suicide. Experienced caregivers value ASIST as “revitalizing,” a “great refresher” or a “new way to organize existing knowledge.” ASIST uses adult learning principles and builds action and skills change. Considering attitudes and beliefs is a critical first step that opens the learner to using new approaches and knowledge. A full description of all known evaluations of ASIST is available from LivingWorks. Evaluation to support further improvements of the program is an ongoing commitment.
- Eggert and others, Gatekeeper training: A selective prevention approach, Washington State Youth Suicide Prevention Program, Univ. of Washington, 1997, 1999

Somewhere in the world, there is another ASIST workshop right now.
Over 3,500 trainers are providing ASIST workshops to 30,000 participants annually. This works out to 29 workshops every week or 4 workshops on any one day of the week. Local trainers offer the standardized curriculum of the workshop to reduce costs and to tailor the program to the needs of their own communities. Every ASIST workshop adds to the number of helpers “ready, willing and able” to provide suicide first aid.
- LivingWorks Education, 2005

Every day, there are people learning suicide first aid.
ASIST is a foundation or core program that prepares participants to do immediate or emergency suicide interventions until the present danger is resolved or until further support resources can be activated. It is suitable for caregivers of all levels and types of expertise. Suicide first aid has been compared to the CPR Heart Saver program of the American Heart Association or the Emergency Level First Aid program of St John Ambulance. Anyone can learn what must/can be done to save the life of a person at risk of suicide or self-harm. With at least 4 ASIST workshops underway on any day of the week, on average there are 80 people learning suicide first aid every day of the year.
- LivingWorks Education, 2003

Suicide first aid can be used anywhere.
The ASIST workshop was designed for caregivers from a wide range of professional and occupational groups, and for all ages 16 years and older. A glance at those who have taken the workshop attests to the fact that it can be used anywhere: school teachers, indigenous people, correctional staff (adult and youth), police officers, military personnel (enlisted and civilian), mental health professionals, child welfare workers, crisis line volunteers, the clergy, addictions workers, medical students, rural workers, social services staff, probation workers, and many others from different walks of life. Not only can suicide first aid be used anywhere, it can be used by any one in any place. Many caregivers have reported the successful use of suicide intervention skills with family, friends, neighbors and coworkers.
- Ramsay and others, Alberta’s Suicide Prevention Programs, Suicide and Life-Threatening Behavior, 1990

General

The World Health Organization calls suicide a significant public health problem.
Global figures estimate one million people die annually by suicide. This represents one death every 40 seconds.
- World Health Organization (WHO), Figures and Facts about Suicide, 1999

Suicide is a global concern.
In all 105 countries providing causes of death information to the WHO, suicide is now one of the three leading causes of death among people aged 15-35 years. Although once primarily a concern among the elderly, it now predominates in younger people in a third of all countries.
- WHO, Figures and Facts about Suicide, 1999

Some things we know about suicide are true, worldwide...
It happens to people of all kinds who are sad, distressed and often desperate to stop their suffering. Many of these people did not want to die. Some, perhaps many, deaths by suicide could be prevented.
- Schmidtke and others, Suicide rates in the world, Archives of Suicide Research, 1999

...but local knowledge can be helpful.
The reasons for living and for dying are often much the same, but the methods of dying may differ, and so may the cultural expectation about seeking help.
- Joseph and others, Evaluation of suicide rates in rural India using verbal autopsies, 1994-9, British Medical Journal, 2003

Surveys are one way to learn about suicide...
Asking a very large number of people about an issue, if done in similar fashion in many places, is a method of collecting data called a survey. The results can be used to make general conclusions about a topic. Certain statistical formulae can be applied to the data to help us know when a conclusion is likely true of the group surveyed. Nothing is ever 100% true or, if it were, it would be a useless conclusion: all who answered this survey were people. The survey conclusions will apply to some of the people in the group but not all. In studying suicidal behaviors, we ask people how often they think of self-harm, how they might do it, and to choose among reasons for living and for dying. All of these help us to develop explanations to aid our understanding of suicide among groups of people like those who answered the survey questions. It is not a way to learn about specific individuals at risk of suicide.
- Thomas and others, Thinking life is not worth living: A population survey of Great Britain, Social Psychiatry and Psychiatric Epidemiology, 2002

...talking with people at risk is another.
Listening to the stories of persons at risk and of those who have self-harmed and lived also aids our understanding. These personal narratives of struggle and sometimes of sacrifice bring the reality of human experiences and suffering to our attention. Meanings of loss, feelings of being truly alone and trapped in the past, the desperation of needing to do something, the turmoil of ambivalence and the tremendous value of hope all become clearer in these stories of life and death.
- O’Carrol and others, Interviewing suicide ‘decendents’: A fourth strategy for risk factor assessments, Suicide and Life-Threatening Behavior, 2001

What is it

The word suicide was first used in the 17th century.
Self-killing is a very old word. Greek (hekousios thanatos) and Latin (mors voluntaria) terms saw it as voluntary death. Suicida was used in the Middle Ages but it was considered bad Latin. English and other modern languages coined the word “suicide” in the 17th century. France accepted the word only in the 18th century. In some places, death by self still has no name. It is called “the silly thing” in at least one culture where ASIST is used.
- Maris, Berman, Silverman, A historical perspective on suicide, Comprehensive Textbook on Suicidology, 2000

Suicide is one way to say how someone dies.
Coroners or medical examiners must certify a mode of death for every person who dies. The accepted ways of certifying death are natural (most common), homicide (least common), accident, suicide and a group where certifying is difficult called, undetermined.
- Neeleman and Wessely, Changes in classification of suicide in England and Wales: Time trends and associations with coroners’ professional backgrounds, Psychological Medicine, 1997

Suicide is generally defined as the act of “self-killing.”
There is no widely accepted definition of suicide. It is a self-inflicted act that results in death (or injury, as in a suicide attempt). The difficulty is deciding whether the person really meant or intended to die — and they can no longer answer for themselves.
- Beautrais, Suicides and serious suicide attempts, Psychological Medicine, 2000

Many who consider suicide would prefer to find a way to live.
Thankfully, we can state with confidence that this is true. Estimates of the number of persons who self-harm compared to those who die by suicide range from 25-100 to 1. This variety of data happens because of different definitions of self-injury/harm activities and because many persons who harm themselves never appear for help or treatment. There are two important conclusions resulting from the ratio of harm to death: 1) The largest number of people who harm themselves do not die; 2) the problem is much larger than indicated by numbers or rates of completed death by suicide.
- Moscicki, Gender differences in completed and attempted suicides, Annals of Epidemiology, 1994

History

Suicide is mentioned in the history of all human societies.
Ancient and modern, from societies of hunting and gathering through to large cities with much technology, there are records of human beings dying by their own hand: “suicida,” “ownslayer,” self-slayer. Sometimes the dying is culturally accepted and even expected, as in ritual suicides or “dying for one’s country (tribe, honor, etc).” Most all of these deaths are also grievous losses no matter what the cultural expectations.
- Maris, Berman, A historical perspective on suicide, Silverman, Comprehensive Textbook on Suicidology, 2000

Suicide keeps on happening — despite being illegal, prohibited, and punished.
From the 5th century in western culture, suicide has been an act against God and state. Terrible penalties were imposed on the survivors and the deceased — getting only a “dogs burial,” their corpses being thrown away like other animals. Occasional arguments for permitted or rational suicide have appeared since the 17th century. In latter half of 20th century, some countries have recognized and accepted suicide as part of the human condition.
- Maris, Berman, A historical perspective on suicide, Silverman, Comprehensive Textbook on Suicidology, 2000

Until recently, trying to kill yourself was against the law.
Making suicide unacceptable by setting laws that made it illegal was intended to discourage suicide. In earlier days, the punishments were extreme as suicide was considered to be a “felony against the self” and thought to undermine religious, social and legal authority. More recently, the stigma has lessened in some places and these laws have largely been discontinued. In most places, however, it is still unlawful to aid, abet or counsel a person to suicide.
- Lester, Guttman, Scaling national laws on suicide, Crisis, 2002

Many people who might have been famous have died by suicide.
Many famous people throughout history and into the present time, have died by suicide: artists, philosophers, poets, singers, scientists, politicians and soldiers. Some of them became famous only after their death. We can feel sorrow and great loss for the contribution that they and others might have made.
- Lester, Encyclopedia of Famous Suicides, 1997

Size

More are dying from suicide than in all the armed conflicts around the world.
One million suicide deaths annually are more than the casualties in all of several armed conflicts around the world and, in many places about the same or more than those dying from motor vehicle collisions.
- WHO, Figures and Facts about Suicide, 1999

Annually, over 1 million people die by suicide around the world — many more attempt suicide.
The global average rate is 16 per 100,000.WHO estimates 10 to 20 times more will attempt suicide worldwide. Some community-based studies indicate this figure could be as high as 40 to 60 times. The highest rates (over 30 per 100,000) are found in Baltic region countries. The highest rates in the regions of Africa, the Americas, South-East Asia and West Pacific are found in island countries, Mauritius, Cuba, Sri Lanka and Japan.
- WHO, Figures and Facts about Suicide, 1999

Someone in the world dies by suicide every 40 seconds.
One million deaths by suicide annually represents one death every 40 seconds.
- WHO, Figures and Facts about Suicide, 1999

Each week, about 3% of people consider ending their lives.
Thinking about suicide is very common. This is a relatively new finding from researchers in Australia. There is nothing surprising in this information, except that it took so long for it to be noticed. Offering great hope is the calculation that the very largest majority of these people never actively harm themselves, despite being at risk. It appears that actively considering suicide is so unpleasant or distressing that people want to find better choices.
- Goldney and others, Suicidal ideation and health-related quality of life in a community, MJA, 2001

Suicide occurs in all states, provinces and countries. Of all deaths each year, suicide is the cause in 2%.
Society counts the ways that people die. They do this to follow changes in the causes of mortality. Most governments publish the data. The information is often used to make decisions about spending money for prevention programs. Deaths by suicide are listed in every such reporting. More people die by suicide than by homicide or liver diseases or AIDS and, in many places about the same or more than those dying from traffic accidents. Relative to how large a problem it is, suicidal behavior and its prevention receive very little funding support from governments or public health authorities around the world.
- WHO, The Injury Chart Book, 2002

Suicide rate is a measure of suicide for a group.
If we want to compare the number of suicides over a period of time in the same group or between different groups of people (such as males and females, city and country folk, influence of months of the year or seasons), we need a measuring tool that adjusts the number of suicides to the size of the group in which they occur. This tool is the rate of suicide. The rate expresses the number of people who die by suicide in a given group of people of the same size over the same amount of time. For suicide, the time standard is one year and the total number of people is 100,000.
Thus, rate of suicide = number of deaths by suicide X 100,000 divided by total population of group. For example, in a city of 1 million with 100 deaths in a 1 year period, the suicide rate would be 100 x 100,000 divided by 1,000,000 = 10 per 100,000. When someone is making comparisons, you should hear a phrase like, “rate per 100,000.”
- Mausner and Bahn, Epidemiology: An introductory text, 1985

Suicide rates provide a way to make comparisons between groups.
As a measuring tool, knowing the rate of suicide in a group allows us to compare it with the rate in other groups. We do this in order to learn more about groups that may be more or less likely to experience suicide. This is how we can compare the rates between Australia, Canada, Norway and the United States with their different population sizes or between different age groups with their different suicide numbers and population sizes.
- Mausner and Bahn, Epidemiology: An introductory text, 1985

Official suicide numbers do not tell the full picture.
There are always more suicides than are officially reported. We know that a number of suicides are misclassified as an accident or left as undetermined because we simply do not know enough to place the death of that person in a category. There are wide differences in the rules or criteria used to classify a death as suicide in different places. Recent studies have shown suicide deaths underestimated by 3-24% with 10% being widely used as a general measure of undercounting. Stigma contributes to the undercounting and variation in criteria.
- Moscicki, Epidemiology of completed and attempted suicide, Clinical Neuroscience Research, 2001

Some drownings may be suicides. Motor vehicle “accidents” are sometimes attempts at suicide.
When these occur as individual deaths, such as single motor vehicle injuries, the possibility of purposeful death or suicide cannot be fully ruled out. Certainly, some drownings and single motor vehicle deaths are “misclassified” as natural or accidental when suicide would be more correct. There is some data supporting this from coroner reports. Misclassifying of such deaths contributes to under reporting of official numbers. Recent studies indicate that probably less than 5% of single occupant motor vehicle and fewer than 10% of drowning deaths are missed as suicides.
- Connolly and others, Single road traffic deaths – accident or suicide?, Crisis, 1995

Trends

Many countries have had large increases in adolescent and young adult suicide since 1975.
In all the countries that report suicide rates to the World Health Organization, suicide is now one of the three leading causes of death among people young adults (15 - 35 years of age). Until recently suicide was predominately an elderly problem.
- WHO, Facts and Figures about Suicide, 1999

Suicide is now a major problem in younger people in a third of all countries.
When 1950s data is compared with 1990s data, suicide is most common among younger people in both absolute and relative terms, in a third of all countries.
- WHO, Facts and Figures about Suicide, 1999

Suicide remains an important issue in the health of elderly persons.
Suicide has always been known as an issue of great concern in the elderly, and suicide rates increase even more with older and very old people. Chronic physical illnesses are a major contributing factor. The problem of suicide in the elderly has not changed, but it has been overwhelmed in recent years by the increase in suicide among younger people. Over the next few decades, there are going to be more and more elderly persons and they are likely to live longer and have less access to resources. By all estimations, the number of suicides is going to increase in these age groups even more.
- Chiu and others, Suicide in the elderly, Current Opinion in Psychiatry, 2001

Suicide rates have been increasing around the world over the last 50 years.
Recent data from the World Health Organization shows that suicide rates between 1950 and 1995 increased from 10.1 per 100,000 to 16 per 100,000. This is almost a 60% increase, although these figures must be interpreted with some caution as far fewer countries were reporting statistics in 1950 than in 1995.
- WHO, Facts and Figures about Suicide, 1999

Explanations

The facts of suicide are not easy to explain.
A person who dies by suicide is no longer available to explain why they suicided. For survivors, feelings about the death make it difficult to know what might have been the real facts. Research theories are only best guesses. They describe a complex decision influenced by many contributing pathways.
- Shneidman, Comprehending Suicide: Landmarks in 20th Century Suicidology, 2001

There is no single cause when a person dies by suicide.
Suicidal behavior is influenced by biology, personal and social psychology, roles and relationships, and issues about the very meaning of each of our lives. Many factors come together in a multitude of different combinations to make a death by suicide.
- Orbach, A taxonomy of factors related to suicidal behavior, Clinical Psychology Science and Practice, 1997

Suicidal behavior occurs for many different reasons.
Suicidal behavior is not a single problem, but a collection of issues that eventually end in self-harm or death. There is no typical suicide but it is very unlikely for suicide to occur “for no reason at all.”
- Jobes and Mann, Reasons for living versus reasons for dying: Examining the internal debate of suicide, Suicide and Life-Threatening Behavior, 1999

There are many choices leading to suicide.
Suicide is an outcome of a process within a person’s life. There is a development of predisposing, precipitating and even perpetuating events and experiences. During this process, there are choice points where suicide can be made less likely. Some of these are choices available to a person at risk and some are choices made by others or even by society at large.
- Lester, Why People Kill Themselves: A 2000 Summary of Research on Suicide (4th ed.), 2000

Many things, big and small, can lead towards suicide.
Seldom does a single catastrophic event lead to suicide, though that does occur. Much more common are events and experiences that eventually overwhelm the person and lead to a loss of their usual effective coping. Suicide may become an option at this point but life can also be chosen and usually will be if there is someone to help sort out the choices.
- Heikkinen and others, Age-related variation in recent life events preceding suicide, Journal of Nervous and Mental Disease, 1995

For many, suicide is about escaping pain.
Suicide is usually not about seeking death. Death may be the outcome, but the goal was to escape a life where the burden of suffering and pain can be removed.

Many who consider suicide would prefer to find a way to live.
Thoughts of suicide occur when living life as it has been is no longer possible. Something must change. One solution is no life, but another is to find another way to live. Most people find another way out. Suicide is not a first choice. There is an interview with a person who jumped off a very high bridge — and lived. He recalled thinking on the way down that he had made the wrong choice and really wanted to live.
- Malone and others, Protective factors against suicidal acts in major depression: reasons for living, American Journal of Psychiatry, 2000

Fewer than 1 in 5 of those who suicide leave a note to explain their action.
Written notes or other messages from those who die by suicide are not common. Those that are left are usually more about who should or should not be blamed for the action than any explanation of the reason(s) for taking the action.
- McClelland, A last defence: The negotiation of blame within suicide notes, 2002

Social Issues

Wealth or success is not a protection against suicide.
This is a very complicated issue. There is international evidence that communities with lower social standing or with diminished expectations of success (less hopeful) are associated with higher suicide rates. Farm laborers have been found to have higher rates than professional workers; blue-collar workers higher than white-collar workers, lower income groups more than higher income groups. Areas with less money in a household appear on average to have more suicide. But there are many explanations for living in lower income areas and a large number of these are also linked to suicide in their own right. It is likely for example that persons with chronic, persistent and severe mental disorders will find themselves living in lower income communities. Is the link to suicide their income level or the disorder that has limited their earning potential? No one knows which is the greater contributor. In another recent study, depression was four times more likely in communities with poverty. If suicide were to occur in these communities, would it be caused by depression or by poverty—or by some contribution of each?
This is an example of a much larger scientific issue in which summary or outcome measures associated with a behavior like suicide are used as if they are a cause of it. The real explanations may lie in factors that lead to the outcome measure or even in some factor that is common to both the underlying factor(s) and the summary measure. Very sophisticated statistical techniques are needed to sort out the relative contribution of different factors. Very few studies have the ability or power to provide sure conclusions about the contribution of individual factors such as economic status. Much more work is needed to sort out the effects of one’s social economic status from the many other factors associated with it.
In our risk review of the factors that alert us to the possibility of suicide, resources are an important item. Financial resources must certainly be considered, but there are many supports against suicide that are available to persons at risk whether or not they have financial security. It may be true that success is more important than wealth because positive outcomes tend to lead to optimistic or hopeful outlooks. But optimism may also be a trait of some persons even when they are consistently challenged by apparent “failures.” It seems inaccurate to draw conclusions based solely on success without knowing the story behind the success. Sometimes the first failure after a lifetime of unbroken success leads to suicide because the person has no skills to cope with the discomfort or distress that comes with it. In sum, we believe that it is a culturally driven and unproven proposition that a person’s financial wealth or social influence afford protection against suicide. There are (too many) wealthy and influential families with suicide survivors, just as there are in every community and at every level of society.
- Hawton and others, The influence of the economic and social environment on deliberate self-harm and suicide, Psychological Medicine, 2001

Individuals with legal concerns can be more at risk than others.
Suicide is the leading cause of death in prisons and correctional institutions. The most common location is the jail, remand centre or lockup — the point of first contact with the justice and legal system for offenders. Suicide may be linked to individual feelings of shame and disappointment associated with breaking the law as much as to any feature of the institution itself. Jail suicide is a very large problem in almost all communities. The importance of this stressor is emphasized in an Alberta study where 14% of suicides in a given year were in active contact with the legal and justice system at or around the time of their deaths. The number of deaths by persons who were witnesses to or victims of criminal activity was even more distressing.
- Bonner, Correctional suicide in the year 2000 and beyond, Suicide and Life-Threatening Behavior, 2000

Increases in suicide have been connected to both good and bad economic times.
Offering explanations based on simple associations to available “hard” or numerical data is a great temptation, but such explanations may offer only limited help in understanding why suicide happens. For example, historical information shows that male suicide rates increased substantially in many nations, some as high as 108%, during the Great Depression in the 1930s. This led to a belief that adversity killed off the weaker members of society, a sort of “survival of the fittest” explanation (or is that “survival of the fittest” rationalization). But even with the increases, most people confronted by material disadvantages in this decade did not kill themselves. Any explanation must invoke some other factor(s) in addition to bad economics. It is notable that the 1930s increase is relative to earlier and later decades in which there were world wars, which are known to decrease the suicide rate. Perhaps the 1930s were not an increase, but the actual measure of the amount of suicide in the population.
Good economic times indicated by measures of financial health of an entire economy may have little relation to some towns and communities in economic difficulties in the midst of these prosperous overall times. Often, the new economic strength is at the cost of leaving behind older communities whose success was based on old or obsolete industries. This was particularly evident during the 1990’s as industrial wealth of nations boomed while agricultural communities were more and more bankrupt and abandoned.
When good economic events can be isolated, it has not been uncommon for new and wealthy satellite suburbs to have major problems with suicide among youths and stay at home partners. Another largely unknown fact is the increased frequency of suicide known among winners of large pools or lotteries prizes.
- Yang and others, Suicide and unemployment: Predicting the smoothed trend and yearly fluctuations, The Journal of Socio-Economics, 1992

Suicide rates are higher among unemployed persons.
Although findings have been mixed in some studies, upward trends in unemployment in a country are statistically associated with increases in suicide. Forced unemployment often signals loss of or change in resources, both financial and social. Suicide related to unemployment occurs at two times: immediately — related to stress with shame and adjustment — and much later when resources are exhausted and hope is diminished. The positive relationship between unemployment and suicide is often stronger for men than for women. Unemployment represents a stress that may have personal meanings such as a loss of esteem and personal consequences such as depression and hopelessness.
- Kposowa, Unemployment and suicide, Psychological Medicine, 2001

Work as a helper or caregiver does not protect against suicide.
Some occupations have more risk of suicide than others, but for different reasons. Physicians, pharmacists, and dentists, with access to and information about lethal drugs and chemicals, have been linked to high suicide risk. Police personnel and psychiatrists also appear to have a higher rate of suicide, as do women physicians. Many explanations have been offered, mostly around the personal isolation that can go with jobs like these. Others have stated that jobs requiring service to other humans are more likely to have risk attached to them because the lack of control over the behavior of others combines with a responsibility for such behaviors and leads to intolerable stress. Whatever the actual reason, being a caregiver offers no special protection or immunity from suicide.
- Boxer and others, Suicide and occupation: A review of the literature. Journal of Occupational and Environmental Medicine, 1995

Individuals from any religious background can be at risk of suicide.
From the beginning of the modern study of suicide, the protective effect of belonging to a religious group has been noted. Not only is there the feeling of belonging, but also the faith itself offers hope and a sense of future: all of these are antidotes to suicide. There is no evidence that a particular faith, belief or religious group offers more individual protection than any other, although some recent country-based evidence indicates that membership in a religion offers some protection for men. Older information noted decreased suicide in countries with a large proportion of Roman Catholics, but the data was distorted by social and political beliefs. These much diminished the likelihood that suicide deaths would be properly labeled or identified. At present, the fact of underreporting of suicide in Catholic nations is widely accepted. Other information suggested that those of Jewish faith were less likely to suicide. This is now recognized as an effect of the cultural and social closeness of the Jewish community more than any specific religious beliefs or practices. All of these religious effects on reducing suicide risk are small.
- Kelleher and others, Religious sanctions and rates of suicide worldwide, Crisis, 1998

Groups

There are many things that can increase suicide risk and the possibility of self-harm. Most of the recognized and labeled factors have been associated with suicidal behaviors in research studies. The association does not mean that a person who has lived or experienced that hazard is bound to become a person at risk. It does mean they are part of a group of people who are more “vulnerable” or at risk than a person that has never had that experience. There is no hazard associated with suicide for which everyone with the hazard becomes a person at risk. If the association were that strong, the factor would actually predict suicidal behavior perfectly. One reason there are nothing close to perfect predictors is that coping, personal choice and the willingness to seek help are all important in estimating how important an event or experience is in making a person vulnerable to suicide.

In all countries, suicide is now one of the leading causes of death among young adults.
In all countries reporting suicide information to the World Health Organization, suicide is now one of the three leading causes of death among young adults (persons 15 - 35 years of age). What was once predominantly a problem in elder age groups now predominates in younger people in a third of all countries.
- WHO, Facts and Figures about Suicide, 1999

Gay and lesbian persons may be more at risk.
This has been a controversial issue for some time. There are many methodology limitations associated with gathering data because there is an almost complete absence of sexual orientation questions in population surveys and there is a lack of researchable sexual orientation information on death records. Results consistently indicated that gay, lesbian and bisexual persons, particularly gay men, had substantially higher self-reported rates of suicidal ideation and suicide attempts, and may have higher suicide rates than heterosexual persons. Both critics and proponents of the research findings often misreported the speculations about suicide rates as facts, which increased misgivings about all findings. Recent research using more representative sampling methods and more rigorous data analysis are confirming earlier findings that this group is considerably more at risk than their heterosexual counterparts. Death-record information about sexual orientation is still too limited for any direct comparisons about suicide rates, so this conclusion remains speculative, not factual.
- Russell, Sexual minority youth and suicide risk, American Behavioral Scientist, 2003

Children as young as 4 years old have died by suicide.
This shocking fact is derived from data on accidental poisons, some case reports of intentional motor vehicle and childhood pedestrian injuries, and very rare coroner verdicts of suicide in young children. Although actual deaths in children are rare, suicidal behaviors are not and indications suggest the prevalence is increasing. There are others who dispute the possibility of child suicide based on theory. They do not believe that children can be held responsible for their actions beneath a certain legal age (around 10 - 14 usually) because they cannot understand the outcomes of their actions. This is particularly true of suicide because child development experts state that a child must be 8 - 10 years old in their intellectual development before having an understanding of the finality of death.
- Pfeffer, Suicidal behavior in prepubertal children: From the 1980s to the new millennium, In Review of Suicidology, 2000

Adult males are the largest group of persons who die by suicide.
From early teens through to extreme old age, males are more at risk of death by suicide. This finding appears across all cultures and countries except in rural China and for younger women in parts of India. In most measures, men are 3 to 8 times as likely to die by suicide as women, and so make up 75-90% of all suicides. More recently, it appears that men are also self-harming more often, though this is still a behavior more identified with females. No satisfactory explanation for this single group being at such definite risk has been put forward.
- Canetto and Sakinofsky, The gender paradox in suicide, Suicide and Life-Threatening Behavior, 1998

Childhood abuse may increase suicide risk later.
Experiencing physical abuse and domestic violence during childhood often leads to difficulties in adult life. Experiences of sexual abuse, especially in mother-child relationships, are known to increase risk in both genders. Women who have experienced childhood abuse are at a greater risk of having attempted suicide.
- Dieserud and others, Negative life events in childhood, psychological problems and suicide attempts in adulthood, Archives of Suicide Research, 2002

Mental health concerns increase suicide risk...
Some professionals regard mental health diagnoses and disorders as a necessary condition for suicidal behavior. These health conditions are certainly found more often in the life history of persons at risk than in persons not at risk. The power of an active episode of certain major mental disorders should not be underestimated. Episodes of major depression, psychoses in either acute and in residual phases and crises of living associated with personality disorders all increase the likelihood of suicidal behavior. The more types of mental disorder that one experiences (called comorbidity), the stronger the state of vulnerability.

...but those without such concerns can also be at risk.
But almost 17% of the populations have one of these disorders at any time and one-half of us will be diagnosed with one of these disorders during our lifetimes. Mental disorders are so common that the vulnerability associated with them is of limited value as a specific indicator for suicidal behavior. Some have argued that the real issue of vulnerability for mental disorders is not the actual problems of thought and feeling that define them, but the ways that society and others fail to support persons with such problems. Stigma exists for mental disorders equally as strongly as it does for suicide. Finally, persons with mental disorders do learn to cope over time. Thus, people with mental disorders are more likely to be at risk than to actually act on their thoughts of suicide.
- Tanney, Psychiatric diagnoses and suicidal acts, Comprehensive Textbook on Suicidology, 2000

People in institutions are at higher risk of suicide.
Jails, prisons and mental hospitals are unusual places. People living in them are stressed physically, socially or mentally and may already be at risk for these reasons. The social organization of a large institution can also contribute to risk by creating dependency, sapping creativity or personal strength, and overall, weakening the coping and adaptive abilities of residents. In sum, they are stressful places to be in no matter how humanely they are organized and often persons who enter them are already stressed, vulnerable and at risk.

Left-handed people are at slightly greater risk.
This is an example of an association which has been demonstrated statistically, but which has no acceptable explanation. It is a good example of a problem with the methods used to study suicide and suicidal persons which use group data and mathematical or actuarial sciences. Of course some persons at risk will be left-handed, but many more will not be. The same is also true for right-handed or ambidextrous persons.
- Chyatte and Smith, Brain asymmetry predicts suicide among Navy alcohol abusers, 1981

Men are more likely than women to die by suicide.
In most countries, this is a fact of suicide. Men die by suicide about three or four times as often as women. It is useful to note that, overall, more women engage in suicidal behavior resulting in injury or a non-fatal outcome. Men as a sex are more vulnerable to death from conception onwards. Some argue that men are socially reared to be more alone and independent, and to have more difficulty seeking help when in distress (men are very unwilling to ask for help when lost, for example). Others still suggest that the coping conditions and styles of men are more aligned to fighting, violence, anger and modification by acute substance abuse. There are many explanations, but some unknown protective factor in women and not just vulnerability in men must also be considered as a possibility. Gender is perhaps the most important, but most ignored, demographic factor that needs consideration in designing both prevention and intervention programs.
- Canetto and Sakinofsky, The gender paradox in suicide, Suicide and Life-Threatening Behavior, 1998

Young women are the largest single group of persons who deliberately harm themselves.
Non-fatal injury is the most common outcome of a suicidal behavior. The highest rates of non-fatal injury are found among young women (14 - 29 years of age). It appears that in most cases their intent is not to die but to change some aspect of their present life circumstances. Ramsay has called these behaviors, “life attempts.” This is of course a very dangerous way to accomplish life change. “Accidental” suicides are possible if rescue is miscalculated or the danger of the chosen method is higher than the person expects.
- Canetto and Sakinofsky, The gender paradox in suicide, Suicide and Life-Threatening Behavior, 1998

Suicide rates tend to be higher in aboriginal communities...
Death by suicide is recognized in almost all native/aboriginal cultures. Rates are higher in young native or aboriginal persons of both genders than for other racial/cultural groups. This has been noted in most locations where data is available (North America, Australia, New Zealand and northern Europe) and thus appears a cultural and not a racial issue. Most explanations refer to a loss of cultural roots and origins (as a minority culture overwhelmed by globalization), cultural dislocation and even disintegration as a critical stressor.
- Chandler and others, A study of Native and Non-Native North American adolescents, Monographs of the Society for Research in Child Development, 2003

...but rates vary among aboriginal communities.
Some native communities appear relatively protected from the problem of suicide. Even tribes a short distance apart geographically may have markedly different experiences with suicide. There may be community beliefs about death and suicide that protect or promote suicide. At this time, there is some but not yet strong evidence that communities with sustained cultural continuity roots are more protected.
- Graham, Using reasons for living to connect to American Indian healing traditions, Journal of Sociology and Social Welfare, 2002

Having children offers some protection from suicide.
Children offer meaning to the lives of parents. Children are frequently mentioned as a reason for living. The desire to ensure the survival and health of our offspring may be “wired” into our biological makeup in some way. The “empty nest” syndrome of parents whose children are grown and leaving home was previously said to account for a increase in suicide that occurred in women in their late forties and fifties, although the increase for women those ages is not obvious in many locations currently.
- Qin and others, Gender differences in risk factors for suicide in Denmark, British Journal of Psychiatry, 2000

People without a life partner can be more at risk.
Being partnered may just mean not being alone and being alone is a risk alert for suicidal behavior. Data from many places about relationship status confirms that being single, divorced or widowed is associated with a higher suicide rate for men and women. Women do seem to manage loss of relationship better than men however. Separating the effect of loss of relationship (stressor) from the resulting being without relationship (alone) is a complex problem.
- Heikkinen and others, Social factors in suicide, British Journal of Psychiatry, 1995

Natural Issues

Suicide is not more common at the full moon.
Folklore has an enduring aspect that defies evidence. A great number of human behaviors have been said to cycle or be influenced by astrological events like the phases of the moon. Despite numerous studies, no relationship has been shown between such events and suicidal behaviors.
- Martin and others, Suicide and lunar cycles, Psychological Reports, 1992

Suicide occurs all year but is slightly more common in spring.
There are two peaks in suicide during the calendar year. They occur with the change of the seasons from hot to cold and from cold to hot six months later. The change from cold to hot in spring is more prominent. Both of these peaks are noticeable in graphs and often mentioned in folklore but the spring peak is actually statistically significant. It is notable that this relationship is present in both Northern and Southern Hemispheres. There is also a peak in the incidence of episodes of biological mood/affective disorder at the same time.
- Chew and McCleary, The spring peak in suicide, Social Science and Medicine, 1995

Suicide has been associated with some climate factors.
High temperatures (well above normal body temperature of 37.2C) accompanied by very high humidity and changes in atmospheric pressure have been related to increases in suicidal behavior in some studies. This is fabled in “going troppo” in Northern Territory Australia. Dry, warm winds blow down the leeward side of mountains in, for example, Alberta (chinook), Norway (fohn) and southern France (Mistral). They are accompanied by large rapid barometric pressure changes and a weak but recognizable statistical relationship to suicidal behaviors.
- Preti, Seasonal variation and meteotropism in suicide, Current Opinion in Psychiatry, 2000

There are locations in every city where suicidal behavior is more common.
The urban geography of cities reflects the influences of many social and economic factors. Suicide occurs in central cores where there are many business buildings but fewer residential communities offering local support. It occurs around universities and colleges where young people are concentrated in institutions often far away from the support of family and friends. In the mid latitudes, suicide is often higher on the east end of town where there is more industrial and less residential development. Micro factors are also noted as suicide is more common on streets which access or support mass transit.
- Kennedy and others, Violence, homicide and suicide: Strong correlation and wide variation across districts, British Journal of Psychiatry, 1999

90% of suicides occur in the home.
This is a surprising fact to many but there are some practical considerations in the choice. Methods are familiar and available, and plans can be developed and implemented in secret. Sometimes the final message of the person who dies by suicide is meant to be directly delivered to those who share the residence. Because schedules of other occupants are known, there is less chance of interruption. Another possibility is that there is a small part of the person at risk that wants to live and is unconsciously hoping for a rescue.
- Avis, Suicide in metropolitan St. John’s 1988-1994, Canadian Society of Forensic Sciences Journal, 1996

Death by suicide is less common before public holidays...
All of us are carried along in the emotional tide of celebration around a festive or special event marked by a holiday. The sense of community is strong and binds us all. Even more, such public celebrations are often annual events that bring back personal memories and experiences of earlier and better days, or hold out a promise for such in the future. These features of support, of hope and of a sense of enduring such times are strong antidotes against suicide.

...but more common after public holidays.
When the day has passed and little has changed and when others carry on with daily life and living, the stark isolation for the person who feels left out seems to throw them back into the “black pit” of suicide. There are numerous studies that support the decrease and then increase in suicide around holidays with the conclusion that no overall effect of holidays can be found.
- Jessen and others, Attempted suicide and major public holidays in Europe, Acta Psychiatr Scand, 1999

Suicides occur in all parts of a country, but rates are lower in cities and towns.
There is no region in which there are not suicides. The number of deaths by suicide differs across countries and in various regions within countries. There are patterns to these differences. One example is found when the rates of suicide for every county in the United States were mapped as part of a mortality atlas. Areas of dense population (metropolitan, urban and suburban) had lower suicide than rural and much lower suicide than isolated and remote rural communities. This surprised many people. Explanations include the relative lack of formal or professional resources, distance and isolation from other informal supports, availability of firearms as necessary tools for sustaining life, and the very nature of people who choose to live their lives in such separation from other human beings, such as proud individualism preventing asking for help, or fatalism about life and death as natural events.
- Yip and others, Urban/rural and gender differentials in suicide rates, Journal of Affective Disorders, 2000

How People Harm Themselves

Making guns harder to obtain would prevent many suicide deaths.
When they can be obtained, firearms are an important method of suicide in both men and women. Whether handguns or long weapons, they are highly likely to cause extensive and severe trauma. In addition, the trauma occurs so rapidly that help cannot be accessed in time. Firearms are a violent method more favored by males and this choice may come from the angry, aggressive and disfiguring meaning that is conveyed by shooting or may simply be an indication of men being more familiar using the device.
When firearms are restricted or unavailable, as has happened in several natural experiments, the overall rate of suicide drops because the number of firearm suicides decrease. It is accepted that substitution by other methods does occur over time, but lives continue until this happens and positive changes might occur in the interim.
- Brent and Bridge, Firearms availability and suicide, American Behavioral Scientist, 2003

Suicidal behavior using drugs or poisons is more common in women.
The availability of and familiarity with drugs and poisons is more likely in women. Suicidal behavior may thus be an act of opportunity, taken when available. Suicidal behavior includes non-fatal or life outcomes and most ingestions of drugs and poisons have this result. There are several explanations. Toxicity or lethality of drugs and poisons is decreasing, especially drugs used to treat mental health conditions. Most ingestions are not rapidly lethal. There is more time for help to become available and more time makes room for one to change their mind. In addition, emergency medical care for poisoning has improved markedly over the past several decades in many countries.
- Canetto and Sakinofsky, The gender paradox in suicide, Suicide and Life-Threatening Behavior, 1998

Preferred methods for suicide change with time.
There will always be means available to end ones life intentionally. The individual’s choice may have symbolic meaning or be intended to convey a message to those left behind. The arrival of new methods may replace older ones. This occurred in Northern Europe when carbon monoxide in coal gas (highly lethal and readily available in every kitchen oven) was replaced by natural gas (low lethality) for cooking. Availability of a certain method can change. This occurs now in efforts to restrict access to obtaining firearms either by legislation or through buyback programs. More ominously, manuals for ending life promoted by the euthanasia movement are known to have increased the use of certain methods.
- Marzuk and others, Increase in fatal suicidal poisonings and suffocations in the year Final Exit was published: A national study, American Journal of Psychiatry, 1994

Different cultures have “preferred” methods for suicide.
Availability is a significant factor in a community’s choice of accepted methods for suicide. In Southeast Asia, the availability of the insecticide Paraquat has led to it being a preferred choice for suicide. Methods also have a cultural meaning of being honorable (or shameful). For example, in Japan deaths using swords, deaths involving a ritual aspect of sacrifice or penance are looked upon more favorably. Some methods are almost “prescribed” as appropriate (or as unacceptable). Water has been particularly noted as defining acceptable death by sacrifice (cleansing) in some regions of the world.
- Qin and Mortensen, Specific characteristics of suicide in China, Acta Psychiatrica Scandinavica, 2001

Certain suicide methods are more common in some regions than others.
The choice of a means for suicide or self-harm changes over time, in different places and in varying cultures. Choice may have a personal meaning, but choice is also impacted by socially prescribed meanings, by availability and by “fashion.” There are also “in vogue” methods such as ”trainwalking” in Europe. Methods that imitate those chosen by famous persons such as overdoses after Marilyn Monroe suicide and an increase in paracetamol (acetaminophen) poisoning after an actress on a popular British soap opera used this method are other studied examples.

Suicides occur by all kinds of methods.
Ingenuity and variety are common in devising ways to end one’s life, but there are certain methods of suicide that are widely and generally used. The International Classification of Diseases (ICD) lists these as ‘E-codes’ (950-959) in ICD 9 and the new ICD 10 lists them as ‘X-codes’ (60-84). The most common causes are poisoning, hanging/strangulation/suffocation, drowning/submersion, firearm, cut/pierce with a sharp or blunt object, fall/jumping, fire/burn, and motor vehicle.
- International Classification of Diseases 10th Revision

Some methods of suicide are more deadly than others.
The likelihood that any particular means of harm may result in death is expressed as the lethality of that method. Lethality includes the actual nature, extent and severity of the damage caused to various organ systems in the body, the rapidity of such action and the potential for reversibility of the damage with appropriate and timely treatment. Various scales to compare the lethality of different methods have been created.

The method people choose may not indicate how serious they are about dying…
Euthanasia manuals and internet “suicide help” sites often elaborate these methods in some detail. We do not list these as our interest is in preserving, protecting and promoting life. Studies support the fact that there is a lack of knowledge in the general community about the anatomy, physiology and pharmacology of methods for self-harm. Industrial chemists, medically trained personnel and pharmacists are all at increased risk not only because of access to lethal methods, but also because of their knowledge about which drugs and chemicals are most dangerous, and in what amounts. Every year, a number of people who take overdoses of acetaminophen/paracetamol with little intention to die tragically lose their lives from the complications of liver damage and destruction that occur when the overdose is not treated promptly. Clinical experience with sites for cutting and for firearm wounding in persons who seriously intended to die indicates (thankfully) their lack of knowledge of anatomy in applying the method ineffectively.
- Cantor and Baume, Changing methods of suicide by young Australians 1974-1994, Archives of Suicide Research, 1998

...but most people are not aware of which methods are more dangerous.
Many caregivers assume that the lethality of a method chosen for self-harm is a measure of how much a person intended to die. A review of all studies (over 15 have been done) indicated that the link between more intent to die and greater lethality of method is only shown in one-half of them. The absence of a significant link is explained in part by availability and knowledge. Personal, regional and cultural preferences for certain methods regardless of lethality is another explanation.

Helping

Modern medical treatments have saved many who might have died by suicide.
Drugs and medicines commonly used in self-harm are safer in overdose than ever before. When available, protective (single-dose) packaging has lowered the amounts taken. Emergency medical services, emergency rooms and intensive care units specializing in the care and treatment of acutely ill or injured persons have appeared over the past 35 years. These treatments do not appear to have affected the overall death or injury rate. If we are “saving” more people who self-harm and the suicide rate is relatively stable, there must be more people trying to harm themselves or complete suicide.
- Hall and others, Association between antidepressant prescribing and suicide in Australia, 1991-2000, British Medical Journal, 2003

Suicide keeps on happening even with improvements in mental health treatments.
The modest impact of modern drug treatments in preventing suicide does not suggest these approaches are to be ignored or abandoned. Lithium for people with serious emotional or mood disorders and the antipsychotic drug, Clozapine, for persons with schizophrenias or other psychoses are clearly able to diminish outcomes of suicide and self-harm. The new antidepressants, which increase activity of the brain chemical Serotonin (5-HT), may be lifesaving in persons with violent and impulsive suicide attempts. The largest problem is making sure that persons who might benefit from these drugs receive them and receive them in adequate doses for a long enough period of time. There are also mental disorders associated with suicide where drugs are not often a first or important treatment at present: personality disorders and substance abuse. As is true with most mental health concerns, resources and research to aid persons with these disorders are often very poorly funded. It is unrealistic to expect a single approach (mental health drug therapy) to aid all persons at risk of suicide. After all, suicide is not a disease.
- van Heeringen, The Neurobiology of suicide and suicidality, Canadian Journal of Psychiatry, 2003

Despite our best efforts, sometimes people die by suicide.
Biomedical care has saved many persons who self-harmed with lethal means and intent. Effective help is available for many of the concerns that may progress to self-harm. There are those who are not helped despite these efforts. There are some who never ask for or even refuse help. There are some who never get the help that could be life saving. There are some for whom effective help could not be offered in time.
- Grunebaum, Outcomes of suicidal behaviors, Clinical Neuroscience Research, 2001

There are a few people who will never be at risk of suicide.
It is estimated that one in eight people have enough reasons for living or other protective factors that thoughts of suicide will never be a consideration for them. No one knows the source of this resiliency.
Most persons who deliberately harm themselves do not come for help or treatment.
In a study of adolescent suicidal behavior, persons receiving hospital treatment for suicidal behaviors are counted. The numbers indicates that as few as 6% of the population who will attempt suicide at some time in their lives arrive at medical treatment facilities. They may seek help from other non-medical resources. They may resolve the issues. They may die by suicide. We do not know. We do know that many persons at risk of suicide—and especially men—will not approach others for help because they fear being labeled or restrained.

Hope

Most suicides could be prevented.
There should be optimism in helping a person at risk. The largest majority of persons who consider suicide never act on these thoughts. Reasons for living often prevail.
A small gesture of support can be life saving.
Deciding for or against suicide is not just a summing or balancing of reasons for living or dying. It often appears to be a matter of which side has the momentum or flow at the particular moment when the decision is made. Although everything may be in favor of life, people still choose to end their lives. In the same way, strong reasons for death can be counterbalanced by the smallest reason for living. Support from another when there is nothing left inside may tip the scales towards carrying on. It need not be solutions or even other choices that are offered. Sometimes it may mean just not being alone. Understanding this is one of the core learning points of suicide first aid.

Suicide is something that can be talked about.
Stigma and taboo surrounded suicide for centuries in an effort to remove suicide from society. As a prevention strategy, it did not work. Suicide is part of the human condition, but it is always a choice. Accepting this as a pain-full reality frees caregivers to explore, understand and do something to help a person at risk find better choices.

Preventing suicide also involves preserving and promoting life.
Suicide first aid is not just turning away from death. It is choosing to live, if only for the moment. To reinforce this choice, communities must not only honor life itself, but also be committed to making it worthwhile and meaningful. Every community can be made suicide-safer when it helps living work.