What is suicide?

What is Suicide

Suicide is the act of intentionally carrying out an action to kill oneself, representing the most severe endpoint on the spectrum of suicidal behaviors that includes suicidal ideation, suicide plans, and suicide attempts. 1

Core Definition and Terminology

• Suicide refers to the deliberate act of ending one's own life through intentional self-killing 1
• The recommended terminology is "died by suicide" rather than "committed suicide," which carries stigmatizing connotations 1
• Suicide represents the final outcome in a continuum of suicidal behaviors, distinct from but related to non-fatal suicide attempts 1

The Spectrum of Suicidal Behaviors

Suicidality encompasses the full range of suicide-related thoughts and behaviors, which clinicians must understand to properly assess risk 1:

• Suicidal ideation (SI): Thoughts, ideas, or ruminations about terminating one's life, ranging from passive wishes to be dead to detailed planning 1
• Suicide plan (SP): Formulation of specific methods, timing, and location for ending one's life 1
• Suicide attempt (SA): A specific episode of self-harming behavior carried out with deliberate intention to end one's life 1
• Died by suicide: The completed act resulting in death 1

Passive vs. Active Suicidal Ideation

• Passive suicidal ideation involves death wishes without active planning or intent, such as "I wish I wouldn't wake up in the morning" or thoughts that one would be better off dead 2
• Active suicidal ideation includes formulation of specific plans, methods, and intent to carry out self-harm 2
• The key differentiator is the absence versus presence of intent and planning, though passive ideation should never be dismissed as it may represent a patient's only way of asking for help 2

Epidemiology and Public Health Impact

• Suicide results in approximately 800,000 deaths globally per year, with an estimated 16 million suicide attempts annually 1
• In the United States alone, approximately 16.6 million adults and adolescents reported serious suicidal thoughts in 2022 3
• For every person who dies by suicide, more than 20 others make non-fatal attempts, representing substantial disease burden 1
• Suicide prevalence has increased 24% over the last 15 years despite intervention efforts, while other causes of death like pediatric cancer have declined 20% 1

High-Risk Populations

Mood Disorders

• Patients with major depressive disorder (MDD) face 8.62 times higher risk of dying by suicide compared to the general population 1, 4
• Those with bipolar disorder (BD) have 8.66 times higher risk of suicide death 1
• Women with MDD face 9.40 times higher odds of death by suicide 4
• The lifetime prevalence of suicide attempts is 5.6% in MDD and 29.2% in bipolar disorder 1
• 2-8% of individuals with MDD and 4-8% with bipolar disorder ultimately die by suicide 1

Critical Risk Periods

• The first year following hospital discharge represents the period of greatest suicide risk in major depressive disorders 1, 4
• Clinical guidelines should consider longer periods of monitoring following discharge from psychiatric hospitalization 1
• The risk for further attempts is greatest in the period from immediate post-discharge up to 12 months after the last attempt 5

Demographic Patterns

• Suicide is exceedingly rare before puberty but becomes increasingly frequent through adolescence, with approximately 2,000 U.S. adolescents dying by suicide annually 1
• Suicide is much more common in males than females, with ratios growing from 3:1 in prepubertal cases to approximately 5.5:1 in 15-24 year-olds 1
• More than 90% of adolescents who die by suicide had an associated psychiatric disorder at the time of death, with over half suffering from psychiatric illness for at least 2 years 1

Risk Factors for Suicide

Psychiatric and Clinical Factors

• Mood disorders (major depression, bipolar disorder) represent the strongest psychiatric risk factors 1
• Substance use disorders are strongly linked to suicidality, particularly in bipolar disorder 1
• Comorbid anxiety disorders are more prevalent and strongly linked to suicidality in MDD 1
• Psychotic symptoms, treatment resistance, and earlier age of illness onset increase risk 1
• Previous suicide attempts make further attempts more likely and predict ultimate death by suicide 1

Psychosocial and Environmental Factors

• Family history of suicidal behavior, bipolar illness, or substance abuse increases risk 1
• Physical or sexual abuse history is associated with high suicide rates, even when controlling for other factors 1
• Family discord and interpersonal relationship problems require assessment 1
• Availability of firearms or lethal medications must be ascertained, with removal or secure storage recommended 1
• Social isolation (runaway, homeless, or isolated living situations) increases risk 1

Behavioral Indicators

• Impulsivity shows a large pooled effect size (OR=5.54) for suicide attempts when assessed within a month of the attempt 1
• Giving away possessions, writing about death, or expressing hopelessness are warning signs 2
• Unusual attempt methods (other than ingestion or superficial cutting) carry worse prognosis 1
• Steps taken to avoid discovery during attempts signify higher intent and greater seriousness 1

Clinical Assessment Priorities

Essential Diagnostic Questions

When evaluating for suicidal ideation, clinicians should ask 1:

• "Did you ever feel so upset that you wished you were not alive or wanted to die?"
• "Did you ever do something that you knew was so dangerous that you could get hurt or killed by doing it?"
• "Did you ever hurt yourself or try to hurt yourself?"
• "Did you ever try to kill yourself?"
• "Did you ever think about or try to commit suicide?"

Evaluating Suicide Intent

• Assess the balance between wish to die and wish to live 1
• Evaluate severity of behavior, efforts to conceal, and formulation of specific plans 1
• Note that children and adolescents systematically overestimate lethality of methods, so significant intent may not result in lethal acts 1
• Assess motivating feelings: attention-seeking, interpersonal change, reunion with deceased, escape from intolerable situations, or revenge 1
• If motivations remain unsatisfied at evaluation, serious suicidal intent may still be present 1

Assessment of Attempt Characteristics

• Document method used (unusual methods carry worse prognosis) 1
• Evaluate potential medical lethality (though not always reliable as predictor) 1
• Assess degree of planning involved and steps taken to minimize discovery 1
• Repeated attempts, unusual methods, and medically serious attempts predict further suicide-attempt behavior and ultimate death 1

Common Clinical Pitfalls

• Never dismiss passive suicidal statements as unimportant or manipulative, as they may represent the only way a patient can ask for help 2
• Avoid premature discontinuation or switching of treatments before completing adequate 6-8 week trials 4
• Do not overlook that children may not appreciate the irreversibility of death, but this should not influence judgment of seriousness 1
• Recognize that stress events often precede suicide but may result from underlying mental disorder itself rather than being independent triggers 1
• Understand that inadequate treatment duration is a modifiable risk factor for persistent suicidality 4