consideration of methods, access to methods, time, day, and place a suicidal behavior may occur, as well as other considerations relevant to facilitating a suicidal behavior. A further behavioral extension of suicide plans may involve preparations for suicidal behavior, including obtaining the preferred methods to facilitate a suicidal behavior (e.g., acquiring a gun) and making end-of-life preparations. (Glenn et al., 2020; Klonsky et al., 2016) Just because an individual has engaged in self-injurious behavior, it should not be assumed that his or her behavior was intended as a suicide attempt. There are a number of forms of behavior that may appear to be suicidal but are actually considered non-suicidal. Common terms relevant to suicidal behavior are as follows: ● Non-suicidal self-injury : This is a self-inflicted, potentially injurious behavior for which there is evidence that the person did not intend to kill him or herself (i.e., no intent to die). An example would be a 13-year-old girl who is noted to have multiple superficial cuts and burns on her forearm, which she said she did when she was feeling especially tense or “empty.” She denied that she was attempting suicide when she cut or burned herself. Non-suicidal self-injury can be further distinguished as clearly having no intent to die or having unknown intent to die (i.e., some level of ambiguity), although these distinctions are generally more relevant to research than clinical practice. From a clinical perspective, ambiguity around intent to die prior to self-injurious behavior is best considered a suicide attempt. ● Suicide threat or gesture : In many instances an individual will act in a way that is meant to lead others to believe they intend to engage in a suicidal act, but they really have no intention of carrying out the act. Such a behavior is often referred to as a “suicide threat” or “suicide gesture” (Frey et al., 2020). It is generally thought that such threats or gestures have the function of communicating inner distress to family or friends or as a “call for help” to others. If a clinician suspects the behavior is simply a threat or gesture, any such disclosure should be taken at face value and treated with the same level of care as other suicide risk scenarios. ● Suicide attempt : This is a self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence of intent to die. Suicide attempts may result in no injuries or nonfatal injuries. An example is a 15-year-old girl who, when confronted about a condom found in her bedroom by her mother, ingests a handful of acetaminophen; her mother forces her to vomit up the pills and brings her to National Violent Death Reporting System (NVDRS) The Centers for Disease Control and Prevention (CDC)’s NVDRS is a surveillance system that pulls together data on violent deaths in 40 states, the District of Columbia and Puerto Rico. CDC authors Fowler et al. (2018) summarized the data compiled in the most recent NVDRS report by following the standard format of previous reports. This report includes data from 18 states that collected statewide data and reported it to CDC by August 2016. Reporting states included Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin. NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) into a single incident (Fowler et al., 2018). The report includes information about homicides, such as homicides perpetrated by an intimate partner, child abuse and neglect or child abuse homicides, suicides, and deaths where individuals are killed by law enforcement in the line of duty (legal intervention deaths). The system also collects data on unintentional firearm injury deaths and deaths of undetermined intent. The NVDRS may include data on mental health problems; recent problems with a job, finances or relationships; physical
the therapist’s office. The girl states that she would rather be dead than live with her mother. It should be noted that suicide attempts vary greatly in their severity, and it is important for clinicians to have some understanding of the lethality of the behavior and methods either planned or utilized (Rojas et al., 2019). For example, a survived suicide attempt that involved jumping from a high place would be considered to have higher lethality than ingestion of a nonlethal medication with suicidal intent, although both should be taken very seriously. ● Interrupted suicide attempt : A youth is interrupted by an external circumstance or source prior to enacting a potentially injurious behavior. Without the external circumstance or source present, an actual suicide attempt would have occurred. An example is a 17-year-old adolescent who plans to end his life with a firearm. While holding the loaded gun to his head, with intent to pull the trigger, he hears his father come home from work early and abandons the plan at that time. ● Aborted suicide attempt : A person begins to take steps toward making a suicide attempt but stops himself or herself before actually having engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual stops himself or herself, instead of being stopped by something or someone else. An example would be a teenager who ties a rope from a tree limb and places the noose around his neck. Prior to stepping off a chair, he changes his mind. ● Suicide death : This is a self-inflicted behavior with a fatal outcome for which there is evidence of intent to die. At times this may be difficult for medical professionals to determine, leading to further confusion and pain for communities and families. Contrary to societal belief, only about one third of suicide decedents (those who have died by suicide) leave suicide notes (Rockett et al., 2018), just one such issue making suicide death a difficult determination in some cases. In contrast, death after instrumental suicide-related behavior as defined in Table 1 (e.g., a knife wound self-inflicted for the purpose of mood regulation rather than death), would be classified as accidental rather than suicide because the intent-to-die is missing. Similar examples can arise, such as accidental substance overdose. Therefore, careful consideration of potential warning signs and behaviors leading up to the eventual death should be determined as accurately as possible. (Glenn et al., 2020; Klonsky et al., 2016)
DEMOGRAPHIC FACTORS AND CIRCUMSTANCES SURROUNDING SUICIDE
health problems; and information about circumstances of death. Such data is far more comprehensive than what is available elsewhere. The CDC continues to improve the NVDRS system by promoting greater functionality and improved access to data. In 2013, NVDRS moved to a web-based system which made the data easily accessible. These data inform the development, implementation, and evaluation of violence- prevention strategies, which can ultimately save lives. The NVDRS collects and organizes data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, child fatality review team data, supplementary homicide reports, hospital data, and crime laboratory data. Once the data are collected on the manner of death – also known as the intent – for each person, a group of trained people called abstractors review information from all source documents. Typically, the manner of death assigned is most consistent with that reported in all the source documents. If a discrepancy occurs among the source documents, the abstractor must assign a manner of death based on the preponderance of evidence in the source documents.
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