_______________________________________________________________________ Depression and Suicide
Psychotic Disorders Suicide is the greatest cause of premature death in individuals with schizophrenia, with the highest risk in young, unemployed men. Other risk factors include recurrent relapses, fears of deterioration in persons with high intellectual ability, positive symptoms of suspiciousness and delusions, and depressive symptoms [469; 470]. The suicide risk is greatest during early- stage illness, early relapse, and early recovery; risk declines with prolonging illness duration [469; 470]. Persecutory panic (a state of terror often associated with com- mand hallucinations and delusions) has been observed in many psychotic disorders. These patients are described as terrified of a threatening and imminent annihilation or dismemberment, imagine that suicide is survivable, and desperately attempt to escape from the danger of imaginary menace by suicide [471]. Therefore, the presence of persecutory panic is considered a risk factor for suicide and should be addressed immediately. SUICIDE MEANS AND METHODS In 2021, firearms were the most common means used in sui- cide deaths (54.6%), followed by suffocation/hanging (25.8%) and poisoning (11.6%) [374]. In the United States, the rate of suicide by firearm is eight times greater than the rates in other economically developed countries [472]. Household gun ownership strongly correlates with firearm suicide, and storage practices impact suicide rates, which are higher in geographic areas with greater household prevalence of loaded guns. The presence of loaded, unlocked firearms within reach is a risk factor for fatal outcomes from suicidal behavior [473]. Suicide by cop is defined as an event in which a suicidal sub- ject intends to die and, aware of the finality, directs behavior against police that is sufficiently life-threatening to compel a deadly force response [474]. Although usually intending to die, the subject is ambivalent about taking his or her own life. Suicide by cop victimizes the suicidal subject, and the police who are often placed in near-impossible situations. In 707 officers-involved shootings between 1998 and 2006, 36% were attempted suicides and 51% of subjects were killed [475]. Sui- cide by cop is characterized by one of the following [475; 476]: • Direct confrontation: The attack on police is premedi- tated with intent to die from a deadly force response. • Disturbed intervention: Emotionally disturbed behav- ior that draws police intervention, without evidence of wanting police involvement. • Criminal intervention: A criminal, believing there is no way out, prefers death to arrest and incarceration. SUICIDE MOTIVATION Most suicides and attempts are driven by the motivation to escape unbearable pain. Other motives include revenge, shame, humiliation, delusional guilt, command hallucinations, gain- ing attention or reaction from others, loneliness, self-hatred, or a sense of being a burden, not belonging, feeling trapped,
or having no purpose [364]. Individuals have a unique balance between their personal motivations for suicide and their rea- sons for living. Reasons for living can include religious beliefs, a sense of responsibility to children or others, plans for the future, or a sense of purpose in life. A strong social support network is also protective against suicide [364]. Importantly, “reasons for living” become irrelevant when suicidal intent is moderate or greater. SUICIDE PREVENTION Large-scale suicide prevention efforts in the United States began in 1958 with the first suicide prevention center in Los Angeles, followed by nation-wide crisis intervention centers [31]. The risk factor approach to suicide prevention was introduced in 1966; organizations and national strategies were established to further these efforts. Survivors of suicide started the Suicide Prevention Advocacy Network USA (SPAN USA) in 1996 to campaign for a national suicide prevention strategy, prompting the creation of the National Strategy for Suicide Prevention (NSSP) in 2001 [477]. Recognizing that decades of suicide prevention research has not decreased suicides, the NSSP partnered with the National Action Alliance for Suicide Prevention in 2012 to develop national priorities for suicide prevention science. Suicide research was prioritized to delineate promising research path- ways toward a set of 12 “aspirational goals” considered areas of focus necessary for preventing substantial numbers of suicide deaths and attempts [478]. The revised NSSP was launched in 2013, elaborating on methods for systemic change in healthcare delivery, public and media conversations around suicide and suicide preven- tion, the timeliness and utility of suicidality surveillance data, prevention, and clinical care [479]. “Zero suicides” is an aspira- tional goal based on the belief that suicide of patients receiving care in any setting is preventable, and one area of commitment is to program approaches that prevent suicidal patients from failing to receive adequate care. In 2014, the NSSP launched the Framework for Successful Messaging, which outlines how individuals working in suicide prevention and behavioral healthcare fields can create hopeful messaging to help save lives. In 2015, the NSSP and partners offered a three-panel series focused on suicide in middle-aged men, teenagers and technology, and military personnel/veterans [479]. Universal suicide risk screening in primary, specialist, and emergency care settings was recommended [480]. Suicide Prevention in the Elderly The elevated suicide risk in the elderly is influenced by the prevalence of isolation, chronic pain, chronic illness, and/or depression (often undiagnosed). Many at-risk elderly adults suffer from intense loneliness, bereavement, or loss of social roles; fears of disability, dependency, or burdensomeness to others are common [481]. Enhancing connectedness to others is a suicide protective factor and formal strategy to prevent suicide in the elderly [480].
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