The term suicide refers to the death of a person that is the result of behaviour undertaken by that person in the knowledge or expectation of that result. Some forms of suicide are direct, such as hanging or shooting oneself. Other forms are indirect, such as going on hunger strike or refusing to take life-preserving medication. Many of the behaviours to which the words suicide or suicidal are attached, however, appear not to be motivated by the wish to die. Often they are not even intended to harm oneself, but only to express or communicate feelings such as despair, hopelessness and anger. Contemporary scientific literature, therefore, acknowledges, apart from suicide, two other categories of suicidal behaviour. First, suicidal communication or ideation refer to cognitions that can vary from fleeting thoughts that life is not worth living via well thought-out plans to kill oneself, to an intense delusional preoccupation with self-destruction. Second, the terms suicide attempt or parasuicide cover behaviours that can vary from what is sometimes labelled as suicidal gestures or manipulative attempts to serious but unsuccessful attempts to kill oneself. Research has shown that considerable overlap exists between the populations of persons involved in the three classes of suicidal behaviour. There is also some evidence of developmental pathways that sequentially link suicidal ideation to parasuicide to suicide. Yet little is known of the causes and patterns of recruitment from suicidal ideation to parasuicide, and from parasuicide to suicide, and on the factors that precipitate or protect against these transformations.
The use of mortality statistics for the scientific study of suicide, initiated by Emile Durkheim in his famous book Le Suicide (1951 [1897]) has been subject to intense debate and criticism as to their validity ever since. There seems to be a general consensus that although suicide is generally underreported, national statistics can be used for analysis of trends between countries, within them, and over time.
Generally speaking, suicide appears to be a relatively rare event. In most countries suicide ranks as the ninth or tenth cause of death for all age groups taken together, accounting for slightly more than (an averaged) 1 per cent of all deaths in females and 2 per rent in males. There are, however, substantial international differences. Some countries, such as Hungary, Japan and Denmark, traditionally have a suicide mortality three to five times as high as, for example, England, Wales and Ireland, suggesting that cultural characteristics play a significant role.
Since the time mortality statistics have been kept, which for some countries goes back to the first half of the nineteenth century, one of the most basic facts about suicide is that its risk increases as a function of age. Suicide is extremely rare in children under the age of 12 and becomes more common after puberty, with its incidence increasing in the following years. In almost all countries the highest suicide rates are among elderly people, for men usually in the age category 75 years and over, but for women often at a considerably younger age, between 55 and 74 years. In the latter half of the twentieth century, however, the median age of persons who died by suicide lowered significantly, due to the fact that in many countries in Europe, North America and Asia suicide mortality reached an all time high among people aged 15–34 years, and consequently ranked among the top three causes of death in that age group.
Research indicates that this development can partially be explained by a simultaneous dramatic increase in the incidence of attempted suicide or parasuicide, a behaviour that is particularly common among adolescents and young adults, with lifetime prevalence rates ranging from 5 to 20 per cent. The risk of suicide among those who have made a previous non-fatal suicide attempt is many times higher than among the general population. Both fatal and non-fatal suicidal behaviour—with a ratio of between twenty and forty non-fatal suicidal acts to every suicide—appear to be related to a number of largely overlapping but partially different social, psychological and physical risk factors. Among the social risk factors are weak or absent social ties or low social participation. The risks may arise from social isolation as a consequence of detention, divorce, being unemployed, being a member of an ethnic minority or migrant group, or belonging to an underprivileged group. Among the psychological factors are the presence of a psychiatric illness, particularly depression, psychoactive substance abuse and personality disorders. Research indicates that these three disorders have become more common over the course of the twentieth century and that they appear earlier in the life cycle, possibly as a consequence of the lowering age of puberty. Among the physical risk factors are chronic illness and physical handicaps. In addition, it has been shown that short-term factors also play a role in the probability of suicide, such as the portrayal of suicides in the media and the occurrence of suicidal behaviour in one’s peer group, perhaps a school community, where one suicidal act might spark off an epidemic of such acts. Given the fact that there are many pathways to suicide or parasuicide and that these are multifactorial behaviours, their prevention must also be multifactorial. Most prevention and intervention efforts, however, have been unifactorial or focus on just one category of factors, particularly psychological factors. Consequently, there is still lack of empirical evidence concerning the impact of preventive programmes and projects on suicide mortality and on the incidence of parasuicide at the population level and even at the clinical level.
René F.W.Diekstra
University of Leiden
Reference
Durkheim, E. (1951 [1897]) Suicide: A Study in Sociology, New York. (Original edn, Le Suicide, Paris.)
Further reading
Blumenthal, S.J. and Kupfer, D.J. (eds) (1990) Suicide over the Lifecycle: Risk factors, Assessment and Treatment of Suicidal Patients, Washington, DC.
Diekstra, R.F.W. (1994) The Anatomy of Suicide: A Treatise on Historical, Social, Psychological and Biological Aspects of Suicidal Behaviours and their Preventability, Dordrecht, The Netherlands.
Douglas, J.D. (1967) The Social Meanings of Suicide, Princeton, NJ.
