If you are in crisis, call 211.

Understanding Suicide

Suicide. We would rather not talk about it. We hope it will never happen to anyone we know. But suicide is a reality, and it is more common than you might think. The possibility that suicide could claim the life of someone you love cannot be ignored. By paying attention to warning signs and talking about the ‘unthinkable,’ you may be able to prevent a death.

Who is at risk?

People likely to die by suicide include those who:

• are having a serious physical or mental illness,
• are abusing alcohol or drugs,
• are experiencing a major loss, such as the death of a loved one, unemployment or divorce,
• are experiencing major changes in their life, such as teenagers and seniors,
• have made previous suicide threats.

Why do people choose suicide?

There are many circumstances which can contribute to someone’s decision to end his/her life, but a person’s feelings about those circumstances are more important than the circumstances themselves. All people who consider suicide feel that life is unbearable. They have an extreme sense of hopelessness, helplessness, and desperation. With some types of mental illness, people may hear voices or have delusions which prompt them to kill themselves.

People who talk about dying by suicide or make an attempt do not necessarily want to die. Often, they are reaching out for help. Sometimes, a suicide attempt becomes the turning point in a person’s life if there is enough support to help him/her make necessary changes.

If someone you know is feeling desperate enough to attempt suicide, you may be able to help him/her find a better way to cope. If you yourself are so distressed that you cannot think of any way out except by ‘ending it all,’ remember, help for your problems is available.

What are the warning signs?

Suicide is rarely a spur of the moment decision. In the days and hours before people attempt suicide, there are usually clues and warning signs.

The strongest and most concerning signs are often verbal – “I can’t go on,” “Nothing matters any more” or even “I’m thinking of ending it all.” Such remarks should always be taken seriously.

And remember that most people who are considering suicide have lost hope and are trying to find a way out of the inner pain and suffering they are experiencing.

Some warning signs that a person may be suicidal include:

• repeated expressions of hopelessness, helplessness, or desperation,
• withdrawal from friends and activities,
• feeling marginalized, rejected,
• behaviour that is out of character, such as recklessness in someone who is normally careful,
• loss of interest in usual activities,
• decrease in appetite or increased use of alcohol and other drugs,
• recent death of a friend or family member,
• job loss, failing academic performance,
• talking about death or wanting to die, e.g. “no one cares if I live or die”
• mood swings, emotional outbursts, high level of irritability or aggression,
• a sudden and unexpected change to a cheerful attitude,
• giving away prized possessions to friends and family,
• making a will, taking out insurance, or other preparations for death, such as telling final wishes to someone close,
• making remarks related to death and dying, or an expressed intent to commit suicide.
• Previous suicidal behaviour

Remember, there is no ultimate list of warning signs. It may be right to be concerned about someone simply because their behaviour is out of character. Sudden shifts in a person’s attitude or actions can alert friends to potential problems.

Thinking about Suicide?

What can you do if you are feeling suicidal?

The beginning of the way out is to let someone else in. This is very hard to do because, if you feel so desperate that suicide seems to be the only solution, you are likely very frightened and ashamed. There is no reason to be ashamed of feeling suicidal and no reason to feel ashamed for seeking help. You are not alone; many people have felt suicidal when facing difficult times and have survived, usually returning to quite normal lives.

Take the risk of telling your feelings to someone you know and trust: a relative, friend, social service worker, or a member of the clergy for your religion. There are many ways to cope and get support. The sense of desperation and the wish to die will not go away at once, but it will pass. Regaining your will to live is more important than anything else at the moment.

Some things that you can do are:

• call a crisis telephone support line (like 211 or 416-929-5200).
• draw on the support of family and friends,
• talk to your family doctor; he/she can refer you to services in the community, including counselling and hospital services,
• set up frequent appointments with a mental health professional, and request telephone support between appointments, · get involved in self-help groups,
• talk every day to at least one person you trust about how you are feeling,
• think about seeking help from the emergency department of a local hospital,
• talk to someone who has ‘been there’ about what it was like and how he/she coped,
• avoid making major decisions which you may later regret.

Losing Someone to Suicide

The death of someone close to us is one of life’s most stressful events. When the death is from suicide, family and friends must cope with sadness at the loss plus all their feelings of confusion and sometimes even anger. It takes time to heal and each of us responds differently. We may need help to cope with the changes in our lives. But in the end, coping effectively with bereavement is vital to our mental health.

How common is suicide?

Approximately one out of four people knows someone who has died by suicide. The deceased leaves behind a network of family and close friends who must cope with the same inner turmoil that you are probably trying to understand and cope with now.

Am I to blame? Could I have helped?

No, you are not to blame. After a suicide, family members and friends often go over the pre-death circumstances and events, blaming themselves for things they think they should or should not have done. ‘If only I had persuaded him to get help!’ or ‘If only I hadn’t told her I wanted a separation…’ Even though suicide is an individual decision, it is a very natural and common reaction for survivors to feel guilt or responsibility. People who are left behind should seek out bereavement counselling or support groups to help relieve this feeling of responsibility.

What are the stages of grieving?

There are many different stages of grieving. The three stages outlined below are ones which most people will experience. However, people do not usually flow from the first stage through to the last in a logical order. Some people may jump back and forth between stages, and the length of time it takes to go through the different stages may vary.

Stage I – Numbness or Shock

Initially, people function almost mechanically. You may also feel anger, confusion or even relief depending on the circumstances. These feelings are normal. Many people at this stage will keep an emotional distance from others to protect themselves and to avoid discussing the death.

Stage II – Disorganization

It is normal to feel lonely, depressed and tearful at this point. You may have problems sleeping or eating. Some people may feel sorry for themselves and even hallucinate. You may agonize over things you think you could have done for the deceased. At this stage, you may need to reach out to someone and discuss your feelings.

Stage III – Re-organization

You will begin to feel more comfortable and may find that there are moments in your day when you do not think about your loss. Your feelings will not be as intense and you will be able to focus on daily tasks. At this point, most people need encouragement to re-enter life’s mainstream.

But remember, there is hope and help. You may never get over the death itself, but you will overcome the grief.

Is anger or relief a natural reaction?

While all kinds of loss are painful, the issues are different when dealing with a death by suicide. The length of time it takes to work through the stages of grief also varies depending on the circumstances.

Feelings of anger, confusion and relief are natural. Do not deny them. If the deceased person had been depressed and/or had previously attempted suicide, there is nothing wrong in feeling relieved that the burden is gone or that you are angry because you have another burden to carry.

If you do not work through these feelings, you will prevent yourself from moving forward in the bereavement process. Not moving forward is dangerous; it can cause mental and physical illness and can tear families and friendships apart. It can stop people from coming to terms with the suicide. You must face your feelings before you can work them out.

How does suicide affect the family?

It is important to realize that not all members of the family will grieve in the same way or go through the same stages at the same time. Every family member needs room and understanding to go through the bereavement process in his/her own way.

Be honest with children about the cause of death. Otherwise, they will go through the grieving process again when they learn the truth. Be careful not to ignore or forget the grief experienced by children. They need help dealing with it but should not be ‘protected’ from it.

How will my friends react?

Generally friends are well meaning. They want to give support and help but they may not know how. They may be afraid that they will overwhelm you or think that you want to be alone.

Guide them. Tell your friends you want and need to talk about your loss. By opening up, you will help yourself and help your friends help you. People who talk out their feelings are usually the people who recover most quickly from a loss by suicide.

If your friends seem uncomfortable talking about the death, or even being with you, it may be a reaction to your discomfort. If you are uncomfortable talking about the circumstances, don’t. Your friends will already know. Let others simply respond to the death of your loved one.

As a friend, what should I do?

Try to understand and be patient with a grieving friend. Do not ignore or overwhelm a person who has suffered a suicide in the family. NEVER BLAME ANYONE. Suicide is a decision made by one person, and judgements should not be made about the family.

Do not try to accelerate the process of bereavement. It can take a long time for a person to work through the grief, to deal with the confusion and to come to terms with his/her feelings.

Treat your friend as you would treat anyone who has lost a family member. Be available to listen or to help out with the chores.

Encourage your friend to consider outside help from a counselling agency or support group in the community. In a Suicide Bereavement Group or similar self-help group, your friend will be able to discuss his/her mixture of feelings with other people who have suffered a similar loss.

Acknowledge your friend’s feelings of guilt; it will help him/her to come to terms with the fact that he/she is not to blame.

Do you need more help?

If you are bereaved and feel you need more assistance than friends and family can provide, contact a community organization that can help you find additional support.

When someone is at risk of suicide

If you are concerned that someone may be suicidal, take action. You cannot prevent them from considering suicide, but you can help them to reconsider and seek other solutions. If possible, talk with the person directly. The single-most important thing you can do is listen attentively without judgement.

Don’t be afraid to mention the topic of suicide. Talking about it will not increase the likelihood that someone will act on suicidal feelings. There is almost no risk that raising the topic with someone who is not considering suicide will prompt him/her to do it.

Find a safe place to talk with the person, and allow as much time as necessary. Assure him/her of your concern and your respect for his/her privacy. Ask the person about recent events, and encourage him/her to express his/her feelings freely. Do not minimize the feelings involved.

Ask whether the person feels desperate enough to consider suicide. If the answer is yes, ask, ‘Do you have a plan? How and where do you intend to end your life?’

Admit your own concern and fear if the person tells you that he/she is thinking about suicide but do not react by saying, ‘You shouldn’t be having these thoughts; things can’t be that bad.’ Remember, you are being trusted with someone’s deepest feelings. Although it may upset you, talking about those feeling will bring the person relief.

Ask if there is anything you can do. Talk about resources that can be drawn on (family, friends, community agencies, crisis centres) to provide support, practical assistance, counselling or treatment.

Make a plan with the person for the next few hours or days. Make contacts with him/her or on his/her behalf. If possible, go with the person to get help.

Let the person know when you can be available, and then make sure you are available at those times. Also, make sure your limits are known, and try to arrange that there is always someone that he/she can call at any time of day.

Ask who else knows about the suicidal feelings. Are there other people who should know? Is the person willing to tell them? Unfortunately, not everyone will treat this issue sensitively. Confidentiality is important, but do not keep the situation secret if a life is clearly in danger.

Stay in touch to see how he/she is doing. Praise the person for having the courage to trust you and for continuing to live and struggle. And remember that no one can solve another person’s problems, but understanding and support can help.

What to do following a suicide attempt

A person may try to attempt suicide without warning or despite efforts to help. If you are involved in giving first aid, make every effort to be calm and reassuring, and get medical help immediately.

The time following an attempt is critical. The person should receive intensive care during this time. Maintain regular contact, and work with the person to organize support. It is vital that he/she does not feel cut off or shunned as a result of attempting suicide.

Be aware that, if someone is intent on dying, you may not be able to stop it from happening. You cannot and should not carry the responsibility for someone else’s choice.

Youth and Suicide

Youth are among the highest risk populations for suicide. In Canada, suicide accounts for 24 percent of all deaths among 15-24 year olds and 16 percent among 16-44 year olds. Suicide is the second leading cause of death for Canadians between the ages of 10 and 24.

Adolescence is a time of dramatic change. The journey from child to adult can be complex and challenging. Young people often feel tremendous pressure to succeed at school, at home and in social groups. At the same time, they may lack the life experience that lets them know that difficult situations will not last forever. Mental health problems commonly associated with adults, such as depression, also affect young people. Any one of these factors, or a combination, may become such a source of pain that they seek relief in suicide. Suicide is the second leading cause of death among young people after motor vehicle accidents. Yet people are often reluctant to discuss it. This is partly due to the stigma, guilt or shame that surrounds suicide. People are often uncomfortable discussing it. Unfortunately, this tradition of silence perpetuates harmful myths and attitudes. It can also prevent people from talking openly about the pain they feel or the help they need.

Suicide can appear to be an impulsive act. But it’s a complicated process, and a person may think about it for some time before taking action. It’s estimated that 8 out of 10 people who attempt suicide or die by suicide hinted about or made some mention of their plans. Often, those warning signs are directed at a friend.

Recognizing the warning signs is one thing; knowing what to do with that information is another. Suicide was a taboo subject for a very long time. Even talking about it is still difficult for most people. But being able to talk about suicide can help save a life. Learning about suicide is the first step in the communication process. Suicide is about escape. Someone who thinks seriously about suicide is experiencing pain that is so crushing, they feel that only death will stop it.

Some myths about youth suicide

Myth: Young people rarely think about suicide.
Reality: Teens and suicide are more closely linked than adults might expect. In a survey of 15,000 grade 7 to 12 students in British Columbia, 34% knew of someone who had attempted or died by suicide; 16% had seriously considered suicide; 14% had made a suicide plan; 7% had made an attempt and 2% had required medical attention due to an attempt.

Myth: Talking about suicide will give a young person the idea, or permission, to consider suicide as a solution to their problems.
Reality: Talking calmly about suicide, without showing fear or making judgments, can bring relief to someone who is feeling terribly isolated. A willingness to listen shows sincere concern; encouraging someone to speak about their suicidal feelings can reduce the risk of an attempt.

Myth: Suicide is sudden and unpredictable.
Reality: Suicide is most often a process, not an event. Eight out of ten people who die by suicide gave some, or even many, indications of their intentions.

Myth: Suicidal youth are only seeking attention or trying to manipulate others.
Reality: Efforts to manipulate or grab attention are always a cause for concern. It is difficult to determine if a youth is at risk of suicide All suicide threats must be taken seriously.

Myth: Suicidal people are determined to die.
Reality: Suicidal youth are in pain. They don’t necessarily want to die; they want their pain to end. If their ability to cope is stretched to the limit, or if problems occur together with a mental illness, it can seem that death is the only way to make the pain stop.

Myth: A suicidal person will always be at risk.
Reality: Most people feel suicidal at some time in their lives. The overwhelming desire to escape from pain can be relieved when the problem or pressure is relieved. Learning effective coping techniques to deal with stressful situations can help.

Suicide: Responsible Media Reporting Guidelines

Certain ways of presenting and portraying suicide in the media appear to precipitate suicidal behaviour in vulnerable people. This evidence has led many countries to develop media guidelines for reporting and portraying suicide.

• Avoid presenting simplistic explanations for suicide. Suicide usually results from a complex set of circumstances and is seldom the result of a single event such as the loss of a job or the end of a relationship.
• Do not engage in repetitive, prominent, or excessive reporting of suicide. This may promote and maintain a preoccupation with suicide among at-risk individuals. For example, suicide reports should be located on an inside page of a newspaper, never as a front-page headline.
• Be careful not to sensationalize coverage. Sensational news coverage of a suicide tends to heighten the general public’s preoccupation with suicide, particularly when a celebrity is involved. For example, sensational coverage can be minimized by avoiding the use of dramatic photographs.
• Avoid “how-to” descriptions of suicide. It is also thought that technical details about the method of suicide used in a particular incidence may provide a vulnerable person with the knowledge they need to imitate the actions of the victim.
• Do not position a suicide as a means to solve problems. Presenting suicide as a means of dealing with personal problems may suggest that suicide is an acceptable coping strategy.
• Avoid glorifying the incident or the victim. Prominent coverage of community expressions of grief (e.g., eulogies, memorials, flags at half-mast) may suggest that society is honouring the suicidal behaviour of the victim, rather than mourning the person’s death.
• Avoid overemphasizing the victim’s positive characteristics. It is important to note the victim’s problems in addition to the positive aspects of his or her life in order to decrease the attractiveness of the suicidal behaviour, especially for individuals who rarely receive positive reinforcement.
• Treat survivors with sensitivity and respect their privacy. Immediately following a death by suicide, grieving family members and friends are in shock, have difficulty understanding what happened, and may be at heightened risk of suicide themselves. Care and consideration should always be shown when interviewing close family and friends of the victim.
• Provide information that increases public awareness. Enhancing general public awareness about suicide risk factors, warning signs, and possible actions to assist a suicidal person can help friends and family members recognize suicidal risk in a vulnerable person.
• List available community resources. Information on available resources (help lines, crisis services, and clinical services) with up-to-date contact information should always be included in media stories dealing with suicide.
• Feature stories about people who adopted life-affirming options. Stories that present positive ways of coping and positive roles models can help prevent further suicide attempts.

Survivor Support Services

If you feel you need more support than family or friends can provide, contact your doctor or counseling agency in your area. Other resources can include spiritual communities, crisis lines and bereavement support groups.

• Toronto Distress Centre – Survivor Support Program    416-595-1716 - https://www.torontodistresscentre.com/suicide-loss/
• Ontario Association for Suicide Prevention - http://www.ospn.ca/

The Relationship between Suicide and Mental Illness

This section takes a look at some of the major types of mental disorders and describes how they may increase the risk of suicidal behaviour in persons with these disorders. Included in this discussion are the principal disorders — depression, bipolar disorder, and schizophrenia; in addition, the relationships between suicide and postpartum depression, eating disorders, self-mutilation, post-traumatic stress disorder, and alcohol/substance abuse are briefly considered.

Studies indicate that more than 90 percent of suicide victims have a diagnosable psychiatric illness. Suicide is the most common cause of death for people with schizophrenia. People with mood disorders are at a particularly high risk of suicide – both major depression and bipolar disorder account for 15 to 25 percent of all deaths by suicide in patients with severe mood disorders.

With each of these disorders there is great need to provide information to the general public about the symptoms of the disease, its epidemiology, risk factors, clinical best practice, and research needs. Mental health education and awareness efforts also need to provide information on the various options for mental health treatment and their efficacy in reducing risk of suicide, the debate surrounding the safety of selective serotonin reuptake inhibitors (SSRIs), and the need to balance the possible benefits and risks in the selection of any method of treatment for mental illnesses.

Suicide and Depression

Depression is a very common mental health problem worldwide. The World Health Organization estimates that 121 million people currently suffer from depression, with 5.8% of men and 9.5% of women experiencing a depressive episode in any given year.¹ It is estimated that depression will become the second most common cause of disability, after heart disease, by 2020.² Women are twice as likely to be diagnosed and treated for depression. However, it is believed that men suffer depression to a larger extent than the statistics show, since men are less likely to seek medical help and when they do, doctors are less likely to detect depressive symptoms.³In light of these high rates of depression, it is a cause for concern that mood disorders (of which depression is the major example) are the most common psychiatric condition associated with suicide.⁴ It is important to note, however, that depression encompasses a wide range of experiences and illness forms from mild to severe, transient to permanent, and the risk of suicide varies substantially with the type of depression. Amongst those diagnosed with depression, a study in Finland⁵ found that key indicators for suicide include: previous self-harm, severity of the illness, alcohol or drug abuse, serious or chronic physical illnesses, lack of a partner, anxiety and personality disorders.

Given the high prevalence of suicide in the community, and the high rates of depression amongst those who die by suicide, it is vital that those who are suffering from depression seek effective treatment that addresses both depression and suicidality. Since there is no evidence that antidepressant medications alone reduce suicide risk, practitioners’ ability to recognize and address suicidality can be a life-saving skill. Since males in the industrialized nations are at higher risk for suicide and are less likely than females to seek medical attention for depression, considering alternative settings to reach at-risk males may require innovative approaches by communities (e.g., providing hot-line numbers in pubs).

Distinguishing Between Depression and Normal States of Sadness and Grief

Experts report that from 20% to 60% of the deaths by suicide occur among people who have a mood disorder. Suicide among such people is more common among those with more severe and/or psychotic symptoms, with late onset, and with coexisting metal and addictive disorders. Death through suicide is also more common among those who have experienced stressful life events, who have a medical illness and who have a family history of suicide.

The sadness of a major depressive disorder differs both in degree and amount from the sadness that strikes anyone at times when life is especially hard. Normal states of grief or sadness generally have less pervasive effects and last for shorter periods of time than those that mark major depression. Furthermore, certain symptoms of severe depression only rarely occur in those experiencing times of normal sadness. These include anhedonia (the inability to experience pleasure), hopelessness, and loss of mood reactivity (the ability to feel a mood uplift in response to something positive). Suicidal thoughts and psychotic symptoms, when associated with depressive symptoms, usually means that a person truly does have a diagnosable depressive disorder.

Nevertheless, many symptoms commonly tied to major depressive disorders do also occur during times of severe stress. Among them: sleep disturbances, changes in appetite, trouble with concentration, brooding on sad thoughts or feelings, or substance use. When a person with these kinds of problems sees a healthcare provider, the challenge to that professional is to distinguish normal sadness from pathological states and then to provide treatment.

Suicide and Postpartum Depression

It is somewhat startling that in many countries suicide is now the leading external cause of death amongst new mothers. In most of these cases, women are suffering with postpartum depression. Between 8-15% of women suffer postpartum depression, and the condition is usually mild and manageable. Severe postpartum depression, however, is linked to an elevated suicide risk, with those who are admitted to hospital up to 70 times as likely to die by suicide.⁷ Risks are especially high in the first year after childbirth.

The huge stigma that women suffering from postpartum depression face must be tackled if suicide rates in this high-risk group are to be reduced. Recent developments including a number of high profile celebrities (including Brooke Shields, Natasha Hamilton and Elle Macpherson) talking about their experiences with postpartum depression are to be applauded, but more needs to be done. In particular it is important that high-risk women are identified during pregnancy and adequate preparations are made for their care. Furthermore, women presenting with postpartum depression must not slip through the cracks in primary health care clinics. One recent study found that only 29% of women presenting with high levels of depressive symptoms on the psychiatric symptom index were diagnosed with postpartum depression.⁸ Increasing this figure might require changes in the way medical professionals are trained to identify this condition. Once diagnosed, there are a host of effective pharmacological and psychotherapeutic treatment options whose efficacy has been well documented.

Suicide and Bipolar Disorder

Bipolar affective disorder is a common condition, and among mental illnesses ranks second only to unipolar depression as a cause of worldwide disability.¹¹ Bipolar depression affects men and women equally, and afflicts about 5 people in 1,000.¹² For those with bipolar depression, suicide risks are approximately 15 times that of the general population.¹³ Suicide often first occurs when work, study, family or emotional pressures are at their greatest. In women, suicidal risks can increase postpartum or during menopause.

Most persons with bipolar affective disorder have the potential, with optimal treatment, to return to normal functioning. With sub-optimal treatment, however, many will have a poor long term outcome with increased risk of suicide. Yet there is evidence that treatment is generally sub optimal. Longitudinal observational studies suggest that the very high lifetime prevalence of suicide attempts in people with bipolar affective disorder (50%¹⁴) could be reduced by maintenance drug treatment and adequate treatment of depression and comorbid alcohol and drug abuse.¹⁵ Adequate treatment goes beyond the simple provision of treatment regimes, and it is at these times that suicide risk is particularly high. People with bipolar disorders need encouragement to initiate and stick to treatment regimens and continued follow-up of their treatment. Despite its shortcomings, lithium has long been the mainstay of treatment for bipolar affective disorder. Several newer drugs have emerged over the past 10 years, but evidence of their suicidal protection effectiveness remains sparse.

Suicide and Schizophrenia

Approximately 24 million people worldwide suffer from schizophrenia, with equal rates (7 per 1000) reported amongst men and women.¹⁶ It is estimated that there is a 4 to 10 percent lifetime risk for suicide among persons with schizophrenia and a 40% lifetime risk of suicide attempts.¹⁷ A World Health Organization study found the most common cause of death in those with schizophrenia was suicide.¹⁸ Risk factors for suicide amongst those suffering from schizophrenia include: positive symptoms, co-morbidity with depression, lack of treatment, downgrading in level of care, chronic illness, a good educational background and high performance expectations. Suicide is more likely to occur earlier in the course of the illness.

If we are to prevent suicide in persons with schizophrenia it is vital that all staff working in mental health receive dedicated training in both risk assessment and management, something that is too often left to experience to provide. Training should also emphasize the importance of addressing co-morbid conditions that have been found to heighten risk, such as depression, substance use and loss of functioning. The simple measure of improving record keeping and care plans may help ensure the entire clinical team is aware of all the risk factors present and how they can be minimized. This also highlights the need for good communication between the patient’s multidisciplinary team, general practitioner, caregivers and relatives.

In 2005, the British Journal of Psychiatry published an analysis that combined a large number of international studies of suicide risk among this population. The most robust finding of this review was that suicide was more likely when people with schizophrenia showed agitation and expressed feelings of worthlessness and/or hopelessness; also when they had a history of suicidal thoughts and of suicide attempts. A family history of suicide also raised the risk.

Among the other important findings of this study:

• The living situation of a person with schizophrenia affects risk. Those who live alone, or do not live with their families, are at increased risk of suicide.
• Those individuals who are better educated seem to be at higher risk for suicide. This may reflect the greater awareness of and fear of mental deterioration.
• Poor adherence to treatment greatly increases risk. In some patients the use of medications known to have anti-suicide effects may be advisable.
• Alcohol misuse did not appear to be a major risk factor for people with schizophrenia. However, abuse of drugs was strongly correlated with heightened risk. Such drug abuse is twice as common among those with schizophrenia compared to the general population.

People with schizophrenia need extra support and supervision at these times:

• Periods when the person is very psychotic and out of touch with reality
• Periods when they are very depressed
• In the first 6 to 9 months after they have started first taking medications, when they are thinking more clearly and learn that they have schizophrenia (with all the negative implications of this)
• The period after hospital discharge. Discharge plans ought to be made with care. Whenever possible, a person at high risk ought not to be left alone, and certainly not for long periods. Suicide often occurs when a person with schizophrenia has been left alone all day.

Anorexia Nervosa and Bulimia Nervosa

Eating disorders have the highest mortality rate of any mental illness. This includes both suicide deaths and deaths from direct complications of their eating disorder. Studies have found that prevalence rates for attempted suicide vary depending on the eating disorder diagnostic subgroup and study setting. The prevalence of suicide attempts is lowest among outpatients with anorexia nervosa (16%). Prevalence rates are higher for bulimic individuals treated as outpatients (23%) and inpatients (39%). The highest rates of suicide attempts are reported among bulimic individuals who have co-morbid alcohol abuse (54%).²⁰ It should be noted that these rates do not include those who die from other complications of the disorder. Further complicating this picture is the high prevalence of non-lethal self-mutilation amongst those diagnosed with eating disorders. Unsurprisingly, most of the women in the study had other psychiatric disorders besides an eating disorder, including depression, drug or alcohol abuse or fearfulness or anxiety. Almost 84 percent of the patients had at least one other psychiatric problem.

Given these statistics it is concerning that the incidence of eating disorders has doubled since the 1960s. Eating disorders, which used to be a largely Western disorder, are also being reported in high levels in many Asian countries for the first time.²¹ More than 90% of those diagnosed each year are young women.²² Dr. Mike Shooter, president of the Royal College of Psychiatrists has argued that eating disorders are “poorly understood by the public and clinicians alike”²³ and that there is a need for intensive research into clinical best practice guidelines.

Self-Mutilation

Self mutilation, especially among young people, is an emerging area of concern. One widely cited estimate is that self-mutilation occurs in at least 1 person per 1,000 annually. Self-mutilation takes many forms and can include self binding and amputation, banging ones’ head, biting oneself, pulling ones hair, and cutting, scratching or burning ones skin.

Self-mutilation should not be confused with suicide attempts, but research suggests that those with mental illnesses are more likely to self-mutilate, with one study of psychiatric outpatients finding that 33% reported engaging in self-harm in the previous three months.²⁴ Furthermore, self-mutilation is an early predictor of suicidal behaviour. About half of all people who kill themselves have a history of deliberate self-harm, an episode having occurred within the year before death in 20-25%.

Substance Abuse and Suicide

International health researchers point to alcohol as the most widely abused substances in the world. Globally, the extent of problem drinking varies widely; overall about 1.7% of the world’s people abuse alcohol. In parts of Eastern Europe and in North America, experts estimate that 5% of the population abuse alcohol. The prevalence of illegal abuse of drugs and drug addiction in the worlds’ nations ranges from 0.4% to 4%. In 2003, the World Health Organization estimated about 5 million people inject illicit drugs. In studies that examine risk factors among people lost to suicide, substance abuse and problem drinking occur more often among youths and younger adults, compared to older people. Also, male gender is a risk factor for both substance abuse and suicide. For particular groups at risk, such as indigenous peoples surrounded by an alien majority culture, depression and alcohol abuse may be co-existing risk factors for suicide.

Alcohol and substance abuse problems contribute to suicidal behaviour in several ways. Persons who use and abuse substances often have several other risk factors for suicide. In addition to being depressed, they are also likely to have social and financial problems. Substance use and abuse tend to occur more often among people who are prone to act on impulse. They also occur often among those who engage in many types of high-risk behaviours that can cause self-harm. In addition, people who are intoxicated may make suicide attempts impulsively and aggressively that they would not make if they were not intoxicated.

Key Facts about Substance Abuse and Suicide

• People with severe alcohol dependency or alcoholism have increased risk for suicide.
• Depression and other mood disorders are involved with the majority of suicides; substance abusers have profoundly increased rates of depression. Left untreated, substance abuse worsens the outcomes of mood disorders.
• Suicide attempts occur more often within the context of a binge-drinking episode.
• People whose drinking causes trouble at work are six times as likely as others to die by suicide in the home.
• Problem drinkers who have been hospitalized for reasons related to alcohol abuse have ten times the risk of suicide, compared to problem drinkers not so hospitalized. Substance dependence raises the risk of work, family and physical health problems that can become more severe over time.
• If a person who is dependent on alcohol also uses cocaine the risk rises significantly.
• Alcoholics who die by suicide are more likely to have partner-relationship troubles and other severe life stressors than alcoholics who have not tried suicide.
• Canadian research indicates that up to 80% of people with schizophrenia will abuse substances at some time; such abuse is associated with suicidal behaviour.
• High-risk alcoholics can be defined as those with a co-occurring depression diagnosis, those in treatment for a prior suicide attempt or those who have tried to ill themselves in the past.
• The risk of suicide among alcoholics increases over time; suicide risk is highest after 10 or more years of having drinking problems.

Web Links and Resources

• Canadian Association for Suicide Prevention
• Talk Suicide Canada
• Centre for Suicide Prevention
• Hope and Healing: A Practical Guide for Survivors of Suicide
  
• Honouring Life Network
  A website developed to combat suicide among Aboriginal youth that targets both Aboriginal youth and suicide prevention workers in First Nations, Inuit and Métis communities.