Suicide claims the lives of more than 30,000 Americans each year, and deaths by suicide exceed deaths by homicide by at least 3 to 2 in the U.S. A recent article in the MMWR (the Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention) reviews data from a recent 10 year period and demonstrates substantial changes in suicide rates that appear to be age specific. In persons between the ages of 10 and 34 years old, the rate remained the same or slightly increased. In those 65 and older, the rate of suicide stayed the same or slightly decreased. However, in people between 35 and 64 years old, the rates increased substantially in whites and in American Indians/Alaska Natives. On average, there was about a 28% increase. Even more striking, the increase in males between 50 and 59 years old was about 48%, and the increase in women between 60 and 64 years old was about 60%. Overall, the rate of suicide in men remained about 3 times higher than the rate in women. Among blacks aged 34 to 64, there was about a 6% increase in suicide rate that was largely driven by increases in women. The increase in suicide rate was spread throughout all regions of the country.
The three most common methods for completing suicide were firearms, suffocation, and overdoses. No single method was associated with the increased suicide rate in the middle-aged group. The most common method of suicide in men involves firearms (about 50%). In women, overdose is the most common method (42%).
As this article in the MMWR emphasizes, “Suicide is an increasing public health concern.” This report states that suicide results in more deaths than motor vehicle accidents.
The authors of this report speculate that the increased rate of suicide observed in middle-aged people may result from several factors. They note recent economic pressures, a stressor that may be associated with increased suicides. They also suggest that the increase may partially result from a “cohort effect,” reflecting the fact that individuals born 35 to 64 years ago also had an increased suicide rate when they were younger. It may be that this group (“cohort”) has an increased suicide risk that will track with them throughout life. Why some cohorts seem to carry a higher rate of suicide throughout their lives is unknown. Finally, the authors note that opiate pain medications have become more readily available, and overdosing on such medications can be lethal. Perhaps, the lethality of this group of drugs may help to explain the increased deaths by suicide, given that musculoskeletal disorders (often manifest as chronic pain) are large contributors to disability in 35 to 64 year olds.
It is important to realize that the vast majority of suicides (more than 90%) are associated with major psychiatric disorders. Stressors can contribute, but when they do, it is typically in the context of a concurrent psychiatric disorder. Research has clearly demonstrated that many persons who take their own lives do so during an episode of clinical depression. Depressive disorders often go unrecognized by a person’s healthcare team even though the diagnosis can be readily determined in a primary care setting. If depressive symptoms are recognized by the healthcare team, the doctor or nurse should inquire about thoughts of self harm. When a patient acknowledges such thoughts, treatment of the depression can decrease the risk of suicide. Sometimes the pain of depression is just too severe, however, and a patient may take his or her own life despite the best efforts of the treatment team. Nevertheless, increased screening for depression, and attentive and aggressive treatment, including hospitalization, can decrease the risk of suicide. Similarly, alcohol and other substance use disorders are associated with increased risk of suicide. In patients with substance use disorders, addressing the substance use is required to diminish suicide risk.
The increasing rate of suicide in middle-aged persons should remind all of us to be alert to the development of depressive symptoms and substance use in our friends, family members, and colleagues. Symptoms such as withdrawn behavior, a change in self-esteem, decreased interest in pleasurable activities, unintended changes in weight or appetite, and sleep pattern changes shouldn’t be ignored. These might be symptoms of clinical depression or some other medical disorder. If a person shows depressive symptoms or indicates thoughts of suicide, he or she needs psychiatric help.
This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD