High-risk populations In addition to the prior risk factors, there are certain populations who are known to be at increased risk for death by suicide, including: sexual and gender minority populations, older adults (65 and older), veterans, and individuals in jail or recently released. Sexual and gender minority populations Individuals who identify as sexual minorities (e.g., individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual or those questioning their orientation; LGBTQIA) face a number of unique challenges and stressors, and these stressors have often translated into elevated rates of suicidal behavior for both adults (Chang, Fehling, & Selby, 2020) and adolescents (Chang, Kellerman, Feinstein, Selby, & Goldbach, 2020). Youth and young adult suicide rates can reach as high as 20% among LGBTQIA groups and as high as 41% in transgender groups (Turban, Beckwith, Reisner, et al., 2019), making assessment and intervention for suicide concerns essential for these high-risk individuals. Senior populations Suicide is a significant problem among older adults. Suicide rates are particularly high among older men; according to the Suicide Prevention Resource Center (SPRC), men 65 and older have the highest rate of any group in the country (SPRC, 2018b; Sheava, Hitching, & Dunn, 2019). Suicide attempts by older adults are much more likely to result in death than attempts by younger persons. Reasons for this may be that: older adults plan more carefully and use more deadly methods; older adults are less likely to be discovered and rescued; or the physical
frailty of older adults means they are less likely to recover from an attempt. Risk factors for this population include depression and other mental health problems; substance use problems (including prescription medications); physical illness, disability, and pain; and social isolation. Protective factors include care for mental and physical health problems, social connectedness, and skills in coping with and adapting to change. Military populations Veterans of the wars in Iraq and Afghanistan have a 41 to 61% higher risk of suicide than the general U.S. population (Wood et al., 2020). While risk increases for many reasons, post-traumatic stress disorder (PTSD) has emerged as one of the strongest predictors, but not every veteran develops PTSD or becomes suicidal. Suicide is influenced by multiple factors, including biological factors, such as sex; socioeconomic factors, such as employment status; and other factors, such as access to firearms. These factors can confer increased risk of suicidal behaviors and suicide. The veteran population in general tends to be more affected by these factors or has more access to these risk factors (i.e., firearms), thereby increasing their risk. Incarcerated populations Rates of suicide in jails are greater than in the overall population (46 vs. 13 per 100,000), but research findings suggest the suicide rate is even higher in the year following release (Noonan, Rohloff, & Ginder, 2015). Legal problems and incarceration can also affect a number of other psychosocial risk factors, which makes suicide risk assessment for patients with these concerns paramount (Gould, McGeorge, & Slade, 2018).
THEORIES OF SUICIDAL BEHAVIOR
Theories about why people die by suicide have been considered for centuries, with historical conceptualizations of suicide often being unfairly harsh, judgmental, or derogatory toward the afflicted individual. Today, the act of attempting or dying by suicide itself can be viewed as a medical problem and one of the leading preventable causes of death. As such, people exhibiting suicidal concerns should be treated with empathy, compassion, and respect. Nonetheless, many researchers, clinicians, and families still desire to understand what factors may lead an individual to engage in, and in many tragic cases, die from suicidal behavior. Theories of suicide are often a function of the lens through which the theory writer views behavior more broadly. For sociologists, the function of suicide may point to broader dysfunction in Durkheim’s Sociological Theory of Suicide French sociologist Emile Durkheim was one of the first to publish a historic account of suicide in 1897, and although multiple models have been advanced since then, Durkheim’s approach is still used to understand aspects of suicide today. Unique in his time, Durkheim reported on occurrences of suicide across groups of individuals. Some of his findings remain true to this day (e.g., suicide rates are higher among men than women, and suicide rates are higher among soldiers than civilians). Perhaps his greatest contribution to the field was his definition of four types of suicides (listed below), derived from the imbalance between social integration and moral regulation (Durkheim, 2005): ● Egoistic suicide : Refers to a suicide resulting from a sense of detachment from society, a lack of belongingness or integration with a community. Apathy and meaninglessness may result. Joiner’s Interpersonal Theory of Suicide Perhaps the most empirically examined and comprehensive model to date is Dr. Thomas Joiner’s Interpersonal Theory of Suicide (IPTS; Joiner, 2005; Van Orden et al., 2010; Ma, Batterham, Calear, & Han, 2016). To date, literally hundreds of studies have been published testing and exploring the theory (Chu et al., 2017), providing an evidence base that rivals the
society. For biological and medically-oriented approaches, suicide may be viewed as either a function of genetic risk or neurophysiological dysfunction (Miller & Prinstein, 2019). For psychologists, suicidal behavior may be viewed as a behavioral reaction to difficult emotional and interpersonal stressors. In any regard, suicidal behavior remains one of the more debated topics at the crossroads of public health, philosophy, and bioethics (Malhi, 2019). Common to all theories of suicide, however, is the premise that the person experiencing the suicidal crisis desires to die, and hopefully, in better understanding what causes this desire, healthcare providers can improve suicide prevention and recovery efforts. This next section briefly reviews some key historical and modern theories of suicide. ● Altruistic suicide : Occurs when an individual is overwhelmed by society’s goals and beliefs and finds the achievement of these goals to be more important than his or her own individual life, such as suicide bombers and other soldiers in war. Thus, in an altruistic society, individuals would have no need for suicide, except in cases where it is expected that the individual kill themself on behalf of society. ● Anomic suicide : Results from moral deregulation and lack of social restraint. The individual does not appear to understand how he fits into society. He is unaware of the limits to desire and is constantly left feeling disappointed. ● Fatalistic suicide : Is the opposite of anomic suicide and occurs when individuals feel societally oppressed, as if their futures are hopelessly directed for them. In these cases, the individual believes it is better to die than to continue to live within that society. best models across all of psychological science. Based on ample empirical support, Joiner’s theory postulates that for an individual to die by suicide, the individual must first develop the desire to die, and second, the individual must have developed the capacity to enact lethal self harm. The desire to die
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