In honor of the upcoming holidays, I’ll be posting information on suicide assessment and intervention in the coming days. You might think this is because December, the holidays, or Winter are highly linked to death by suicide, but in fact, although the holidays can be a depressive trigger for some individuals, Winter is NOT associated with especially high suicide rates. Instead, somewhat surprisingly, Spring is consistently the season when suicide rates are highest.
Suicide risk factors are the main focus of today’s post . . . along with an embracing of the reality that even with the best suicide risk factors and predictors available, predicting suicide and managing suicidal behaviors is exceedingly difficult. The following material is adapted from our textbook titled, “Clinical Interviewing” and published by John Wiley and Sons (2014).
I hope you’re all having the best time possible in the run-up (as the Brits would say) to the holidays.
Suicide Risk Factors
A suicide risk factor is a measurable demographic, trait, behavior, or situation that has a positive correlation with suicide attempts and/or death by suicide. Not surprisingly, given the immense number of variables involved in human decision-making, the science of predicting suicide risk is challenging and complex. For example, in 1995 a renowned suicidologist wrote:
At present it is impossible to predict accurately any person’s suicide. Sophisticated statistical models . . . and experienced clinical judgments are equally unsuccessful. When I am asked why one depressed and suicidal patient commits suicide while nine other equally depressed and equally suicidal patients do not, I answer, “I don’t know.” (Litman, 1995, p. 135)
Since Litman’s 1995 statement, research on suicide risk has accumulated. This is good news in that research potentially aids in the prediction and prevention of death by suicide. However, as researchers have increased their focus, the number and range of potential suicide risk factors have multiplied and when considered in the context of a practical suicide assessment, can feel overwhelming. To help clinicians deal with so many possible suicide-related variables, researchers and practitioners have developed various acronyms to use as a guide to risk factor assessment (see my IS PATH WARM post:http://johnsommersflanagan.com/2013/07/12/is-path-warm-an-acronymn-to-guide-suicide-risk-assessment/).
As you read this post and my next post, keep in mind that although knowledge of suicide risk factors is useful, developing a positive working alliance with potentially suicidal clients is of far greater import. Additionally, at the end of this risk factor frenzy, we will step back and look at another model for anticipating suicide. Finally, always remember that an absence of risk factors in an individual client is no guarantee that he or she is safe from suicidal impulses.
Sex, Age, and Race as Suicide Predictors
Historically, various client demographics have been used to estimate suicide risk. For example, because males, in general, commit suicide at approximately three to four times the rate of females, boys and men are usually considered a higher risk for suicide than girls and women.
Unfortunately, most demographic variables include moderating and mediating factors that increase uncertainty when trying to predict suicide risk. To return to the example of sex as a suicide predictor, it also happens to be true that females attempt suicide at approximately three times the rate of males. Although there are many potential explanations for these apparently contradictory trends, no one really knows why these patterns exist and persist. However, preventing suicide attempts (primarily among females) is nearly as important as preventing death by suicide (primarily among males). Consequently, every male and female who enters your office should receive equal care, attention, and if appropriate, a suicide assessment interview and intervention. Similarly, just because Black females have extremely low suicide base rates and older Asian women have somewhat elevated suicide base rates doesn’t mean that we should always conduct a suicide assessment interview with Chinese American women, while never conducting one with Black American women. Obviously, whether a suicide assessment interview is conducted and how extensive that interview is, depends on the characteristics of the specific client in the consulting room.
Despite these unique patterns of suicide potential associated with sex, age, and race, there are some trends in the data worth committing to memory. Based on 2005–2009 mortality data from the Centers for Disease Control, these include:
• White males over 65 have very high suicide rates (32.4/100.000).
• Alaskan Native and American Indian males, ages 10 to 24 have very high suicide rates (31.3/100,000).
• White males from 25 to 64 years old and American Indian/Alaskan Native males have similarly high suicide rates (slightly over 29/100,000)
• The lowest suicide rates seem to consistently be among Black females at less than 2/100,000.
• Across all ages and races, males are about 4 times more likely to commit suicide than females.
• Although suicide rates typically increase with age, rates among Alaskan Native and American Indian males typically decrease with age.
To get a sense of how difficult it is to predict suicide even in the highest risk demographic group, the percent of completed suicides among White males over 65 is 0.032 percent or approximately 1 per every 3,125. The good news is that suicide continues to be a rare event, even in high-risk populations. The bad news is that it remains highly improbable that we can efficiently predict, in advance, which one white male over 65 out of a group of over 3,000 will commit suicide.
Race and religion may sometimes function as suicide protective factors. For example, African American women have exceedingly low suicide rates. It has been speculated that these rates may be associated with a high sense of familial responsibility, which in turn may be associated with specific religious beliefs or convictions (C. L. Davidson & Wingate, 2011). suicide rates and speculation suggests that these rates may be associated with a high sense of familial responsibility, which in turn may be associated with specific religious beliefs or convictions (C. L. Davidson & Wingate, 2011).
Overall, remember that knowledge about suicide risk factors is important and sometimes useful, but nothing replaces positive relationship connections among friends, family, social groups, and/or with competent mental health professionals.
More on risk factors soon.