Depression and Suicide _ ______________________________________________________________________
Armed Forces and Combat Veterans The historically low U.S. Army suicide rate began climbing in 2004 and has exceeded the civilian rate since 2009 [406]. In response, the Army has invested significant resources in suicide prevention efforts [369]. In one study, veterans during the Iraq and Afghanistan war era (317,581 deployed to war zones, 964,493 nondeployed) were followed from the time of discharge to 2010. With 1,868 suicide deaths, both veteran cohorts had 41% to 61% higher risk of suicide relative to the general population, but suicide risk was not associated with a history of war zone deployment and multiple deployments were not associated with greater suicide risk among deployed veterans [407]. Among U.S. Armed Forces veterans, the estimated lifetime prevalence of suicide ideation was 12.7% for men and 20.1% for women, and the prevalence of lifetime suicide attempts was 2.5% and 5.1%, respectively [408]. Among active Armed Forces suicide decedents, roughly 50% accessed health care in the month before their death and more than 25% accessed care in the week before their death. Male, never married, and non-Hispanic Black individuals were less likely to access care prior to death. The number of mental health encounters was the only predictor of suicide risk documentation among dece- dents at 4 weeks and 52 weeks prior to death [409]. Incarcerated Individuals Jails and juvenile justice facilities have suicide rates higher than the national averages, and suicide is often the single greatest cause of death in correctional settings. Inmates at highest risk are young men, persons with mental illness, those who are socially disenfranchised and socially isolated, individuals with substance use disorders, those who have previously attempted suicide, gender/sexual minorities, and juveniles placed in adult correctional facilities [410]. Factors that increase suicidal risk include the psychologic effects of arrest and incarceration; intense stressors of prison life, including physical and sexual predation and assault from other inmates; and absence of formal policies for managing suicidal patients, staff training, or access to mental health care [411]. At greatest suicide risk are young (i.e., 20 to 25 years of age), unmarried, male, first-time offenders arrested for minor, usu- ally substance-related, offences. Typically intoxicated at the time of arrest, these individuals tend to attempt suicide at an early stage of confinement, often within the first few hours, from the impact of sudden isolation, shock of imprisonment, lack of information, and fear about the future [411]. This sug- gests an important role for medical assessment of substance abuse and suicide proneness and inmate suicide prevention programs [31; 412]. SUICIDE AND PUBLIC PERCEPTION Stigma often surrounds persons with suicidal behavior and suicide itself. Stigma and negative attitudes interact with postmortem determinations and media reporting, and stigma can be antecedent or consequence.
Misclassification of Suicide Deaths Suicide determinations are not easy, even after the event, and coroners vary considerably in the verdicts they give to individuals who probably died by suicide [360]. Stigma can influence under-reporting, with families or physicians hiding evidence. Death determination may be judged by variable local standards, and ambiguous cases involving suicide may be clas- sified “accidental” or “undetermined” deaths [413]. Context can influence how ambiguous cases of suicides are classed. Institutions such as prisons, hospitals, and religious orders may consider a suicide less embarrassing than homicide. Despite substantial doubt, declaring death a suicide can be motivated by the required investigation of homicide and apprehension of a murderer and negligence lawsuits with accidental death [413]. Suicide Reporting in the Media Especially among youth, suicide rates may temporarily spike with intense coverage of a suicide in media reports or movies and television [414; 415; 416]. Imitation is the core factor, which is most powerfully illustrated by highly publicized sui- cides of celebrity figures [417]. Media coverage of suicide can misinform by attributing suicide to a single event (e.g., job, relationship loss) without acknowl- edging a broader context of ongoing depression, substance abuse, or lack of access to treatment for these conditions. The time from media exposure to action is brief, typically a few min- utes. This gives media outlets little time for mitigating actions after population exposure to a harmful story, stressing the need to evaluate news items before publication [418]. Responsible suicide coverage can educate audiences about the causes, warn- ing signs, treatment, and prevention of suicide [414]. Shortcomings are also found in media reporting of cyberbul- lying-related suicide. Few media outlets follow guidelines to protect against suicidal contagion. Few reports reference suicide or bullying prevention resources, and most suggest suicide has a single cause. A subset of reports uses individual suicides as cautionary tales to elevate cyberbullying awareness [419]. Stigma and Suicide The stigma of mental illness and substance abuse, both closely linked to suicide, prevents many persons from seeking help over fears of prejudice and discrimination [420]. People with a substance use disorder face added stigma over prevalent beliefs that addiction is a moral failing of persons capable of control- ling these behaviors [31; 421]. The stigma of suicide inhibits many from seeking treatment. Family members of suicide attempters often hide the behavior from friends and relatives, believing it reflects badly on their own relationship with the attempter or that suicidal behavior itself is shameful or sinful. These same feelings are held by many who attempt suicide [31]. Systemic, persistent stigma contributes to inadequate fund- ing for preventive services and insurance reimbursement for treatments, perpetuates under-treatment of substance use and mental health disorders, limits access to tailored services, and maintains unnecessarily high suicide rates [31].
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