Elsevier

The Lancet

Volume 373, Issue 9672, 18–24 April 2009, Pages 1372-1381
The Lancet

Seminar
Suicide

https://doi.org/10.1016/S0140-6736(09)60372-XGet rights and content

Summary

Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention. Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many more men than women die by suicide. Although suicide rates in elderly people have fallen in many countries, those in young people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people who die by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personality disorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associated with physical characteristics and disorders and smoking. Family history of suicidal behaviour is important, as are upbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches to suicide prevention include those targeting high-risk groups and population strategies. There are, however, many challenges to large-scale prevention, especially in developing countries.

Section snippets

Background and epidemiology

The estimated global burden of suicide is a million deaths per year,1 and an international policy statement by WHO in response to the large burden2 has prompted many countries to initiate suicide prevention policies. Estimated annual mortality is 14·5 deaths per 100 000 people, which equates to one death every 40 s.1 Self-inflicted death accounts for 1·5% of all deaths and is the tenth leading cause of death worldwide.3 Suicide rates vary according to region, sex, age, time, ethnic origin, and,

Methods of suicide

When a person is contemplating suicide, access to specific methods might be the factor that leads to translation of suicidal thoughts into action. The danger of available methods might determine whether the outcome is fatal or not. In general, men tend to choose more violent means (eg, hanging or shooting) and women less violent methods (eg, self-poisoning).28

Availability of specific means for suicide affects national patterns in the methods used. In the USA, firearms are used in most suicides,

Contributory factors

Numerous factors contribute to suicide, which is never the consequence of one single cause or stressor. These factors can be categorised as state-dependent or trait-dependent, or as distal or proximal factors (panel). The relation between risk factors can be described in explanatory models of suicide, such as the stress–diathesis model (figure 2).

Acute psychosocial crises and psychiatric disorders are commonly the proximal stressors leading to suicidal behaviour, while pessimism or hopelessness

Pathophysiology

Early studies suggested involvement of neurobiological dysfunction in attempted and completed suicide.84, 85 Several biological systems might be involved in suicidal behaviour. Post-mortem studies have shown changes in central neurotransmission functions in association with suicide, particularly with regard to the serotonin and noradrenalin systems, and in postsynaptic signal transduction.31 Furthermore, dysfunction of the hypothalamic-pituitary-adrenal axis might predict suicide in patients

Suicide in young and elderly people

Suicide rates rise throughout the teenage years, especially in males. Many factors associated with suicide in adults are also present in younger people. Family transmission of suicide risk is important, especially when suicide occurs on the maternal side.102 Most young people who die by suicide have psychiatric disorders, with affective disorders, substance-related disorders, and disruptive behaviour disorders being most frequent, and, as in adults, comorbidity of disorders being common.11

Prevention

Several countries have established national suicide prevention strategies. Some strategies include specific targets for reduction in suicides. Although the value of these steps has not been proven, they do seem to help focus attention on the problem of suicide. Prevention of suicide can best involve strategies that focus on individuals in known high-risk groups and strategies aimed at general reduction in population risk of suicide.

Future prospects

Because suicide is a complex problem, no single approach is likely to contribute to a significant substantial decline in suicide rates. Clinical studies of suicide prevention are hindered by methodological and ethical problems, especially since many people at risk do not have contact with clinical care. Knowledge about who is at risk of suicide has nevertheless increased substantially, and a number of interventions show promising effects. Future research must focus on the development and

Search strategy and selection criteria

We searched the Cochrane Library, Psycinfo, Medline (January, 2003, to July, 2008), and Embase (January, 2003, to July, 2008). We used the search term “suicide” in combination with the terms “aetiology”, “epidemiology”, “prevention”, and “psychological autopsy”. Index terms were used in preference to free text search terms whenever possible; no language restrictions were applied to the search. We commonly referenced older publications. We also searched the reference lists of articles

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