Suicide in the United States
by Jane Pearson, Ph.D.*
In 1995, the year for which we have the most recent national death statistics, suicide was the ninth-leading cause of death in the United States. It accounted for 31,284 deaths, or 1.3 percent of all U.S. deaths. In contrast, 32 percent of all deaths were from diseases of the heart, and 23 percent from malignant neoplasms (cancer).
Suicide rates are typically presented as the number of deaths per 100,000 persons, taking into account the number of people in the population and its age distribution. The age-adjusted suicide rate in the U.S. in 1995 was 11.1 per 100,000, which ranks the U.S. among the countries in the middle in terms of suicide rates among industrialized nations. U.S. suicide rates vary from state to state. The western states have the highest rates, with Nevada leading the nation at 23.93/100,000. The lowest rate is for the District of Columbia at 6.05/100,000, followed by New Jersey at 6.75/100,000.
In the U.S. suicide rates vary dramatically by age, gender, and racial group. White males commit suicide at a rate higher than black males and white and black females. Another way of putting this is that 73 percent of all suicides are committed by white men. However, rates for black males have been rising, particularly those ages 15 to 24, where rates have nearly doubled since 1986. The age group with the highest rate of suicide is older white males. This pattern is also common in other countries: older males have the highest rate of suicide in nearly every industrialized nation.
In the United States, the most common method of suicide is death by firearm, which accounts for 60 percent of all suicide methods. Of all firearm deaths, about 80 percent are committed by white men.
Mental Disorders and Suicide
Findings from psychological autopsy (PA) studies, where the individuals state of mind prior to the suicide is determined through extensive interviews and review of medical history, indicate that about 90 percent of persons who completed suicides in all age groups had a diagnosable mental or substance abuse disorder. In other words, having a mental or substance abuse disorder is nearly a necessary condition for suicide to occur. Having a mental or substance abuse disorder does not necessarily mean that someone is at high risk for suicide, however; clearly the majority of people with these disorders do not die in this manner. When using the PA method, different patterns of mental and substance abuse disorders have been found across different age groups of suicide victims. Substance abuse and behavior problems such as conduct disorder are more common among adolescent suicides, while depression without substance abuse is the most common pattern among older adults.
Another approach to studying risk for suicide among persons with mental or substance abuse disorders is to follow-up people who have been hospitalized for such a disorder. The advantage with this approach is that a high-risk group has been identified and risk factors are recorded prior to the persons death. However, the disadvantages to this approach include the following: not all persons with mental or substance abuse disorders are hospitalized, not all hospitals keep the same records, and different studies use different approaches, including different follow-up time intervals.
The results are often mixed when it comes to estimating the particular rates of suicide for people with certain mental or substance abuse disorders or determining what risk factors, in addition to the disorder, played a role in the suicide. For example, although most researchers agree that persons with schizophrenia have a much higher risk of suicide than the general population, the estimates have ranged from 2 percent to 15 percent. In some studies, younger males with schizophrenia appear to be most at risk, while other studies find that women with schizophrenia commit suicide as frequently as men with schizophrenia. Among persons with depression, some have found psychotic symptoms to increase risk for suicide, while others have not found this risk pattern.
In addition to the mental or substance abuse disorders, there is a long list of factors that have been investigated to determine if they increase the risk for suicide. This list (in no particular order) includes having a second mental or substance abuse disorder, hostile and/or rigid temperament, history of sexual abuse, history of previous suicide attempt, hopelessness, inability to carry out activities of daily living, stressful life events such as the loss of a close relationship, and change in healthcare providers.
Opportunities for Prevention
Preventing suicide is an enormous challenge for several reasons. Although it is considered a preventable cause of death, suicide is a very rare occurrence compared to other causes of death or compared to the occurrence of mental and substance abuse disorders. Second, when researchers have tried to predict suicide using as many known risk factors as possible, they are still unable to predict who will and who will not commit this act. Third, the design and testing of preventive interventions is very difficult and challenging, but is necessary to avoid unexpected, negative outcomes. For example, a prevention program designed for high-school aged youth found that participants were more likely to consider suicide a solution to a problem after the program than prior to the program. This is not to say that it is risky to talk about suicide. Rather, there are contexts where talking about suicide is very appropriate and helpful. For example, an individual who has survived a family members suicide needs to have the opportunity to talk about suicide and receive support. Indeed, it is critical for clinicians to assess persons in distress for their suicide potential in order to take steps to minimize the suicide risk.
Given these cautions, the best approach for prevention of suicide would appear to be improving our treatments for mental and substance abuse disorders and being more vigilant in screening for suicide risk among persons with these disorders. Much more effort is needed to test prevention programs that consider these approaches. Proven programs and practices that prevent suicide should, in turn, be more broadly implemented in our healthcare services.
*About the author: Jane Pearson, Ph.D., chairs the National Institute of Mental Health (NIMH) Suicide Research Consortium and heads the adult and geriatric preventive interventions program in the Adult and Geriatric Treatment and Preventive Interventions Branch of NIMH. She is a graduate of Concordia College in Moorhead, Minnesota, and did her graduate work at Michigan State University. Dr. Pearson is an adjunct assistant professor at Johns Hopkins University, and she also has a private practice in clinical psychology. She has authored a number of papers on grandparents caring for children, caregiver burden in Alzheimers disease, late-life depression, and suicide and aging.