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THE BIBLICAL ASPECTS OF SUICIDE

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THE BIBLICAL ASPECTS OF SUICIDE

MEDICAL RESEARCH IN THE BIBLE

FROM THE VIEWPOINT OF CONTEMPORARY
PERSPECTIVE

Liubov Ben-Nun
 Suicide is a very agonizing and traumatic event for patients as well
as for families. It is an end of suffering for those who succeed, but
for their families it is only the beginning of the agony. The individuals
who committed suicide fulfilled their own will, ignoring the
catastrophic effect on their families, friends, and acquaintances.
Was suicidal behavior prevalent in biblical times? Who committed
suicide in biblical times? What were the reasons for this behavior?
Was it justifiable? Was the suicide preventable? This research aims to
answer these questions. All biblical texts were examined and
characters who committed suicide were studied closely.

58th Book

About the Author

Dr. Liubov Ben-Nun, the Author of dozens Books and Articles that have
been published in scientific journals worldwide.
Professor emeritus at Ben Gurion University of the Negev, Faculty of
Health Sciences, Beer-Sheva, Israel. She has established the "LAHAV"
International Forum for research into medicine in the Bible from the
viewpoint of contemporary medicine.
 THE BIBLICAL ASPECTS OF SUICIDE

Professor Liubov Ben-Nun

Ben-Gurion University of the Negev
Faculty of Health Sciences
Beer-Sheva, Israel

Death of Saul.
Elie Marcuse. 1848.

B.N. Publication House. Printed in Ashkelon, Israel. 2015.

Fax: +(972) 8 6883376 Mobile 050 5971592

E-Mail: L-bennun@zahav.net.il
Technical Assistance: Carmela Ben-Nun-Moshe.
All rights reserved

Distributed Worldwide

NOT FOR SALE

`
 BIBLICAL EXEGESIS
It should be noted and stressed that this research is
in no way concerned with a discussion of any
interpretations of the Bible by the great commentators
such as Rambam, the sages of the Talmud and the
Mishnah, or interpretation based on knowledge of the
ancient world found in Julius Preuss’ book. The
research is based solely on the actual words on the
verses of the Bible.
CONTENTS

MY VIEW 9
PREFACE 10
FOREWORD 11
INTRODUCTION 13
SUICIDE IN ANCIENT GREECE/ROME 15
THE BIBLICAL STORIES 17
SAMSON
KING SAUL
AHITHOPEL
KING ZIMRI
ABIMELECH
BIOLOGICAL TESTS 32
HEREDITY 36
ADVERSE LIFE EVENTS 44
EPIDEMIOLOGY 48
SPECIAL GROUPS 59
PEDIATRICS 59
YOUNG PEOPLE 66
ADULTS 68
THE ELDERLY 71
OTHER GROUPS 73
INDIVIDUALS WITH EATING DISORDERS 73
VETERANS 76
STROKE SURVIVORS 77
PATIENTS WITH CANCER 79
DOCTORS/NURSES 81
DRIVERS 83
PRISONERS 86
MILITARY 89
PERSONS WITH MENTAL DISORDERS 96
DEPRESSION 97
MOOD DISORDERS 101
GENERALIZED ANXIETY DISORDER 104
OBSESSIVE-COMPULSIVE DISORDER 107
PERSONALITY DISORDERS 109
SCHIZOPHRENIA 113
EMERGENCY DEPARTMENT VISITS 115
HOSPITALIZED PATIENTS 119
METHODS OF SUICIDE 121
RISK FACTORS 122
INTERNET 134
PROTECTIVE FACTORS 137
JEWISH PERSPECTIVE 139
PREVENTION 140
SUMMARY 152
THE AUTHOR'S LIST OF PUBLICATION 165
PICTURES 170
ABBREVIATIONS

AHR Adjusted hazard ratio

AN Anorexia nervosa
ANBN Anorexia nervosa and bulimia nervosa
ANBP Anorexia nervosa binge-purge subtype
ANR Anorexia nervosa restricting subtype
AOR Adjusted Odds Ratio
ASPD Antisocial personality disorder
BDI Beck Depression Inventory
BED Binge eating disorder
BHS Beck Hopelessness Scale
BDNF Brain-derived neurotrophic factor
BN Bulimia nervosa
BPD Borderline personality disorder
CBT Cognitive-behavioral therapy
CI Confidence intervals
CIDI Composite International Diagnostic Interview
COHb Carboxyhemoglobin
CRH Corticotrophin-releasing hormone
CSDD Cornell Scale of Depression in Dementia
CSF Cerebrospinal fluid
CSI Core Symptom Index
DBT Dialectical behavior therapy
eBridge Electronic Bridge to Mental Health Services
ED Eating disorder
GAD Generalized anxiety disorder
GDS Geriatric depression scale
GPs General practitioners
GWA Genome-wide association
HAM-D Hamilton Rating Scale for Depression
HPA Hypothalamic-pituitary-adrenal
HR Hazard ratio
HVA Homovanillic acid
IPTS Interpersonal Psychological Theory of Suicide
IQ Intelligent quotient
IQR Interquartile range
MBT Mentalization-based therapy
MDD Major depressive disorder
MDE Major depressive episode
MHPG 3-Methoxy-4-hydroxyphenylglycole
MINI Mini International Neuropsychiatric Interview
MSA Metropolitan statistical areas
NA/A Noradrenaline/adrenaline
OCD Obsessive-compulsive disorder
OCPD Obsessive-compulsive personality disorder
OEF Operations Enduring Freedom
OIF Operations Enduring Iraqi Freedom
OR Odds ratio
PD Purging disorder
PTSD Posttraumatic stress disorder
PY Person-years
RCS Randomized controlled study
RCT Randomized controlled trial
RFL Reasons for Living Inventory
RR Rate ratio
SD Standard deviation
SEER Surveillance, Epidemiology, and End Results
SMD Standardized mean difference
SMR Standardized mortality ratio
SNPs Single nucleotide polymorphisms
SSRIs Selective serotonin reuptake inhibitors
TBI Traumatic brain injury
 9
L. Ben-Nun Suicide

MY VIEW

MEDICINE IN THE BIBLE

AS A RESEARCH CHALLENGE
This is a voyage along the well-trodden routes of contemporary
medicine to the paths of the Bible, from the time of the first man to
the period of the People of Israel. It covers the connection between
body and soul, and the unbroken link between our earliest ancestors,
accompanied by spiritual yearning and ourselves. Through the verses
of the Bible flows a powerful stream of ideas for medical research
combined with study of our roots and the Ancient texts.
It would not be too adventurous to state that if there is one book
in the world that all Jews are proud of, that is the Book of Books, the
greatest classic among all literary works, whose original language is
not Greek or Latin, but the Hebrew that I and other Israelis speak
every day, our mother tongue, the language of Eliezer Ben Yehuda.
The Bible exists as evidence in the Book of Books, open to all
humankind. For thousands of years it has been placed before us, still
as fresh as before, the history of peoples who have disappeared and
of the Jewish people, which has survived with its Holy Text that has
been translated into hundreds of languages and dialects, and remains
our eternal taboo.
Many people ask me about the connection between the Bible and
medical science. My reply is simple: the roots of science are buried
deep in the biblical period and I am just the archeologist and medical
researcher. This scientific medical journey to the earliest roots of the
nation in the Bible has been and remains moving, exciting and
enjoyable. It has created a kind of meeting in my mind between the
present and those Ancient times, through examining events frozen in
time.
Sometimes it is important to stop, to look back a little. In real
time, it is hard to study every detail, because time is passing as they
appear. However, when we look back we can freeze the picture and
examine every detail, see many events that we missed during that
fraction of a second when they occurred.
The Book of Books, the Bible, is not just the identity card of the
Jewish, but an essential source for the whole world.
 10
L. Ben-Nun Suicide

PREFACE
The purpose of this research is to analyze the medical situations
and conditions referred to in the Bible, as we are dealing with a
contemporary medical record.

These are scientific medical studies incorporating verses from the

Bible, without no interpretation or historical descriptions of places.

Fundamentally, this Research is constructed purely from an

examination of passages from the Bible, exactly as written.

The research is part of a long series of published studies on the

subject of biblical medicine from a modern medical perspective.

This is not a laboratory research. The Research is built entirely on

a secular foundation. With due to respects to people faith, this
Research takes a modern look at medical practices. Each to his own
beliefs.
 11
L. Ben-Nun Suicide

FOREWORD
Suicidal behavior is a significant public health problem. Suicide
alone represents the 10th leading cause of death worldwide. Suicide
is a complex phenomenon and may be the result of an interaction of
biological, psychological and socioeconomic factors. Although there
are many differences in suicide rates between different countries in
the world, some studies reported huge differences of suicide rates
between different regions within the same country as well. The
studies that investigated the regional differences in suicide rates
were gathered. Depression frequently remained unidentified and
thus untreated and could contribute to high regional suicide rates.
Access to services, which increases the possibility of diagnosis and
treatment of mental disorders, could have an impact on regional
suicide rates. Thus, the availability of services may be relevant in
explaining geographical variations in suicide incidence. Suicide is a
major public health issue of particular concern among rural
populations, which experienced consistently higher suicide rates than
urban areas considering that the availability of psychiatric services
was typically less available in rural regions. It seems that
socioeconomic factors outweighed climatic factors in explaining
regional differences in the suicide rates but further research is
needed (1).
Suicide and suicide attempts are a major cause of death and
morbidity worldwide. Suicide is generally a complication of a
psychiatric disorder, but it requires additional risk factors because
most psychiatric patients never attempt suicide. A hypothesized
stress-diathesis model has implications for detection of high-risk
patients and treatment interventions (2).
Suicidal breakdown requires attention both to attack upon the self
(ego) as aggressive forces are unleashed against it by the superego,
but also to the phases of self-breakup (ego regression) that follow.
Less attention has been directed to ego-regression in suicide than to
superego-directed assault on the ego in the psychoanalytic literature;
attention to the phenomena of ego failure and disarticulation of the
self-representation is essential. Clinical study of suicidal patients
shows four aspects of suicidal collapse as ego loosens: affective
flooding, desperate maneuvering to counter the resulting mental
emergency, loss of control as the self begins to disintegrate, and
grandiose magical scheming for mental survival as the self-
 12
L. Ben-Nun Suicide

representation splits up and body jettison becomes plausible. These

phenomena include: failed affect regulation, ego helplessness,
narcissistic surrender, breakdown of the representational world, and
loss of reality testing (3).
Although not a disease, suicide is a tragic endpoint of complex
etiology and a leading cause of death worldwide. Just as preventing
heart disease once meant that specialists treated myocardial
infarctions in emergency care settings, in the past decade, suicide
prevention has been viewed as the responsibility of mental health
professionals within clinical settings. By contrast, over the past 50
years, population-based risk reduction approaches have been used
with varying levels of effectiveness to prevent morbidity and
mortality associated with heart disease. The current urgency to
develop effective interventions for suicide prevention can benefit
from an understanding of the evolution of population-based
strategies to prevent heart disease (4).
There is increasing evidence that the Internet and social media
can influence suicide-related behavior. Important questions are
whether this influence poses a significant risk to the public and how
public health approaches might be used to address the issue (5).
Suicide is the worst acute outcome in psychiatry, in part because
it is preventable. Globally, nearly a million people die yearly by
suicide, yet despite research and prevention efforts, global suicide
rates have increased in the past half century, and the WHO projects
rise more in the years ahead. Suicide is overwhelmingly associated
with mental illness, mostly depressive disorders, though substance
use and psychotic disorders are also significant risks (6).

References
1. Jagodic HK, Agius M, Pregelj P. Inter-regional variations in suicide rates.
Psychiatr Danub. 2012;24 Suppl 1:S82-5.
2. Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern
Med. 2002;136(4):302-11.
3. Maltsberger JT. The descent into suicide. Int J Psychoanal. 2004;85(Pt 3): 653-
67.
4. Knox KL, Conwell Y, Caine ED. If suicide is a public health problem, what are
we doing to prevent it? Am J Public Health. 2004;94(1):37-45.
5. Luxton DD, June JD, Fairall JM. Social media and suicide: a public health
perspective. Am J Public Health. 2012;102 Suppl 2:S195-200.
6. Grunebaum MF. Suicidology meets "Big Data". J Clin Psychiatry. 2015;76(3):
e383-4.
 13
L. Ben-Nun Suicide

INTRODUCTION
Suicide (Latin suicidium, from sui caedere, "to kill oneself") is the
act of intentionally causing one's own death. Suicide is often carried
out because of despair, the cause of which is frequently attributed to
a mental disorder such as depression, bipolar disorder,
schizophrenia, borderline personality disorder (1), alcoholism, or
drug abuse (2). Stress factors such as financial difficulties or troubles
with interpersonal relationships often play a role. Efforts to prevent
suicide include limiting access to method of suicide such as firearms
and poisons, treating mental illness and drug misuse, and improving
economic circumstances. Although crisis hotlines are common, there
is little evidence for their effectiveness (3).
Suicide, also known as completed suicide, is the "act of taking
one's own life" (4). Attempted suicide or non-fatal suicidal behavior is
self-injury with the desire to end one's life that does not result in
death (5).
Assisted suicide is when one individual helps another bring about
their own death indirectly via providing either advice or the means to
the end (6). This is in contrast to euthanasia, where another person
takes a more active role in bringing about a person's death (6).
Suicidal ideations are thoughts of ending one's life but not taking any
active efforts to do so (5).
There is no other such complex physical, biological, somatic,
mental, psychological, psychiatric, cultural, social and spiritual
phenomenon and general public health problem, so much
unexplained, meaningless, so tragic, painful, and unreasonable, so
difficult, contradictory and mystified like suicide. In spite of the
several already identified background factors, we do not and we
cannot know the real reasons behind suicide, because suicide is
multi-causal, and can never be traced back to one single cause, but
there are always many biological, psychological-psychiatric, historical,
social and cultural factors involved in its development. However, the
strongest suicide risk factor is an unrecognized and untreated mental
disorder. Suicide among young people is one of the most serious
public health problems. In Hungary, 1,395 young people, 1150 males
and 245 females lost their lives due to suicide in the > 24-year age
group between 2000-2010. According to epidemiological studies,
24.7% of children and adolescents suffer from some form of
behavior-, conduct- or other psychiatric disorders. Among
 14
L. Ben-Nun Suicide

adolescents (aged 15-24 years) suicide was the first leading cause of
death in 2010. Despite great advances in the psychopharmacology
and psychotherapy of mental disorders, suicides persist as a major
cause of mortality, especially among the 15-24-year old population.
Victims of suicide are not healthy individuals. They always suffer from
psychiatric or mental, physical or somatic, cultural (social, historical,
mythological) and spiritual disorders. Suicide protective and risk
factors according to physical-biological, mental-psychological,
cultural-social, and spiritual aspects are classified. However, these
factors are not necessarily present in each and every case and may
vary from one country to another, one person to another, depending
on cultural, political, (spiritual) and economical features. Risk and
protective factors can occur 1] at the physical or biological-somatic
level which includes physical circumstances, genetics, health, and
diseases; 2] at the mental or psychological level, which includes
mental health, self-esteem, and ability to deal with difficult
circumstances, manage emotions, or cope with stress; 3] at the
cultural level or the broader life environment, and this includes
social, political, environmental, and economic factors that contribute
to available options and quality of life; 4] at the social level, which
includes relationships and involvement with others such as family,
friends, workmates, the wider community and the person's sense of
belonging; 5] at the spiritual level, which includes faith, hope, charity,
despair, and salvation. Children and adolescents spend a lot of time
at school, so teachers must be educated to notice any warning signs
of suicide, but the majority of pedagogues not only do not know the
most important mental and psychosomatic symptoms, but also do
not recognize them in children and do not know how to handle them
either. Hopelessness is the most important spiritual risk factor. The
BHS is a tool for easy application in general practice. Some important
symptoms and signs neither parents nor teachers are able to
recognize and handle (6).
Was suicidal behavior prevalent in biblical times? Who committed
suicide in biblical times? What were the reasons for this behavior?
Was it justifiable? Was the suicide preventable? This research aims to
answer these questions. All biblical texts were examined and
characters who committed suicide were studied closely.
 15
L. Ben-Nun Suicide

References
1. Paris J. Chronic suicidality among patients with borderline personality
disorder. Psychiatric services. Washington, D.C. 2002;53(6):738–42.
2. Hawton K, van Heeringen K. Suicide. Lancet. 2009;373(9672):1372–81.
3. Sakinofsky I. The current evidence base for the clinical care of suicidal patients:
strengths and weaknesses. Can J Psychiatry. 2007;2(6 Suppl 1):7S–20S.
4. Stedman's Medical Dictionary. Philadelphia: Lippincott Williams & Wilkins.
th
28 ed. 2006. ISBN 978-0-7817-3390-8.
5. Krug, Etienne. World Report on Violence and Health. Genève: World Health
Organization. Vol 1. 2002, p. 185. ISBN 978-92-4-154561-7.
6. Gullota TP. In Thomas P, Bloom M (eds.). The encyclopedia of primary
prevention and health promotion. New York: Kluwer Academic/Plenum. 2002, p.
1112. ISBN 978-0-306-47296-1.

SUICIDE IN ANCIENT GREECE/ROME

The theme of suicide appears several times in ancient Greek
literature. However, each such reference acquires special significance
depending on the field from which it originates. Most of the
information found in mythology, but the suicide in a mythological
tale, although in terms of motivation and mental situation of heroes
may be in imitation of similar incidents of real life, in fact is linked
with the principles of the ancient Greek religion. In ancient drama
and mainly in tragedies suicide conduces to the tragic hypostasis of
the heroes and to the evolution of the plot and also is a tool in order
to be presented the ideas of poets for the relations of the gods, the
relation among gods and men and the relation among the men. In
ancient Greek philosophy, there were the deniers of suicide, who
were more concerned about the impact of suicide on society and
these who accepted it, recognizing the right of the individual to put
an end to his life, in order to avoid personal misfortunes. Real
suicides are found mostly from historical sources, but most of them
concern leading figures of the ancient world. Closer to the problem of
suicide in the everyday life of antiquity are ancient Greek medicines,
who studied the phenomenon more general without references to
specific incidents. Doctors did not approve in principal the suicide
and dealt with it as insane behavior in the development of the
mental diseases, of melancholia and mania. They considered that the
discrepancy of humors in the organ of logic in the human body will
cause malfunction, which will lead to the absurdity and consequently
 16
L. Ben-Nun Suicide

to suicide, either due to excessive concentration of black bile in

melancholia or due to yellow bile in mania. They believed that
greater risk to commit suicide had women, young people and the
elderly. As therapy they used the drugs of their time with the
intention to induce calm and repression in the ill person, therefore
they mainly used mandragora. In general, there were many reasons
to suicide someone in antiquity. Important factor was to avoid
captivity and the consequent overcrowding of indignity, especially for
politicians and military leaders. Intention in these circumstances was
to avoid torture and the disgrace of rape. Strong grief is another
reason, as in case of death of family members. The erotic
disappointment had place in ancient suicides, which concerned both
men and women, while there were also suicide for financial reasons.
Especially for the elderly, the despair of the anility in conjunction
with physical illness and cachexia, were important factors for these
people to decide the suicide. The methods of suicide fitted their
epoch, but bear resemblance to those of the modern time. Poisoning
was very common to both men and women but equally popular in
both sexes was also the hanging. It was not unusual to fall from a
high in order to reach the death, while stabbing a sword in the body
for self-killing was widespread in men and soldiers (1).
The aim of this study was to present and analyze suicidal behavior
in the ancient Greek and Roman world. Drawing information from
ancient Greek and Latin sources (History, Philosophy, Medicine,
Literature, and Visual Arts) points out to psychological and social
aspects of suicidal behavior in antiquity. The shocking exposition of
suicides reveals the zeitgeist of each era and illustrates the prevailing
concepts. Social and legal reactions appear ambivalent, as they can
oscillate from acceptance and interpretation of the act to
punishment. In the history of these attitudes, we can observe
continuities and breaches, reserving a special place in cases of mental
disease. The delayed emergence of a generally accepted term for the
voluntary exit from life (the term suicidium established during the
17th century), is connected to reactions triggered by the act of
suicide than to the frequency and the extent of the phenomenon. In
conclusion, the social environment of the person, who voluntary
ended his life usually, dictated the behavior and historical evidence
confirmed the phenomenon (2).
 17
L. Ben-Nun Suicide

Assessment: in ancient Greek and Rome, reasons for suicide

included avoiding captivity, the consequent overcrowding of
indignity, especially for politicians and military leaders, avoiding
torture, and the disgrace of rape. The methods of suicide fitted their
epoch, but bear resemblance to those of the modern time. Poisoning
and hanging were common to both men and women. It was not
unusual to fall from a high, while stabbing a sword in the body for
self-killing was widespread in men and soldiers. The social
environment of the person, who voluntary ended his life, usually
dictated the behavior and historical evidence confirmed this
phenomenon.

References
1. Laios K, Tsoukalas G, Kontaxaki MI, et al. Suicide in ancient Greece.
Psychiatriki. 2014;25(3):200-7.
2. Lykouras L, Poulakou-Rebelakou E, Tsiamis C, Ploumpidis D. Suicidal behaviour
in the ancient Greek and Roman world. Asian J Psychiatr. 2013;6(6):548-51.

THE BIBLICAL STORIES

SAMSON
Samson, son of Manoah, was born with special strength in his hair
that had not been cut since his birth. During his life, Samson had
sexual relations with three women. The first was from Timnath. After
this woman was killed, Samson had sexual relations with a harlot
from Gaza, “…and went in to her” (Judges 16:1). Later, Samson fell in
love with Delilah “.. he loved a woman in the valley of Sorek, whose
name was Delilah” (16:4). The Philistines came to Delilah with a
special request to find out the source of Samson’s strength. After
Delilah’s endless questionings, Samson was exhausted and was sick
to death (16:16). In the end, Samson told Delilah his great secret “….if
I be shaven, then my strength will go from me…” (16:17). In spite of
Samson’s love, this woman betrayed him, disclosing his secret to
Philistines. As he slept on Delilah’s knee, she shaved his head and his
powerful strength left him. Now the Philistines captured him, and his
eyes were put out. But gradually his hair grew again. When
Philistines were gathered, Samson “ …bowed himself with all his-
 18
L. Ben-Nun Suicide

might; and the house fell upon the lords, and upon all the people”
(16:30). Samson, who had been chained to the middle pillars of a
temple, pushed them apart, and caused the collapse of the building.
Samson died together with the death of thousands people inside.
The death toll exceeded the number of people that he killed
throughout the rest of his life. Samson, who was now blind, no
longer wanted to live in captivity.
Did Samson have an ASPD? Altshuler and his colleagues (1)
analyzed this question thoroughly. According to their analysis the
DSM-IV requires three out of seven criteria be met for a diagnosis of
ASPD. Samson meets six. 1] Failure to conform to social norms with
respect to lawful behavior: The Philistines tried to arrest Samson
after he burned the Philistine fields (Judges 15:5) and went to Gaza
(16:1). 2] Deceitfulness, as indicated by repeated lying: Samson did
not tell his parents that he killed a lion. Furthermore, he proffered
honey for his parents to eat, but did not tell them it had come from
the carcass of a lion (14:9) and thus caused them to violate their
dietary laws. 3] Impulsivity: his burning of the Philistine fields (15:5).
4] Irritability and aggressiveness: This is indicated by his repeated
involvement in physical fights. 5] Reckless disregard for safety of self
or others: Samson is reported to have taken on and killed 1000
Philistines single-handedly (15:5). Telling Delilah the secret to his
strength (16:17), even after she attempted three times previously to
get this secret, can also be considered reckless disregard for safety of
self. 6] Lack of remorse: He gloated (15:16) after killing 1000 men (1).
Samson also committed many of the actions listed in the criteria
for conduct disorder - fire setting, cruelty to animals (15:5), bullying,
initiating physical fights, using weapon (jawbone of ass) (15:5), and
stealing from a victim (14:9) (1).
However, Ryan (2) suggested that there is insufficient data to
suggest that Samson had ASPD. Conformity to social norms is not
generally expected in wartime. Samson was at war, as almost
everyone in the book of Judges. 1. The burning of enemy fields and
food stocks is a skillful act of the guerilla fighter that is described as a
military tactic in the writings of the ancient historians Herodotus and
Livy. 2. Samson was not deceitful to his parents. He did not tell them
about the lion, which he has killed, because his safety not to boast
about what he had been able to do. Eating honey from the carcass of
an “unclean” animal only makes the family ceremonially “unclean”
until evening, if all, which is no serious violation of dietary laws. 3.
 19
L. Ben-Nun Suicide

Burning the Philistine’s fields and food stocks required careful

planning, timing, and preparation - hardly an impulsive act. 4.
Samson engages in three fights with his enemy, the Philistines: he
kills 30 and takes their clothing, in a judicial act, he slaughters others
“hip and thigh,” and on his own he is able to kill 1000. He kills an
attacking lion in self-defense; when blinded and imprisoned, he is
able to pull down a Philistine temple on top of his enemies and
himself. All these conflicts are either acts of self-defense or proactive
acts of war, nor irritability or aggressiveness. 5. Is it not an act of
heroism to single-handedly kill 1000 armed and armored enemy
troops with no weapon but a dog’s dinner, a bone? No recklessness
here except the kind of heroism for which he would have received
regimental honors in recent wars. Moreover, a close reading
suggests Samson and Delilah are in love and he is playing a lover’s
game as lovers do. He is at ease in her company and unaware that
she has a hidden agenda and hidden Philistines awaiting their
opportunity. No recklessness or disregard for personal safety here
either, just the type of games lovers plays when at ease in each
other’s company. Judges 15:16 is a victory song; Samson has
survived against overwhelming odds. Victory is a time for celebration,
not remorse (2).
With regard to conduct disorder, according to Ryan Samson does
make incendiaries of 300 foxes (or jackals) and this may be offensive
to contemporary supporters of animal rights (2). However, Judges is a
book of cruel actions against men, women, and children and we
should not expect harvest pests to be treated better. Therefore,
Samson’s behavior is understandable, even heroic, and even
acceptable! (2).
Both the present-day individual and the mythological hero
(Samson) share a distinct behavioral pattern (3). Both manifest the
compulsion to repeatedly reenact the experience of betrayal by a
woman, followed by destructive attacks of rage against others and
ultimately against their own tormented selves. That pattern has
been named “Samson’s complex” and is viewed as a deep-seated,
personality defect stemming from faulty attachments (3). The
existential despair and suicidal longings typify men with Samson’s
complex and strongly suggest that mythical Samson does not fit the
profile of sociopath (3).
In Kutz’s opinion, Althschuler and his colleagues apply the DSM
without regard to the mental and behavioral norms of biblical times.
 20
L. Ben-Nun Suicide

Killing a lion, in a society of warriors and hunters, is mistakenly

labeled by them as “cruelty to animals”. Similarly, they
misunderstood that in such a society, self-praise after vanquishing
one’s foes is the norm, rather than an antisocial thing to do (4).
Thus, there is a debate in the literature whether Samson was
affected by ASPD or conduct disorder. It seems that DSM-IV criteria
defining ASPD should be applied more cautiously in Samson’s case.
The same true is for conduct disorder. In any case, “Samson’s
complex” seems to give better answer to his behavior when analyzed
as a whole.
According to the modern psychoanalytical aspects of suicidology
(narcissistic theory, object relation, self-psychology) Samson’s origin
is marked by the uncertainty of his parents, their megalomanic
fantasies which are projected onto the child (5). His relationships are
characterized by violent emotions, intensive conflicts over intimacy
and distance, and raging anger at insults and privation. By his
suicide, Samson fuses himself with the highly ambivalent primary
object and destroys it at the same time by destroying himself. People
with narcissistic personality are considered extremely suicidal,
especially in combination with the destructive potency of narcissistic
anger (5). Therefore, it seems that Samson had narcissistic
personality features.
Samson had the extraordinary strength in the hair. The previous
research found no association between different parameters
including hormones, vitamins, trace elements, and different agents
as well as various hair diseases, including congenital, and the
extraordinary strength of Samson's hair (6). In addition to the special
power of his hair, Samson suffered from aggressive violent behavior.
He may have suffered from an ASPD. Whatever the case, we have
two parameters: the extreme power in Samson's hair + and his
aggressive behavior (ASPD). In this case, we are most likely dealing
with a congenital disorder. No other similar cases have been reported
so far. Samson is the only person described with such characteristics
(6).
For Samson suicide was a real way to end his humiliation, when
continuation of life represented unnecessary suffering. Suicide was
an answer for his damaged ego, a punishment not for him but for his
hated enemies, who captured and blinded him (7).
The biblical story of Samson may be understood at various levels
and from different perspectives. Since the story of Samson in the
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L. Ben-Nun Suicide

Bible is sketchily drawn, the interpretations of the narrative are

numerous. One version, according to David Grossman, a
contemporary writer and liberal Israeli political activist, regards
Samson critically, viewing him as a tormented individual who opts to
end his life in order to end his suffering. Another version is that of
Ze'ev Jabotinsky, a twentieth century author and nationalistic Jewish
political activist, who regards Samson as a heroic figure exemplifying
the ultimate Jewish hero who killed himself to help his people. While
suicide is considered a tragic event, viewed as the outcome of an
unstable state of mind from a psychopathological point of view, and
a controversial issue in Judaism (as in other religions), there is value
in examining how each of these authors explains the act. Since the
personal and political opinions of the authors influenced their
interpretations, the discussion will briefly expound on their
biographies. A comparison between their two versions of the
narrative will be made. A word of caution is introduced regarding the
merits and demerits of artistic and creative analysis of the biblical
narrative (8).
Can Samson’s suicide be regarded as heroic? The use of his
special strength to kill so many of his enemies does indeed indicate a
heroic victory over his enemies. He wanted vengeance, so his
behavior came because of his humiliation and suffering, and of the
fact that he refused to live as a prisoner in the hands of the cursed
Philistines.

Assessment: Samson was driven to seek vengeance by Delilah’s

betrayal, his capture by Philistines, loss of vision, humiliation, and
loss of social status. His vengeance, cumulating in suicide, was the
best answer to his capturers, the cursed Philistines. Samson’s death,
together with thousands of Philistines, shows that his enemies failed
to defeat this powerful man and sent a special message to all his
enemies. He never accepted his defeat, and died like a hero
struggling alone against countless enemies.

References
1. Altschuler EL, Haroun A, Ho B, Weimer A. Did Samson have antisocial
personality disorder? Arch Gen Psychiatry. 2001;58:202.
2. Ryan R. Samson was heroic, exhausted, depressed, and in love, but he does
not have antisocial personality disorder. Arch Gen Psychiatry. 2002;59:564-5.
3. Kuz I. Samson’s complex: the compulsion to re-enact betrayal and rage. Br J
Med Psychol. 1989;62:123-34.
4. Kutz I. Samson, the Bible, and the DSM. Arch Gen Psychiatry. 2002;59:565.
 22
L. Ben-Nun Suicide

5. Lindner R. Suicide in the Bible from the current psychodynamic viewpoint:

“There Saul took a sword and fell upon it”. Fortschr Neurolog Psychiatr. 1998;66(4):
151-9.
6. Ben-Nun Nun L. In Ben-Nun L. (ed.) Evaluation of Biblical Samson's Hair
Characteristics from the Viewpoint of Contemporary Medicine. B.N. Publication
House. Israel. 2013.
7. Ben-Nun L. Suicide from the biblical perspective. In Ben-Nun L (ed.). Psychiatry
in Biblical Times. The Roots. Israel. 2007, pp. 197-212.
8. Shoenfeld N1, Strous RD. Samson's suicide: psychopathology (Grossman) vs.
heroism (Jabotinsky). Isr Med Assoc J. 2008;10(3):196-201.

KING SAUL
King Saul, the first King of Israel, ruled the country more than
3000 years ago. Saul’s life ended when he lost the battle against the
Philistines on Mount Gilboa. Saul’s three sons, Jonathan, Abinadab,
and Melchishua were killed. “Then Saul said to his armor bearer
“draw your sword and pierce me through with it, lest these
uncircumcised come and pierce me through and abuse me. But his
armor bearer would not, for he was greatly afraid” (I Samuel 31:4). So
Saul committed suicide “ ...Saul took a sword, and fell upon it (31:4).
“And when his armorbearer saw that Saul was dead, he fell likewise
upon his sword, and died with him” (31:5). The Philistines cut off
Saul’s head and fastened his body to the wall of Bet-Shean. The
brave men of Jabesh-Gilead took the bodies of Saul and his three
sons at night and buried them at Jabesh. Later King David re-buried
the remains of Saul and his son Jonathan in the country of Benjamin
in Zelah, in the sepulcher of his father Kish.
His death was the only way of sending a message to the Philistines
that they would not succeed in capturing and killing the King of Israel.
So Saul requests assisted suicide from his armor-bearer, but this help
is denied. Saul is isolated in his decision, but he turns and falls on his
sword, committing suicide. Shortly afterwards, his armor-bearer also
kills himself (1).
King Saul also suffered from manic-depressive psychosis (2).
Manic-depressive disorder is mental disorder involving manic
episodes that are usually accompanied by episodes of depression (3).
The manic phase of the disorder is characterized by abnormally
elevated or irritable mood, grandiosity, sleeplessness, extravagance,
and a tendency toward irrational judgment. During the depressed
phase, the person tends to appear lethargic and withdrawn, shows a
 23
L. Ben-Nun Suicide

lack of concentration, and expresses feelings of worthlessness, self-

blame, and guilt. The dual character of manic-depressive disorder
has given it the name of bipolar disorder, in contrast to the unipolar
depression symptomatic most of majority mood disorders.
Individuals suffering from bipolar disorder may have long periods in
their lives without episodes of mania and depression, while manic-
depressive patients have the highest suicide rates of any group with a
psychological disorder (3).
Suicide, which is both a stereotypic yet highly individualized act, is
a common end for many patients with severe psychiatric illnesses (4).
The mood disorders (depression and bipolar manic-depression) are
the most common psychiatric conditions associated with suicide (4).
It has been shown that greater severity of bipolar disorders and
higher body mass index were significantly correlated with a history of
suicide attempts (5). At least 25% to 50% of patients with bipolar
disorder attempt suicide at least once (4). If untreated, the suicide
rate is 15% (6).
King Saul was a great warrior, fighting with the Philistines all his
life. Unfortunately, he lost his last battle with the Philistines, his three
sons were killed, and there were no pathways to escape from the
mount of Gilboa. Did Saul, a manic-depressive patient (2), develop
such severe depression that led it to his suicide? The answer is found
in Saul’s words “lest these uncircumcised (Philistines) come and thrust
me through, and abuse me” (31:4). He faced a tragic reality, with no
incentive to survive, since the Philistines would torture and kill him,
the great King. Therefore, it seems likely that manic–depressive
disorder was not a factor in this case. The King understood his
position and the consequences of his captivity, so he decided
honestly to end his life. His understanding of what might happen if
even humiliated Saul’s body (after his death), cutting off his head and
fastening the body to the wall, and in this way celebrating their
victory.
A double suicide is an agreement between two or more people to
kill themselves. They represent 0.6-4.0% of all suicides, with the vast
majority being double suicides. Double suicides are quite rare and are
generally seen in old, married couples. This case report describes a
double suicide pact which involved two young brothers aged 20 and
22 years (7).
Most suicides are solitary and private; but few result from a pact
between two people to die together. Two young men made a pact to
 24
L. Ben-Nun Suicide

commit suicide by hanging on a tree. It was the first case among

1,320 single suicides in more than two decades in eastern Croatia.
Double suicide between people of the same gender is an unusual
event. Male-female partners predominantly make it by less violent
methods. One of the two members experienced depression. He may
have been the initiator and the other partner may have been the
dependent. The initiator usually plans the act and stimulates the
other party. Whether both partners shared the decision and initiative
came from one of the two or it was result of two independent
decisions remains open for analysis. Double suicide is interesting
from the perspective of medical examiners. They need to make
comprehensive postmortem examination to conclude the proper
cause and the manner of death (8).
Thus, double suicide is an agreement between two people or
more to kill them. Double suicides are quite rare and are generally
seen in old, married couples.
Can this event be defined as a double suicide in King Saul's case?
The decision to commit suicide was shared by two individuals - King
Saul and his armor-bear and was independently accepted by both
men. This suicide can be defined as double suicide.
Seppuku, (Sape-puu-kuu) the Japanese formal language term for
ritual suicide [Hara-kiri (Har-rah-kee-ree)] was an integral aspect of
feudal Japan. Hara-kiri, which literally means "stomach cutting" is a
particularly painful method of self-destruction when a victim falls on
the sword and in this way ends his life. This method was ordered as
punishment or chosen in preference to a dishonorable death at the
hands of an enemy and was unquestionable demonstration of a
victim honor, courage, loyalty, and moral character (9).

We see that King Saul's suicide resembles the characteristics of

Japanese Hara-kiri suicide. Instead of submitting the dishonor of
 25
L. Ben-Nun Suicide

capture by enemy, he fell on his sword, thereby demonstrating

strength of character, courage, and a high strong code of ethics (9).
The suicide in military circumstances of King Saul and his armor-
bearer can be defined as double suicide that resembles Japanese
Hara-kiri (stomach cutting). The threat of disgrace, prosecution,
hopelessness, impulsivity, the death of his sons, and access to a
weapon - a sword - are identifiable factors linked to King Saul's
suicide (10).
Obviously, King Saul and his armor-bearer were not alone in the
field battle. What happened to the other warriors? Since the medical
record (the biblical text) tells us that the other soldiers died in the
battle, we can assume that they fought bravely to their death.

TO SUM UP: the suicide in military circumstances of King Saul and

his armor-bearer can be defined as double suicide that resembles
Japanese Hara-kiri (stomach cutting). Identifiable factors linked to
King Saul's suicide include the threat of disgrace, prosecution,
hopelessness, impulsivity, the death of his sons, and access to a
weapon - a sword.

References
1. Ben-Nun L. Suicide from the Biblical Perspective. In: Ben-Nun L. (ed.).
Psychiatry in Biblical Times. The Roots. Israel. 2007, pp. 197-212.
2. Ben-Noun L. What was the mental disorder that afflicted King Saul? Clin Case
Studies. 2003;2:4-6.
3. Manic-depressive disorder. The Columbia Encyclopedia. Sixth edition. 2001-5.
Available 20 July 2015 at http:www.bartleby.com/65/ma/manicdep.htm.
4. Jamison KR. Suicide and bipolar disorder. J Clin Psychiatry. 2000;61 Suppl.9:47-
51.
5. Fagiolini A, Kupfer DJ, Rucci P, et al. Suicide attempts and ideation in patients
with bipolar I disorder. J Clin Psychiatry. 2004;65(4):509-14.
6. Lewis R. Evening out the ups and downs of manic-depressive illness.
http://www.fda.gov/fdac/features/596_ bipo.htm. Accesses 9 November 2005.
7. Hocaoglu C. Double suicide attempt. Singapore Med J. 2009;50:e81-4.
8. Marcikic M, Vuksic Z, Dumencic B. et al. Double Suicide. Am J Forensic Med
Pathol. 2011;32(3):200-1
9. Hara-kiri. Available 2 May 2015 at https://www.facebook.com/
notes/japanese-weapons/hara-kiri/307339548826.
10. Ben-Nun L. In: Ben-Nun L (ed.). How Did Biblical King Saul die? B.N.
Publication House. Israel. 2012.
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L. Ben-Nun Suicide

AHITHOPEL
Ahithophel was a senior adviser to King David. When Absalom
rebelled against his father David, Ahithophel came to Absalom’s side
and advised Absalom to pursue David and kill him. In this way, the
people would be on Absalom side, but his advice was rejected.
Absalom chose the opposite way, by preparing his army to fight.
Because of this, “Now when Ahithophel saw that his advice was not
followed, he saddled a donkey, and arose and went home, to his city.
Then he put his household in order, and hanged himself, and died;
and he was buried in his father’s tomb” (II Samuel 17:23).
This case-control study investigated adverse life-events as risk
factors for self-immolation patients admitted to a burn center
serving the western region of Iran. Variables investigated included
the following adverse life-events: unplanned pregnancy, infertility,
homelessness, financial hardship, problems with friends, intimate
relationship break-up, school or university failure, anxiety about
school/university performance, problems at work, personal history
of suicide attempts, family history of suicide attempts, individual
history of mental disorders, and malignant disease. Financial
hardship (OR 3.35, 95% CI 1.19-9.90), intimate relationship break-
up (OR 5.45, 95% CI 1.20-11.99), and personal history of suicide
attempts (OR 7.00, 95% CI 1.38-35.48) were associated with
increased risk of self-immolation. In conclusion, financial hardship,
intimate relationship break-ups, and personal history of suicide
attempts are risk factors for self-immolation. Other variables
studied did not play a role as individually protective or risk factors
for self-immolation (1).
In Mexico, suicides are increasing in certain latitudes where local
rates have grown to levels of alert; suicide is also the second most
common cause of death for the group aged 15 to 19 years. The
psychological autopsy method was utilized to uncover and analyze
common factors in all of the registered suicides within 2011 and 2012
in a small town of the state of Guanajuato, located in the center of
Mexico. Nine decedents were analyzed, and 22 interviews were
conducted. The most salient factors were as follows: poverty,
financial stress, substance abuse, low levels of education, conflictive
relationships, and a poor handling of emotions. The concepts of
social exclusion and vulnerability were employed to analyze suicides
as symptoms of a much deeper problem of this country, suggesting
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L. Ben-Nun Suicide

that anomie and social malady are nowadays important suicidal

factors, mostly for children and young people (2).

Assessment: Ahithophel, a senior adviser to King David, came to

Absalom’s side and advised Absalom to pursue David and kill him. In
the end, Absalom was killed. For Ahithophel this was a real tragedy.
When his advice was not accepted, he understood that this fight was
lost, and David would surely execute him. These adverse life events
lead to intimate relationship break-up with David, a poor handling of
emotions, social exclusion and hopelessness. There was no other
way to solve the forthcoming hostility and avoid David’s vengeance.
Ahithophel was so depressed that he decided to end his life.

References
1. Ahmadi A, Schwebel DC, Bazargan-Hejazi S, et al. Self-immolation and its
adverse life-events risk factors: results from an Iranian population. J Inj Violence
Res. 2015 Jan;7(1):13-8.
2. Chávez-Hernández AM1, Macías-García LF. Understanding suicide in socially
vulnerable contexts: psychological autopsy in a small town in Mexico. Suicide Life
Threat Behav. 2015 Apr 20.

KING ZIMRI
King Elah, who ruled over Israel in Tirzah for two years, was the
son of King Baasha (I Kings 16:8). “His servant Zimri, captain of half his
chariots, conspired against him, as he (King Elah) was in Tirzah,
drinking himself drunk …” (16:9). “And Zimri went and smote him, and
killed him…. And reigned in his stead” (16:10). So Zimri became King
and reigned seven days over Tirzah. Zimri was very wicked man. He
assassinated King Elah, and subsequently the members of King
Baasha’s household. So all the people were against Zimri, and the
army besieged the city. Having no choice Zimri committed suicide: he
“went into the citadel of the king’s house and burned the king’s house
down upon himself with fire, and died” (I Kings 16:15-20). We see that
Zimri committed suicide by setting the house on fire.
Suicide by fire (self-incineration) for the purpose of political
protest has appeared in several countries during the previous
decade. In this paper, the history of this form of suicide has been
explored. The authors examined all cases of suicide by fire reported
in the London Times and New York Times between 1790 and 1972. Of
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L. Ben-Nun Suicide

these reported suicides, 71% occurred during the most recent

decade, 1963 to 1972, with all cases of political self-incineration
occurring during this period. The socio-cultural context, in which this
form of protest may occur and the psychological factors in individuals
who choose this method of suicide, play a significant role. It is
suggested that the occurrence of self-incineration as a means of
political protest may be yielding to more aggressive acts of terrorism
as popular methods of forcing political change (1).
Thirty-two self-immolation deaths by fire, representing about 1%
of suicides, occurred in the province of Ontario (population nine
million), Canada, from 1986 through 1988. The victims, mostly male
(male/female ratio, 26:6), were between 21 and 71 years old (mean
age, 38 years). Although the scene of self-immolation was usually
familiar to the deceased, some chose remote locations. Eleven were
found dead in motor vehicles. An accelerant, usually gasoline, was
used in most cases. Many of these individuals had, at some time,
indicated their intent to commit suicide, a few by self-immolation,
but only about half had a diagnosed psychiatric illness. Most of the
victims had a reason to kill themselves, but the factors that
motivated them to choose self-immolation by fire were uncertain.
Fourteen individuals died in hospitals from severe burn
complications. The remainder was found dead at the scene. The
postmortem findings of soot in the airway and elevated carbon
monoxide in the blood of most of these victims, and the COHb
concentration was in one case less than 10%, in 10 cases greater than
or equal to 10% to 50%, and in seven cases greater than 50% were
helpful in determining that the individuals were not only alive at the
time of the fire but also that a significant number died from smoke
inhalation and carbon monoxide poisoning. The highest levels of
carbon monoxide were observed in victims discovered in motor
vehicles (2).
A study of self-immolation or suicidal fire deaths was performed
on the case files of the Office of the Medical Examiner of
Metropolitan Dade County in Miami, Florida, during the 8-year period
from 1977 to 1984. Twenty-four case records, representing 0.96% of
the suicides that occurred during this period, were collected and
analyzed as to age, race, sex cause of death of the victim along with
the blood alcohol content at autopsy, drugs detected at autopsy, and
the terminal COHb. Additionally, the scene circumstances, geographic
location of the terminal incident, the reason for the suicide, whether
 29
L. Ben-Nun Suicide

or not there was a past suicide attempt, a past psychiatric history,

how the fire was started, presence or absence of an outside example,
time of occurrence, presence of hospitalization, and presence of a
suicide note were also noted. Most of the victims were white women
of over 50 years of age who died of thermal injuries. Half of the time
the blood alcohol content was negative at autopsy, 1/3 of the time
the drug screen was negative, and 1/3 of the time a small amount of
COHb was noted. Most fires originated at home, although motor
vehicles were also common. Reasons for the suicide varied. Of the
cases, 1/3 had a precious suicide attempt and approximately 1/2 of
the cases had a psychiatric history The fire started by pouring a
flammable liquid on one-self as isopropyl (rubbing) alcohol or
gasoline and igniting it. No outside media examples were noted.
These events occurred frequently in the afternoon or evening (3).
Self-inflicted burn injuries carry considerable mortality and
morbidity among otherwise fit young individuals. This study assessed
the epidemiologic pattern and outcome of these injuries in a burn
care facility in Pakistan. The study was carried out at Pakistan
Institute of Medical Sciences Burn Care Centre in Islamabad over a
period of two years. It included all adult patients of either gender,
aged over 14 years who presented as cases of burn suicides and
attempted burn suicides during the study period. Convenience
sampling technique was employed. The sociodemographic profile of
the patients, motives underlying the act of self-immolation, any
underlying psychiatric illness, alcohol abuse, total body surface area
burnt, depth of burn injury, associated inhalation injury, duration of
hospital stay, and mortality were all recorded. Seventy-five patients
(80.64%) were female while 18 patients (19.35%) were male. The
overall mean age was 26.89±6.1 years (range=15-52 years). The
affected total body surface area ranged from 15%-100% with an
overall mean of 69.30±25.42%. The hospital stay ranged from 1-37
days with a mean of 7.16±6.60 days. Marital conflicts constituted the
most frequent motive underlying the suicidal attempts (n=57,
61.29%) followed by failed love affairs (n=9, 9.67%). There was an
overall mortality of 84.95%. The most common sufferers of self-
inflicted burn injuries were young, married, illiterate housewives who
were resident of rural area. Getting marriage was the most common
triggering cause for such injuries. In conclusion, there is need to
institute appropriate preventive measures to address the issue in a
national perspective (4).
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L. Ben-Nun Suicide

While suicide by burns is a relatively uncommon form of suicide in

developed countries, it is one of the most common methods of
suicide in the Middle East region including Iran. The aim of this study
was to describe epidemiologic characteristics of suicidal behaviors by
burns in the province of Fars, Iran. A prospective population-based
study of all suicidal behaviors by burns requiring hospitalization was
conducted in the province of Fars, Iran, from March 21, 2005 to
March 20, 2006. Data were obtained from patients, family members,
and/or significant others through interviews during the course of
hospitalization. A total of 125 patients with suicidal behavior by
burns requiring hospitalization were identified, representing an
overall incidence rate of 4.3 per 100,000 (95% CI 3.6-5.1). Females
(6.2 per 100,000) had a higher rate of suicidal behavior by burns than
males (2.4 per 100,000, p<0.001). The age-specific rate of suicidal
behavior by burns peaked at age 20-29 years (10.1 per 100,000). The
rate of suicidal behavior by burns was higher among single (7.2 per
100,000) vs. married persons (4.2 per 100,000; p=0.03). Single males
aged 20-39 years and young married women aged 15-29 years were
at greatest risk of suicidal behavior by burns. The most common
precipitating factor (74.4%) for suicidal behavior was a quarrel with a
family member, a relative, and/or a friend. In conclusion, the high
rate of suicidal behavior by burns among young/married women in
Fars is of concern. Social, cultural, and economic factors may
contribute to suicidal behavior and need to be addressed through
education, support, and commitment (5).
At the critical moment, Zimri was depressed and so despaired that
his life had no meaning. Zimri reigned only for a few days over Tirzah,
before committing suicide by setting fire to his house. The Bible
provides no details about Zimri's family, quarrel with a family
member, a relative, and/or a friend. He knew he would be
overthrown and could not cope with the idea of defeat. Thus,
psychosocial factors played a decisive role to commit suicide. There
was only one escape from the disgrace of defeated by his enemies to
end his life in the way that he chose.

References
1. Crosby K, Rhee JO, Holland J. Suicide by fire: a contemporary method of
political protest. Int J Soc Psychiatry. 1977;23(1):60-9.
2. Shkrum MJ, Johnston KA. Fire and suicide: a three-year study of self-
immolation deaths. J Forensic Sci. 1992;37(1):208-21.
3. Copeland AR. Suicidal fire deaths revisited. Z Rechtsmed. 1985;95(1):51-7.
 31
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4. Saaiq M, Ashraf B. Epidemiology and outcome of self-inflicted burns at

Pakistan institute of medical sciences, Islamabad. World J Plast Surg. 2014;3(2):107-
14.
5. Lari AR, Alaghehbandan R, Panjeshahin MR, Joghataei MT. Suicidal behavior by
burns in the province of Fars, Iran. Crisis. 2009;30(2):98-101.

ABIMELECH
Abimelech a son of Jerubbaal, went to Ophrah and killed his 70
half-brothers, the sons of Jerubbal from different wives (Judges 9:5).
Later, Abimelech was anointed King, and he “…had reigned three
years over Israel” (9:22). But, subsequently the men of Shechem
betrayed Abimelech so a war developed between the people of
Shechem and Abimelech. During this war Abimelech captured the
city of Thebez (Judges 9:50,51), and from the tower of this city one
woman “cast a piece of a millstone upon Abimelech’s head, and
crushed his skull” (9:53). Seeing approaching death, Abimelech asked
his armour-bearer to kill him with a sword. Here Abimelech
committed assisted suicide, rather than having it said that he died at
the hands of a woman.
Historical records on suicides among the British Army during the
Crimean War for the years 1854-1856 were examined. There were 18
documented suicides in the British Army during this period.
Calculating an accurate annual suicide rate per 100,000 is impossible
because it is unclear how many of the 111,313 military personnel
were in country for each of the two years of the war. However, the
range is estimated at 8-16 per 100,000, with the likely answer
somewhere near the middle. This suggests the possibility that
increasing suicide rates among active duty military may be a modern
U.S. phenomenon (1).
Since 2010, suicide has been the second leading cause of death
among U.S. service members, exceeded only by war injury. Suicide
mortality rates in the Army and Marine Corps have increased during
the conflicts in Iraq and Afghanistan; however, most active duty
service members who die by suicide have never deployed. During
1998-2011, 2,990 service members died by suicide while on active
duty. Numbers and rates of suicide were highest among service
members who were male, in the Army, in their 20s and of white
race/ethnicity. Suicide death rates were 24 percent higher among
divorced/separated than single, never-married service members.
 32
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Firearms were the most frequently used method of suicide among

both males and females. Numbers and rates of suicide among
military members have increased sharply since 2005 and an
increasing proportion of these suicides were by firearms. When
adjusted for age, rates of suicide were somewhat lower among active
military members than civilians. There are not well-established and
clearly effective interventions to prevent suicides - in general or
specifically in a military population during wartime (2).

Assessment: military suicide is a prevalent human behavior.

Abimelech was a brave warrior; he fought with his enemies during
most of his life, but in the end was defeated by a simple stone cast by
a woman. His pride would not allow him to die at this woman’s hand
and there was no possibility of being rescued and healed. The
prognosis for traumatic skull injury accompanied by fracture is very
grave with no chance of survival, so he chose assisted suicide. In this
way his death would appear as the death of a warrior, not kneeling
before an unknown simple woman.
Abimelech died like a hero completing suicide in military
circumstances.

References
1. Smith JA, Masuhara KL, Frueh BC. Documented suicides within the British
Army during the Crimean War 1854-1856. Mil Med. 2014;179(7):721-3.
2. Armed Forces Health Surveillance Center (AFHSC). Deaths by suicide while
on active duty, active and reserve components, U.S. Armed Forces, 1998-2011.
MSMR. 2012;19(6):7-10.

BIOLOGICAL TESTS
HPA axis function was examined in relation to suicidal behavior in
depression. There were insignificant differences between depressed
patients who had or had not attempted suicide for either CSF
concentrations of CRH, plasma cortisol levels predexamethasone or
postdexamethasone, or for urinary-free cortisol outputs. However,
depressed patients who had made a violent suicide attempt had
significantly higher 4r PM and maximum postdexamethasone plasma
cortisol levels, and significantly more of them were cortisol
nonsuppressors than patients who had made nonviolent suicide
attempts. A 5-year follow-up was carried out. There were
 33
L. Ben-Nun Suicide

insignificant differences on indices of HPA function between

depressed patients who did or did not reattempt suicide during the
follow-up or who had never attempted suicide. These results suggest
the possibility that dysregulation of the HPA axis may be a
determinant of violent suicidal behavior in depression (1).
Hyperactivity of the HPA-axis is a common finding in MDD. Similar
studies on suicide attempters are less abundant, and the results are
divergent. The main aim of the present study was to investigate HPA-
axis parameters by the time of a suicide attempt and at follow-up in
search for associations between HPA-axis function and suicidal
behavior. Thirty-five suicide attempters and 16 non-suicidal controls
were admitted to a psychiatric ward between the years of 1986 and
1992. CRH in CSF and urinary cortisol were obtained for the suicide
attempters. The patients were followed up approximately 12 years
after the index admission. Cortisol was measured in saliva, and
additional suicide attempts and current psychiatric symptoms were
registered. At follow-up, evening salivary cortisol was lower in
suicide attempters compared to controls. Low cortisol levels at
follow-up were associated with severe psychiatric symptoms. Among
women, repeated suicide attempts were associated with low
morning and lunch salivary cortisol and in this subgroup, significant
correlations between salivary cortisol at follow-up, and CRH as well
as urinary cortisol at index were found. In conclusion, there is an
association between low HPA-axis activity and suicidal behavior. This
could be due to long-lasting and severe psychiatric morbidity, which
in turn has exhausted the HPA-axis of these patients. The potential
role of hypocortisolism should be given more attention in studies on
suicidal patients (2).
Risk factors for suicidal behavior include adverse life events as
well as biochemical parameters acting, e.g. within the HPA axis
and/or monoaminergic systems. The aim of the present investigation
was to study stressful life events and biological stress markers among
former psychiatric inpatients, who were followed up 12 years after
an index suicide attempt. At the time of the index suicide attempt,
and before treatment, CSF samples were taken, and 24 h urine was
collected. MHPG in CSF and 24 h urinary samples of cortisol and NA/A
were analyzed. Data concerning stressful life events were collected
retrospectively from all participants in the study through semi-
structured interviews at follow-up. Patients who reported sexual
abuse during childhood and adolescence had significantly higher
 34
L. Ben-Nun Suicide

levels of CSF-MHPG and urine-NA/A, than those who had not. Low 24
hour's urine-cortisol was associated with feelings of neglect during
childhood and adolescence. In conclusion, significant and discrepant
biological stress-system was related to some adverse life events (3).
Tyrosinase is a copper-containing mono-oxygenase, widely
distributed in nature, able to catalyze the oxidation of both phenols
and catechols to the corresponding ortho-quinones. Tyrosinase is
characterized by a hitherto unexplained irreversible inactivation
which occurs during the oxidation of catechols. Although the
corresponding catechols are formed during tyrosinase oxidation of
monophenols, inactivation in the presence of monophenolic
substrates is minimal. Previous studies have established the kinetic
features of the inactivation reaction which is first-order in respect of
the enzyme concentration. The inactivation reaction exhibits the
same pH-profile and saturation properties as the oxidation reaction,
classing the process as a mechanism-based suicide inactivation. The
recent elucidation of the crystallographic structure of tyrosinase has
stimulated a new approach to this long-standing enigma. The results
of an investigation of the tyrosinase-catalysed oxidation of a range of
hydroxybenzenes establish the structural requirements associated
with inactivation. Evidence for an inactivation mechanism is based on
catechol hydroxylation, with loss of one of the copper atoms at the
active site. The inactivation mechanism involves two linked processes
occurring in situ: 1] catechol presentation resulting in alpha-
oxidation, and 2] deprotonation of an adjacent group. Based on these
experimental, a similar mechanism may account for the inhibitory
action of resorcinols (4).
This paper selectively reviews the author's recent studies on
suicidal behavior in depression. Data are reviewed from a study of
depressed patients who had monoamine metabolites measured in
both the CSF and urine. Depressed patients who had attempted
suicide had significantly reduced CSF concentrations of the dopamine
metabolite HVA and significantly lower urinary outputs of HVA than
patients who had not attempted suicide. Similarly, patients who went
on to reattempt suicide over a 5-year follow-up period had both
significantly reduced CSF concentrations of HVA and lower urinary
outputs of HVA than patients who did not reattempt. These data
suggest a role for diminished central dopaminergic
neurotransmission in suicidal behavior in depression. Patients who
 35
L. Ben-Nun Suicide

had made a violent suicide attempt showed evidence of

dysregulation of the HPA axis (5).
Biochemical studies related with suicidal behavior have mainly
dealt with monoaminergic and corticosteroidal measures. Some of
these measures were used in a study of 61 suicide attempters who,
except for occasional doses of benzodiazepines, had been medication
free for a mean of 16 days. The monoamine metabolites 5-
hydroxyindoleacetic acid, HVA, and 3-methoxy-4-
hydroxyphenylglycol were measured in lumbar CSF. Violent suicide
attempters (n=18) had 5-hydroxyindoleacetic acid concentrations
below the median of all patients, whereas the concentrations of 3-
methoxy-4-hydroxyphenylglycol were mainly above the median.
Insignificant differences were found between violent and nonviolent
(n=43) attempters concerning CSF HVA, 24-hour urinary
norepinephrine-epinephrine and cortisol, activity of monoamine
oxidase in platelets, or post-dexamethasone plasma cortisol. Four
patients completed suicide, and three of them had CSF 5-
hydroxyindoleacetic acid concentrations at or below the median. All
completed suicides had CSF 3-methoxy-4-hydroxyphenylglycol
concentrations above the median. Urinary measures and platelet
monoamine oxidase activity of completed suicides were in the higher
concentration ranges. Patients who repeated suicidal behavior after
the index investigation had low 24-hour urinary cortisol levels more
often than those who did not repeat. Because subgroups of patients
are small, any firm conclusions about the value of our CSF and urinary
biochemical findings predicting suicidal behavior cannot be drawn.
However, the CSF findings in violent suicide attempters are similar to
those observed in other studies (6).

Assessment: suicidal behavior can be predicted by a variety of

biological tests.

References
1. Roy A. Hypothalamic-pituitary-adrenal axis function and suicidal behavior in
depression. Biol Psychiatry. 1992;32(9):812-6.
2. Lindqvist D, Isaksson A, Träskman-Bendz L, Brundin L. Salivary cortisol and
suicidal behavior - a follow-up study. Psychoneuroendocrinology. 2008;33(8):1061-8.
3. Sunnqvist C, Westrin A, Träskman-Bendz L. Suicide attempters: biological
stressmarkers and adverse life events. Eur Arch Psychiatry Clin Neurosci. 2008;
258(8):456-62.
4. Land EJ, Ramsden CA, Riley PA. The mechanism of suicide-inactivation of
tyrosinase: a substrate structure investigation. Tohoku J Exp Med.2007;212(4):341-8.
 36
L. Ben-Nun Suicide

5. Roy A. Recent biologic studies on suicide. Suicide Life Threat Behav.

1994;24(1):10-4.
6. Träskman-Bendz L, Alling C, Oreland L, et al. Prediction of suicidal behavior
from biologic tests. J Clin Psychopharmacol. 1992;12(2 Suppl):21S-26S.

HEREDITY
A family study of adolescent suicide victims (suicide probands)
and community control probands (controls) was conducted to
determine if the rates of suicidal behavior were higher in the
relatives of adolescent suicide probands even after adjusting for
differences in the familial rates of psychiatric disorders. The
relatives of 58 adolescent suicide probands and 55 demographically
similar controls underwent assessment for Axis I and II psychiatric
disorders, lifetime history of aggression, and history of suicidal
behavior (attempts and completions) using a combination of family
study and family history approaches. The rate of suicide attempts
was increased in the first-degree relatives of suicide probands
compared with the relatives of controls, even after adjusting for
differences in rates of proband and familial Axis I and II disorders
(OR 4.3, 95% CI 1.1-16.6). On the other hand, the excess rate of
suicidal ideation found in the relatives of suicide probands was
explained by increased familial rates of psychiatric disorders.
Among suicide probands, higher ratings of aggression were
associated with higher familial loading for suicide attempts. In
conclusion, liability to suicidal behavior might be familially
transmitted as a trait independent of Axis I and II disorders. The
transmitted spectrum of suicidal behavior includes attempts and
completions, but not ideation, and the transmission of suicidal
behavior and aggression are related (1).
Evidence from twin, adoption, and family studies suggests that
there is strong aggregation of suicidal behaviors in some families. By
comparison, the role of social modeling through peers has yet to be
convincingly established. This paper uses data from four large studies
(the WHO/EURO Multicentre Study on Suicidal Behavior, the
WHO/SUPRE-MISS, the CASE study, and the Queensland Suicide
Register) to compare the effects of exposure to fatal and nonfatal
suicidal behavior in family members and nonfamilial associates on
the subsequent suicidal behavior of male and female respondents of
 37
L. Ben-Nun Suicide

different ages. Across all studies, prior suicidal behaviors among

respondents' social groups were more important predictors of
suicidal behavior in the respondents themselves than previous
research had indicated. Community-based suicide attempters in the
WHO SUPRE-MISS had higher rates of exposure to prior suicide in
nonfamilial associates than in family members. In an adolescent
population, exposure to prior fatal suicidal behavior did not predict
deliberate self-harm when exposure to nonfatal suicidal behavior
(both familial and social) were controlled for, but exposure to
nonfatal suicidal behaviors in family and friends was predictive of
deliberate self-harm and suicide ideation, even after controlling for
exposure to fatal suicidal behavior. The potential impact of
"containment" of information regarding suicidal behaviors as a
prevention initiative is discussed, in light of information behavior
principles of social marketing (2).
Suicidal behavior is highly familial, and based on twin and
adoption studies, heritable as well. Both completed and attempted
suicide form part of the clinical phenotype that is familially
transmitted, as rates of suicide attempt are elevated in the family
members of suicide completers, and completion rates are elevated in
the family members of attempters. A family history of suicidal
behavior is associated with suicidal behavior in the proband, even
after adjusting for presence of psychiatric disorders in the proband
and family, indicating transmission of attempt that is distinct from
family transmission of psychiatric disorder. Impulsive aggression in
probands and family members is associated with family loading for
suicidal behavior, and may contribute to familial transmission of
suicidal behavior. Shared environment effects such as abuse,
imitation, or transmission of psychopathology are other possible
explanations (3).
There is substantial evidence suggesting that suicide aggregates
in families. However, the extent of overlap between the liability to
suicide and psychiatric disorders, particularly MDD, remains an
important issue. Similarly, factors that account for the familial
transmission of suicidal behavior remain unclear. Thus, through
direct and blind assessment of first-degree relatives, the authors
conducted a family study of suicide by examining three proband
groups: probands who committed suicide in the context of MDD,
living depressed probands with no history of suicidal behavior, and
psychiatrically normal community comparison probands.
 38
L. Ben-Nun Suicide

Participants were 718 first-degree relatives from 120 families: 296

relatives of 51 depressed probands who committed suicide, 185
relatives of 34 nonsuicidal depressed probands, and 237 relatives
of 35 community comparison subjects. Psychopathology, suicidal
behavior, and behavioral measures were assessed via interviews.
The relatives of probands who committed suicide had higher levels
of suicidal behavior (10.8%) than the relatives of nonsuicidal
depressed probands (6.5%) and community comparison probands
(3.4%). Testing cluster B traits as intermediate phenotypes of
suicide showed that the relatives of depressed probands who
committed suicide had elevated levels of cluster B traits; familial
predisposition to suicide was associated with increased levels of
cluster B traits; cluster B traits demonstrated familial aggregation
and were associated with suicide attempts among relatives; and
cluster B traits mediated, at least in part, the relationship between
familial predisposition and suicide attempts among relatives.
Analyses were repeated for severity of attempts, where cluster B
traits also met criteria for endophenotypes of suicide. In
conclusion, familial transmission of suicide and MDD, while partially
overlapping, are distinct. Cluster B traits and impulsive-aggressive
behavior represent intermediate phenotypes of suicide (4).
First-degree relatives of persons with mood disorder who
attempt suicide are at greater risk for mood disorders and
attempted or completed suicide. This study examined the shared
and distinctive factors associated with familial mood disorders and
familial suicidal behavior. First-degree relatives' history of DSM-IV-
defined mood disorder and suicidal behavior was recorded for 457
mood disorder probands, of whom 81% were inpatients and 62%
were female. Probands' lifetime severity of aggression and
impulsivity were rated, and probands' reports of childhood physical
or sexual abuse, suicide attempts, and age at onset of mood
disorder were recorded. Of the probands, 23.2% with mood
disorder who had attempted suicide had a first-degree relative with
a history of suicidal behavior, compared with 13.2% of the
probands with mood disorder who had not attempted suicide (OR
1.99, 95% CI 1.21-3.26). Thirty percent (30.8%) of the first-degree
relatives with a diagnosis of mood disorder also manifested suicidal
behavior, compared with 6.6% of the first-degree relatives with no
mood disorder diagnosis (OR 6.25, 95% CI 3.44-11.35). Probands
with and without a history of suicide attempts did not differ in the
 39
L. Ben-Nun Suicide

incidence of mood disorder in first-degree relatives (50.6% vs.

48.1%). Rates of reported childhood abuse and severity of lifetime
aggression were higher in probands with a family history of suicidal
behavior. Earlier age at onset of mood disorder in probands was
associated with greater lifetime severity of aggression and higher
rates of reported childhood abuse, mood disorder in first-degree
relatives, and suicidal behavior in first-degree relatives. In
conclusion, risk for suicidal behavior in families of probands with
mood disorders appears related to early onset of mood disorders,
aggressive/impulsive traits, and reported childhood abuse in
probands (5).
Familial transmission of mood disorders is important but
insufficient for family transmission of suicidal behavior (6). Impulsive
aggression and violent suicidal behavior in suicide attempters or
completers are associated with much greater family loading for
suicidal behavior (1). Family discord increases the risk for suicide
attempt and completion in young people (7-90). Family discord and
abuse may also be explained by increased rates of parental mental
disorder, tendency to impulsive aggression, and suicide attempt in
abusive parents (10-12).
Suicide is the third leading cause of death among adolescents
and a non-trivial percentage of adolescents report knowing
someone who has attempted suicide. In light of this, a growing
body of literature has explored whether suicidal behavior in one
person may be imitated by others in their social networks. The aim
of this study was to seek to determine the extent to which suicidal
behavior in individuals is influenced by suicidal behaviors of their
peer and family members. Using a nationally representative
sample of adolescents, multivariate regression analysis with
controls for known factors associated with suicidal behaviors was
performed to help isolate the effects of peer and family members
on suicidal behaviors. This methodology allowed accounting for
environmental confounders, simultaneity and to a limited extent,
non-random peer selection. Peer measures were drawn from the
nomination of close friends by the individuals and suicidal
behaviors among the peer group were constructed using the peers'
own responses. A 10% increase in suicide attempts by family
members was associated with a 2.13% and 1.23% increase in
adolescent suicidal ideation and attempts, respectively. A 10%
increase in peer suicidal ideation and attempts lead to a 0.7% and
 40
L. Ben-Nun Suicide

0.3% increase in such behavior by the individuals. However, these

positive associations between peer and individual suicide behavior
become smaller and insignificant after adjustments were made for
environmental confounders and peer selection. Although the
overall importance of environmental confounding factors was
established, the specific components or characteristics of the
surroundings that can explain suicidality cannot be identified. The
complex relationships between peer selection and suicidality limit
the determination of causality. In conclusion, an increase in
suicidal behavior by family members is positively associated with
suicidal behavior among adolescents and effective policies aimed at
reducing suicidal rates should consider these impacts. However,
attributing correlations in suicidal behaviors among peers to social
network effects should be undertaken with caution, especially
when environmental confounders are not adequately controlled for
in the analysis (13).
Suicide behavior spans a spectrum ranging from suicidal ideation
to suicide attempts and completed suicide. Strong evidence suggests
a genetic susceptibility to suicide behavior, including familial
heritability and common occurrence in twins. Recent molecular
genetic studies in suicide behavior include case-control association,
genome gene-expression microarray, and GWA. The work also
includes epigenetics in suicide behavior and pharmacogenetic studies
of antidepressant-induced suicide. Suicide behavior fulfills criteria for
a complex genetic phenotype in which environmental factors interact
with multiple genes to influence susceptibility. So far, case-control
association approaches are still the mainstream in suicide behavior
genetic studies, although whole genome gene-expression microarray
and GWA studies have begun to emerge in recent years. Genetic
association studies have suggested several genes (e.g., serotonin
transporter, tryptophan hydroxylase 2, and brain-derived
neurotrophic factor) related to suicidal behavior, but not all reports
support these findings. The case-control approach while useful is
limited by present knowledge of disease pathophysiology. Genome-
wide studies of gene expression and genetic variation are not
constrained by the limited knowledge. However, the explanatory
power and path to clinical translation of risk estimates for common
variants reported in GWA studies remain unclear because of the
presence of rare and structural genetic variation. As whole genome
sequencing becomes increasingly widespread, available genomic
 41
L. Ben-Nun Suicide

information will no longer be the limiting factor in applying genetics

to clinical medicine. These approaches provide exciting new avenues
to identify new candidate genes for suicide behavior genetic studies.
The other limitation of genetic association is the lack of a consistent
definition of the suicide behavior phenotype among studies, an
inconsistency that hampers the comparability of the studies and data
pooling. In summary, suicide behavior involves multiple genes
interacting with non-genetic factors. A better understanding of the
suicidal behavior genes by combining whole genome approaches
with case-control association studies, may potentially lead to
developing effective screening, prevention, and management of
suicide behavior (14).
Suicide is a serious public health concern, and it is partly genetic.
The BDNF gene has been a strong candidate in genetic studies of
suicide (15,16) and BDNF regulates the expression of the dopamine
D3 receptor. The role of the BDNF and DRD3 genes in suicide was
examined. Four tag SNPs in BDNF and 15 SNPs in the D3 receptor
gene DRD3 for possible association with suicide attempt history in
Canadian sample of schizophrenia patients of European ancestry
(n=188) were examined. In this sample, a possible interaction
between the BDNF Val66Met and DRD3 Ser9Gly SNPs in increasing
the risk of suicide attempt(s) in schizophrenia sample was found.
Specifically, a larger proportion of schizophrenia patients who were
carrying at least one copy of the minor allele at each of the Val66Met
and Ser9Gly functional markers have attempted suicides compared
to patients with other genotypes (Bonferroni p<0.05). However, this
finding could not be replicated in samples from other psychiatric
populations. In conclusion, an interaction between BDNF and DRD3
may not play a major role in the risk for suicide attempt, though
further studies, especially in schizophrenia, are required (17).
Genome wide array studies have reported limited success in
identifying genetic markers conferring risk for suicidal behavior.
This may be attributable to study designs with primary outcome
other than suicidal behavior. GWAs on suicides and cases with a
history of nonfatal suicide attempts were compared with
psychiatric controls and healthy volunteers. A consortium of USA,
Canadian and German teams assembled two groups of cases
(suicide attempters and suicides, n=577) and non-attempter
psychiatric and healthy controls (n=1,233). No SNP reached
genome-wide significance, but several SNPs within STK3,
 42
L. Ben-Nun Suicide

ADAMTS14, PSME2, and TBX20 genes reached p < 1 × 10-5 . The top

SNPs for the suicide attempt analysis included two from DPP10, 1
from CTNNA3 and1 from STK32B. In the suicide analysis, seven
SNPs from the TBX20 gene in the top hits were found. Pathway
analysis identified the following pathways: "Cellular Assembly and
Organization," "Nervous System Development and Function," "Cell
Death and Survival," "Immunological Disease," "Infectious Disease,"
and "Inflammatory Response." The top genes in the suicidal
behavior analysis did not overlap with those in the ideation
analysis. No genome wide significant results suggest that
susceptibility to suicidal behavior has genetic risk factors with
smaller effect sizes. The strongest candidate genes, ADAMTS14,
and PSME2 (both linked to inflammatory response), STK3 (neuronal
cell death), and TBX20 (brainstem motor neuron development),
have not been previously reported in association with suicide and
warrant further study (18).

Assessment: there is strong aggregation of suicidal behaviors in

some families. A family history of suicidal behavior is associated with
suicidal behavior in the proband, even after adjusting for presence of
psychiatric disorders in the proband and family, indicating
transmission of attempt that is distinct from family transmission of
psychiatric disorder. Familial transmission of suicide and major
depression, while partially overlapping, are distinct. Cluster B traits
and impulsive-aggressive behavior represent intermediate
phenotypes of suicide. Risk for suicidal behavior in families of
probands with mood disorders is related to early onset of mood
disorders, aggressive/impulsive traits, and reported childhood abuse
in probands.
Molecular genetic studies indicate a genetic susceptibility to
suicide behavior, including familial heritability and common
occurrence in twins.
Familial factors were not present in the biblical characters
studied. In other words, there was no history of sexual abuse,
substance abuse disorder, family discord, or history of twins, whether
monozygotic or dizygotic, or mention of a family member who
committed suicide.
All the biblical characters who committed suicide were men, all
fought with their enemies. All suffered from damaged ego, all felt
hopeless about finding another solution to their problems, all wanted
 43
L. Ben-Nun Suicide

to escape from this world, and none of them wanted to suffer in

captivity, losing their social status, pride and dignity.

References
1. Brent DA, Bridge J, Johnson BA, Connolly J. Suicidal behavior runs in families. A
controlled family study of adolescent suicide victims. Arch Gen Psychiatry. 1996;
53(12):1145-52.
2. de Leo D, Heller T. Social modeling in the transmission of suicidality. Crisis.
2008;29(1):11-9.
3. Brent DA, Mann JJ. Family genetic studies, suicide, and suicidal behavior. Am J Med
Genet C Semin Med Genet. 2005;133C(1):13-24.
4. McGirr A, Alda M, Séguin M, et al. Familial aggregation of suicide explained by
cluster B traits: a three-group family study of suicide controlling for major depressive
disorder. Am J Psychiatry. 2009;166(10) : 1124-34.
5. Mann JJ, Bortinger J, Oquendo MA, et al. Family history of suicidal behavior and
mood disorders in probands with mood disorders. Am J Psychiatry. 2005;162(9):1672-9.
6. Egeland JA, Sussex JN. Suicide and family loading for affective disorders. JAMA.
1985;254:915-8.
7. Gould MS, Fisher P, Parides M et al. Psychosocial risk factors of child and
adolescent completed suicide. Arch Gen Psychiatry. 1996;53:1155-62.
8. Brent DA, Perper JA, Liotus L, et al. Familial factors for adolescent suicide: a case-
control study. Acta Psychiatr Scand. 1994;89:52-8.
9. Taylor EA, Stansfeld SA. Children who poison themselves, I: a clinical comparison
with psychiatric controls. Br J Psychiatry. 1984;145:127-32.
10. Pfeffer CR, Normandin L, Tatsuyuki K. Suicidal children grow up: suicidal behavior
and psychiatric disorders among relatives. J Am Acad Child Psychiatry. 1994;33:1087-97.
11. Chaffin M, Kelleher KL, Hollenberg J. Onset of physical abuse and social risk factors
from prospective community data. Child Abuse Negl. 1996;20:191-203.
12. Roberts J, Hawton K. Child abuse and attempted suicide. Br J Psychiatry.
1980;137:319-23.
13. Ali MM, Dwyer DS, Rizzo JA. The social contagion effect of suicidal behavior in
adolescents: does it really exist? J Ment Health Policy Econ. 2011;14(1):3-12.
14. Tsai SJ, Hong CJ, Liou YJ. Recent molecular genetic studies and methodological
issues in suicide research. Prog Neuropsychopharmacol Biol Psychiatry. 2011;35(4):809-
17.
15. Dwivedi Y, Rizavi HS, Conley RR, et al. Altered gene expression of brain-derived
neurotrophic factor and receptor tyrosine kinase B in postmortem brain of suicide
subjects. Arch Gen Psychiatry. 2003;60(8):804-15.
16. Zai CC, Manchia M, De Luca V, et al. Association study of BDNF and DRD3 genes in
schizophrenia diagnosis using matched case-control and family based study designs. Prog
Neuropsychopharmacol Biol Psychiatry. 2010;34(8):1412-8.
17. Zai CC, Manchia M, Sønderby IE, et al. Investigation of the genetic interaction
between BDNF and DRD3 genes in suicidical behaviour in psychiatric disorders. World J
Biol Psychiatry. 2015;16(3):171-9.
18. Galfalvy H, Haghighi F, Hodgkinson C, et al. A genome-wide association study of
suicidal behavior. Am J Med Genet B Neuropsychiatr Genet. 2015 Jun 16. doi:
10.1002/ajmg.b.32330. [Epub ahead of print]
 44
L. Ben-Nun Suicide

ADVERSE LIFE EVENTS

The purpose of this study was to assess the influence of multiple
adverse life experiences (sexual abuse, homelessness, running away,
and substance abuse in the family) on suicide ideation and suicide
attempt among adolescents at an urban juvenile detention facility in
the U.S. The study sample included 3,156 adolescents processed at a
juvenile detention facility in an urban area in Ohio between 2003 and
2007. The participants, interacting anonymously with a voice-enabled
computer, self-administered a questionnaire with 100 items related
to health risk behaviors. Overall 19.0% reported ever having thought
about suicide (suicide ideation) and 11.9% reported ever having
attempted suicide (suicide attempt). In the multivariable logistic
regression analysis, those reporting sexual abuse (OR 2.75, 95%
CI 2.08-3.63) and homelessness (OR 1.51, 95% CI 1.17-1.94) were
associated with increased odds of suicide ideation, while sexual
abuse (OR 01, 95% CI 2.22-4.08), homelessness (OR 1.49, 95% CI
1.12-1.98), and running away from home (OR 1.38, 95% CI 1.06-1.81)
were associated with increased odds of a suicide attempt. Those
experiencing all four adverse events were 7.81 times more likely
(2.41-25.37) to report having ever attempted suicide than those who
experienced none of the adverse events. In conclusion, considering
the high prevalence of adverse life experiences and their association
with suicidal behaviors in detained adolescents, these factors should
not only be included in the suicide screening tools at the intake and
during detention, but should also be used for the intervention
programming for suicide prevention (1).
Life events are often reported to precede suicide. This paper aims
to determine the frequency, timing and type of life events preceding
suicide by young people and those with and without a mental illness.
Informants, usually family members, were interviewed for a sample
of young (less than 35 years) suicides. Information was recorded on
events occurring in the six months before death. Equivalent
information was obtained for living controls who had been matched
for age and gender and obtained through the general practices of the
suicides. Suicide was associated with life events in the previous three
months, and particularly in the previous week. Specifically,
interpersonal and forensic (being arrested, charged or sentenced)
events distinguished suicides and controls. The number of life events
in the different time under study did not distinguish suicides with and
 45
L. Ben-Nun Suicide

without severe mental illness, although more suicides without a

severe mental illness had a reported life event in the week before
their death. In conclusion, adverse life events frequently precede
suicide in young people with and without severe mental illness.
However, recent life events may have a lesser causal role in those
with severe mental illness. Clinical and health promotion measures to
improve the way that young people cope with interpersonal
problems and other crises may be an important part of any suicide
prevention strategy (2).
Adverse life events have been associated with increased risk of
suicide. Mental disorders are also major risk factors for suicide.
Matching cases and controls for mental disorder is thus appropriate
in studies of suicide. This procedure was used to study the degree
to which excess adversity was more common in cases who
committed suicide as opposed to living controls matched for
mental disorder. The study formed part of a retrospective case-
control comparison of cases of suicide/undetermined death with
living controls using psychological autopsy in southeast Scotland.
Cases and controls were matched for age, sex and mental disorder.
Informants were those closest to cases and controls. Cases and
controls were assessed for life events using the Interview for Life
Events. The subjects were 45 cases of suicide/undetermined death
and 40 living controls. Cases and controls did not differ significantly
in severity of mental disorder. Adverse interpersonal events within
the family (p=0.01) with an OR of 9.0 (95% CI, 1.3-399) and adverse
physical health-related events (OR 5.0, 95% CI 1.1-47, p=0.04) were
significantly more common in cases than controls. In conclusion,
cases had significantly more adverse life events than controls
overall. The categories accounting for these differences were
interpersonal family adversity and physical ill health. There were
insignificant differences in either the number or severity of ongoing
difficulties between cases and controls. Recent adverse life events
contribute to the increased risk of suicide even when age, sex and
mental disorder are controlled for (3).
The occurrence of recent life events during the last three months,
and social support received were studied in a nationwide suicide
population (n=1,067) in Finland. Recent life events were reported in
80% of the suicides. Job problems (28%), family discord (23%),
somatic illness (22%), financial trouble (18%), unemployment (16%),
separation (14%), death (13%), and illness in family (12%) were the
 46
L. Ben-Nun Suicide

most common life events. Sex differences were found in recent life
events: any life event, separation, financial trouble, job problems and
unemployment were more common among males. The mean
number of life events was also higher among males. Living alone was
more common among female victims. Females had children more
often than males. In terms of friendships, more females had a close
friend, whereas more males had friends sharing common interests.
Females had complained of loneliness more often than males. Those
females who had lived alone had encountered a recent death more
often than other females. The male victims who had lived alone had
experienced separation, financial trouble and unemployment during
the last three months more frequently than other males, suggesting a
concurrent stressor effect of these recent life events with living alone
in male suicides (4).
Suicidal ideation substantially increases the odds of future suicide
attempts, and suicide is the second leading cause of death among
adolescents. A history of adverse life events has been linked with
future suicidal ideation and attempts, although studies examining
potential mediating variables have been scarce. One probable
mediating mechanism is how the individual copes with adverse life
events. For example, certain coping strategies appear to be more
problematic than others in increasing future psychopathology, and
emotional suppression in particular has been associated with poor
mental health outcomes in adults and children. However, no studies
to date have examined the potential mediating role of emotional
suppression in the relation between adverse life events and suicidal
thoughts/behavior in adolescence. The goal of the current study was
to examine emotional suppression as a mediator in the relation
between childhood adversity and future suicidal thoughts/behaviors
in youth. A total of 625 participants, aged 14-19 years, seeking
emergency room services were administered measures assessing
adverse life events, coping strategies, suicidal ideation in the last two
weeks, and suicide attempts in the last month. The results suggest
that emotional suppression mediates the relation between adversity
and both (1) suicidal thoughts and (2) suicide attempts beyond
demographic variables and depressive symptoms. This study has
important implications for interventions aimed at preventing suicidal
thoughts and behavior in adolescents with histories of adversity (5).
This study aimed to examine the association between negative life
events and attempted suicide in rural China. Six rural counties were
 47
L. Ben-Nun Suicide

selected from disease surveillance points in Shandong province. A

total of 409 suicide attempters in rural areas between October 1,
2009, and March 31, 2011, and an equal number of matched controls
were interviewed. Negative life events experienced within 1 month,
1-3 months, 3-6 months, and 6-12 months prior to attempted suicide
for cases and prior to interview for controls were compared. Suicide
attempters experienced more negative life events within the last year
prior to suicide attempt than controls prior to interview (83.1% vs.
33.5%). There was a significant dose-response relationship between
negative life events experienced within the last year and increased
risk of attempted suicide. Timing of negative life events analysis
showed that negative life events experienced in the last month and
6-12 months prior to suicide attempt were associated with elevated
risk of attempted suicide, even after adjusting for mental disorders
and demographic factors. Of negative life events, quarrelling with
spouse, quarrelling with other family members, conflicting with
friends or neighbors, family financial difficulty, and serious illness
were independently related to attempted suicide. In conclusion,
negative life events are significantly associated with increased risk for
attempted suicide. Stress management and intervention are
important to prevent suicidal behavior in rural China (6).

Assessment: adverse life events have been associated with

increased risk of suicide.
In all biblical characters studied in this research, adverse negative
life events such as war, and or adverse social events such as
disrupted interpersonal relationships were associated with the
suicidal behavior.

References
1. Bhatta MP, Jefferis E, Kavadas A, et al. Suicidal behaviors among adolescents in juvenile
detention: role of adverse life experiences. PLoS One. 2014;9(2):e89408.
2. Cooper J, Appleby L, Amos T. Life events preceding suicide by young people. Soc
Psychiatry Psychiatr Epidemiol. 2002;37(6):271-5.
3. Cavanagh JT, Owens DG, Johnstone EC. Life events in suicide and undetermined death in
south-east Scotland: a case-control study using the method of psychological autopsy. Soc
Psychiatry Psychiatr Epidemiol. 1999;34(12):645-50.
4. Heikkinen M, Aro H, Lönnqvist J. Recent life events, social support and suicide. Acta
Psychiatr Scand Suppl. 1994;377:65-72.
5. Kaplow JB, Gipson PY, Horwitz AG, et al. Emotional suppression mediates the relation
between adverse life events and adolescent suicide: implications for prevention. Prev Sci.
2014;15(2):177-85.
6. Zhang WC, Jia CX2, Zhang JY3, et al. Negative life events and attempted suicide in rural
China. PLoS One. 2015;10(1):e0116634.
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L. Ben-Nun Suicide

EPIDEMIOLOGY
Suicide constitutes a major public health problem. It is a
manifestation of self-destructive behavior that results from a crisis
often not sufficiently recognized by relatives and friends or by the
medical profession. It affects all age categories and both sexes.
Suicide attempts are at least ten times more frequent than fatal
suicides and repeated attempts are common. According to the WHO,
approximately one million people die by suicide worldwide every
year, and the phenomenon is constantly and globally on the increase.
This plague affects all countries in varying degrees. The suicide rate
varies from 0.5/100,000 in Jamaica to 75.6/100,000 in Lithuania for
men and from 0.2/100,000 in Jamaica to 16.8/100,000 in Sri Lanka
for women. In France, the estimated number of suicides is about
11,000 per year. This represents 2% of the annual death toll, which is
in the upper average relative to other European countries. It is the
second cause of mortality among 15–44 year olds after road
accidents and the first cause of mortality among 30–39 year olds.
Although the proportion of suicides thereafter diminishes
significantly with age, the number of deaths by suicide increases
markedly. Indeed the rate of fatal suicides is six times higher among
the aged over 85 years than among 15–24 year olds. In 1999, suicide
rates for the population as a whole were 26.1/100,000 for men and
9.4/100,000 for women. In addition, there are strong geographical
discrepancies, with higher suicide prevalence in northwestern regions
of France. Analyzing mortality data enables one to evaluate the
suicide situation in a particular country in relation to the rest of the
international community or establish the suicide burden among the
causes of death of certain population categories, such as teenagers.
To do this, gathering statistical data on the population deceased by
suicide requires that one takes into account the medical causes of
death reported on death certificates. Should suicide not be explicitly
mentioned, the prevalence of death by suicide may be
underestimated. Sporadic investigations involving medico-legal
institutions and conducted by INSERM's CépiDC (Epidemiological
Center for Mortality by Medical Causes) have assessed that 1998
suicides in France were under-declared by 20%. Suicidal conduct
presents a number of very heterogeneous phenotypes. "Suicidal
behavior" usually refers to a whole variety of conducts that include
suicide "attempts" (defined as an intentional gesture aimed at dying
 49
L. Ben-Nun Suicide

and requiring evaluation or medical treatment) and suicide as such.

Suicidal behavior may be classified according to the subject's
intentionality (desire to escape, vengeance, altruistic suicide, risk
taking, ordeal behavior, and self-sacrifice), suicidal ideation, means of
suicide (violent or non-violent), degree of lethality (with or without
necessity for intensive care hospitalization), the degree of alteration
of cognitive function (aggressive and impulsive behavior), aggravating
or triggering circumstances (mental confusion, intoxication, and
specific sociodemographical context), and the presence of psychiatric
or other comorbidities. Predictability of suicidal action is uncertain
and it is impossible to draw a precise portrait of the suicidal subject.
Nonetheless, various risk factors have been identified over time, in
particular by using the technique known as psychological autopsy.
This technique is practiced in a number of countries such as Canada,
Great Britain and Finland but is still virtually unpublicized in France.
The aim is to reconstitute the psychological, social and medical
circumstances of death of a person who has committed suicide by
collecting data, especially among friends and relatives. This can then
be used in research efforts to improve our knowledge of risk factors
in suicidal behavior and develop prevention (1).
Over the past 20 years, the WHO has considerably improved
world mortality data. There are still shortcomings but more countries
now report data and worldwide estimates are regularly made. Data
about mortality have been retrieved from the WHO world database.
Worldwide injury mortality estimates for 2008 as well as trends of
the suicide rate from 1950 to 2009 were analyzed. Suicides in the
world amount to 782 thousand in 2008 according to the WHO
estimate, which is 1.4% of total mortality and 15% of injury mortality.
The suicide rate for the world as a whole is estimated at 11.6 per
100,000 inhabitants. The male-female rate ratio of suicide is
estimated to be highest in the European Region (4.0) and the lowest
in the Eastern Mediterranean region (1.1). Among males, the highest
suicide rate in the 15-29 age group is in the South-East Asian region,
in the 45-59 age group in European males and for ages above 60
years in the Western Pacific region. Females from South-East Asia
have a remarkably high suicide rate among 15-29-year-olds and from
age 45 years in the Western Pacific region. The leading country is
currently Lithuania, with a suicide rate of 34.1 per 100,000
inhabitants. Also among males, the suicide rate is the highest in
Lithuania at 61.2. Among females, South Korea with 22.1 is at the top
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L. Ben-Nun Suicide

of world suicide rates. In conclusion, during the past six decades

according to the WHO, Japan, Hungary, and Lithuania have topped
the list of world countries by suicide rate, but if the current trends
continue, South Korea will overtake all others in a few years. The
heart of the problem of suicide mortality has shifted from Western
Europe to Eastern Europe and now seems to be shifting to Asia. China
and India are the biggest contributors to the absolute number of
suicides in the world (2).
The objective of this study was to examine the prevalence and
correlates of attempting suicide in the past 12 months among adults
with past-year suicidal ideation in the U.S. Data were from 229,600
persons aged 18 years or older who participated in the 2008-2012
National Survey on Drug Use and Health. Among them, 12,300
reported having past-year suicidal ideation, and over 2,000 of those
reported attempting suicide within the past 12 months prior to
survey interview. Descriptive analyses and pooled and stratified (by
suicide plan and MDE) multivariate logistic regression models were
applied. MDE was based on assessments of individual diagnostic
criteria from the DSM-IV. Among persons aged 18 years or older in
the U.S, 3.8% reported having suicidal ideation in the past 12 months.
Among past-year suicidal ideators, 13.2% attempted suicide in the
past 12 months. The prevalence of past 12-month suicide attempt
among past-year ideators with MDE was higher than among those
without MDE (14.1% vs. 12.0%). Past 12-month suicide attempt was
more common among ideators with a suicide plan than among
ideators without a plan (37.0% vs. 3.7%). However, the prevalence of
suicide attempt was higher among ideators with a plan but without
MDE than among ideators with a plan and MDE (42.1% vs. 32.9%).
Compared with ideators without a plan, ideators with a plan had a
higher (AOR 2.2, 95% CI 1.47-3.45) suicide attempt risk among those
without MDE (AOR 22.4, 95% CI 16.55-30.27) than among those with
MDE (AOR 10.7, 95% CI 7.91-14.49). In conclusion, among adult
suicidal ideators, factors associated with their progression from
ideation to suicide attempt may vary by their suicide plan and major
depression status. Focusing attention on high-risk subgroups may be
warranted (3).
Firearm homicides and suicides are a continuing public health
concern in the U.S. During 2009-2010, a total of 22,571 firearm
homicides and 38,126 firearm suicides occurred among U.S.
residents. This includes 3,397 firearm homicides and 1,548 firearm
 51
L. Ben-Nun Suicide

suicides among persons aged 10-19 years; the firearm homicide rate
for this age group was slightly above the all-ages rate. This report
updates an earlier report that provided statistics on firearm
homicides and suicides in major metropolitan areas for 2006-2007,
with special emphasis on persons aged 10-19 years in recognition of
the importance of early prevention efforts. Firearm homicide and
suicide rates were calculated for the 50 most populous U.S. MSAs for
2009-2010 using mortality data from the National Vital Statistics
System and population data from the U.S. Census Bureau.
Comparison statistics were recalculated for 2006-2007 to reflect
revisions to MSA delineations and population estimates subsequent
to the earlier report. Although the firearm homicide rate for large
MSAs collectively remained above the national rate during 2009-
2010, more than 75% of these MSAs showed a decreased rate from
2006-2007, largely accounting for a national decrease. The firearm
homicide rate for persons aged 10-19 years exceeded the all-ages
rate in many of these MSAs during 2009-2010, similar to the earlier
reporting period. Conversely, although the firearm suicide rate for
large MSAs collectively remained below the national rate during
2009-2010, nearly 75% of these MSAs showed an increased rate from
2006-2007, paralleling the national trend. Firearm suicide rates
among persons aged 10-19 years were low compared with all-ages
rates during both periods. These patterns can inform the
development and monitoring of strategies directed at reducing
firearm-related violence (4).
This article compares the prevalence of lifetime suicidal ideation
and suicide attempts among major U.S. Latino ethnic subgroups and
identifies psycho-sociocultural factors associated with suicidal
behaviors. The National Latino and Asian American Study includes
Spanish- and English-speaking Mexicans, Puerto Ricans, Cubans, and
other Latinos. A total of 2,554 interviews were conducted in both
English and Spanish by trained interviewers between May 2002 and
November 2003. Lifetime psychiatric disorders were measured using
the WHO-CIDI. The lifetime prevalence of suicidal ideation and
suicide attempts among Latinos was 10.1% and 4.4%, respectively.
Puerto Ricans were more likely to report ideation as compared with
other Latino subgroups, but this difference was eliminated after
adjustments for demographic, psychiatric, and sociocultural factors.
The majority of lifetime suicide attempts described by Latinos were
reported as occurring when they were under the age of 18 years. Any
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L. Ben-Nun Suicide

lifetime DSM-IV diagnoses, including dual diagnoses, were associated

with an increased risk of lifetime suicidal ideation and suicide
attempts among Latinos. In addition, female gender, acculturation
(born in the U.S. and English speaking), and high levels of family
conflict were independently and positively correlated with suicide
attempts among Latinos, even among those without any psychiatric
disorder. In conclusion, these findings reinforce the importance of
understanding the process of acculturation, the role of family, and
the sociocultural context for suicide risk among Latinos. These should
be considered in addition to psychiatric diagnoses and symptoms in
Latino suicide research, treatment, and prevention, especially among
young individuals (5).
Suicides remain a major public health problem in Greenland. Their
increase coincides with the modernization since 1950. A significant
proportion of participants in countrywide surveys reports serious
suicidal thoughts. The objective of this study was to analyze the time
trend by region of suicides and suicidal thoughts among the Inuit in
Greenland. Data included the Greenland registry of causes of death
for 1970-2011 and two cross-sectional health surveys carried out in
1993-1994 and 2005-2010 with 1,580 and 3,102 Inuit participants,
respectively. Suicide rates were higher among men than women
while the prevalence of suicidal thoughts was higher among women.
Suicide rates for men and women together increased from 1960 to
1980 and have remained around 100 per 100,000 PY since then. The
regional pattern of time trend for suicide rates varied with an early
peak in the capital, a continued increase to very high rates in remote
East and North Greenland and a slow increase in villages relative to
towns on the West Coast. Suicidal thoughts followed the regional
pattern for completed suicides. Especially for women there was a
noticeable increasing trend in the villages. The relative risk for suicide
was highest among those who reported suicidal thoughts, but most
suicides happened outside this high-risk group. In conclusion, suicide
rates and the prevalence of suicidal thoughts remain high in
Greenland but different regional trends point towards an increased
marginalization between towns on the central West Coast, villages
and East and North Greenland (6).
MDD is a common but still underdiagnosed and undertreated
illness which, with its complications (suicide, secondary alcoholism,
loss of productivity, increased cardiovascular morbidity and
mortality), is a major public health problem worldwide. Implementing
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L. Ben-Nun Suicide

the present pharmacological and non-pharmacological treatment

strategies, MDD can be successfully treated resulting in a significant
decline in suicide risk and the economic burden caused by untreated
depression is much higher than the cost of treatment. There is the
impact of the development of the Hungarian psychiatric care system
in the past three decades and the 2008 recession on the changing
national suicide rate. Like international data, Hungarian studies show
that more widespread and effective treatment of depression is the
main component of the more than 50% decline of suicide mortality in
Hungary during the last 30 years (7).
An analysis of suicide and homicide rates was made for countries
of the Eastern Mediterranean Region using global burden disease
data for 2000. The suicide/homicide ratio by age, sex and country
level of income was calculated by dividing the suicide rate by the sum
of the suicide and homicide rate. Males were more often victims of
homicide whilst females were more often victims of suicide. For all
male age groups except males 60+ years in high-income countries,
the suicide/homicide ratio was 50% or less while for all female age
groups except those 60+ years in high-income countries and females
5-14 years old in low- and middle-income countries, the
suicide/homicide ratio was over 50% (8).
As one of the more specific and distinctive problems of human
beings, suicide has been investigated with increasing attention all
over the world. Several risk factors have been described as well as
limitations arising from their study. The WHO estimates that this
scourge affects one million people annually, which corresponds to
one death every 40 seconds worldwide. According to recent studies,
Portugal, despite the good rates (10 suicide deaths per 100,000
inhabitants), had shown an increasing trend among younger people.
This work aims to characterize the evolution of the suicidal profile
autopsied at the Forensic Pathology Department of the Centre
Branch of the National Institute of Legal Medicine and Forensic
Sciences of Portugal, analyzing several variables: age, gender, marital
status, employment status, suicidal methodology, toxicological
analysis and some conditions/behaviors regarding personal history
(alcoholism, suicidal ideation, suicide attempts, physical illness, and
psychiatric disorder). All the autopsies from the 1 January, 2003 to 31
December, 2009 were analyzed. The suicide profile achieved
corresponded to a man (77%), aged between 65 and 74 years old
(20.4%), married (54.5%), employed, who committed suicide by
 54
L. Ben-Nun Suicide

hanging, in September, May or February. Clinical records include an

organic health problem or psychiatric one, in addition to risk
behaviors such as alcoholism, suicidal thoughts or suicide attempts.
The number of suicides autopsied at the Centre Branch has
increased, resembling the profile to the result of many other authors.
However, new medical and social developments place hanging as the
favorite suicide method in our study. Many barriers remain to
overthrow but several prevention programs begin to be designed and
implemented (9).
The objective of this hybrid, ecological and time-trend study was
to describe mortality from homicides in Itabuna, in the State of Bahia.
The mortality coefficients per 1,000 inhabitants, adjusted by the
direct technique, proportional mortality by sex and age range, and
Potential Years of Life Lost were all calculated. Since 2005, the
external causes have moved from third to second most-common
cause of death, with homicides being responsible for the increase. In
the 13 years analyzed, homicides have risen 203%, with 94% of these
deaths occurring among the male population. Within this group, the
growth occurred mainly in the age range from 15 to 29 years of age.
It was ascertained that firearms caused 83% of the deaths; 57.2%
occurred in public thoroughfares; and 98.4% in the urban zone. In
2012, the 173 homicides resulted in 7,837 potential years of life lost,
with each death causing, on average, the loss of 45.3 years. In
conclusion, mortality by homicide in a medium-sized city in Bahia
reaches levels observed in the big cities of Brazil in the 1980s,
evidencing that the phenomenon of criminality - formerly
predominant only in the big urban centers - is advancing into the
rural area of Brazil, causing changes in the map of violent homicide in
Brazil (10).
The aim of the study was to evaluate the prevalence of suicidal
ideations and suicide attempts in a representative sample of the
general population of the urban area of Casablanca, Morocco. The
survey was conducted based on face-to-face household interviews.
The MINI was used to assess axis I diagnoses according to DSM-IV
criteria and the MINI suicidality module to rate the severity of
active suicidality. The 1-month prevalence of suicidal ideation was
6.3%. Seventeen subjects (2.1%) reported at least one suicide
attempt during their lifetime. Some variables were positively
associated to suicidal ideation: the non-married status, subjects
with a history of psychiatric disorders, and subjects without
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L. Ben-Nun Suicide

children. At least one mental disorder was present among 88.2% of

subjects with suicidal ideation. MDD was the most prevalent one
(23.5%). In conclusion, suicidal ideation being relatively frequent in
the general population, there is a need to develop programs of
prevention of suicide (11).
Attempted and completed suicide constitutes a major public
health problem among young people worldwide, including South
Africa. Suicide attempt and completed suicide increase during the
adolescent period. One in five adolescents considers attempting
suicide, but statistics are frequently unreliable. Data for this study
were derived from the 2002 and 2008 South African Youth Risk
Behavior Surveys. The study population comprised grades 8, 9, 10
and 11 students in governmental schools in the 9 provinces of
South Africa (n=10,699 in 2002 and 10,270 in 2008). Key outcome
measures were suicide ideation and suicide attempts. Of the total
sample, 18% of the students in 2002 and 19% in 2008 reported to
have seriously considered and/or made a plan to commit suicide
during the past six months (Suicide ideation), whereas 18.5% of
students in 2002 and 21.8% in 2008 reported that they had
attempted suicide at least one time during the past six months. On
both suicide measures, girls have higher prevalence scores than
boys, and older school learners score higher than younger learners
do. In addition, 32% of the learners reported feelings of sadness or
hopelessness. These feelings contributed significantly to the
explanation of suicide ideation and suicide attempt next to being
the victim or actor in violent acts and illegal substance use. In
conclusion, the prevalence of suicide ideation and suicide attempts
among South African adolescents is high and seems to be
influenced by a wide spectrum of factors at the demographic,
psychological and behavioral level (12).
The present study aimed to survey the suicide trends in Fars
province (Iran), during 2004-2009 to better understand the
prevalence and status of suicide. This survey was a cross-sectional
study. The demographic data were collected from the civil status
registry between 2004 and 2009. Suicide and suicide attempt data
were collected of three sources including the affiliated hospitals of
Shiraz University of Medical Sciences, mortality data of Vice
Chancellery of Health in Fars province and data from forensic
medicine. During the study, 10,671 people attempted suicide, of
which 5,697 (53%) were women and 4,974 (47%) were men. Among
 56
L. Ben-Nun Suicide

them, 1,047 people (9.8%) died, 363 (34%) were women and 679
(64%) were men. There was a significant relationship between
gender and fatal suicide. The mean suicide attempt for both genders
was 53 per 100,000 and 49, and 57 for men and women, respectively.
The trends in the incidence of suicidal attempts were decreasing. In
conclusion, without implementing effective preventive measures, the
health care system in Iran will face a further burden of fatal suicides
among young people. Therefore, enhancing the primary health care
and specialized mental health services for those with unsuccessful
suicide attempts can effectively reduce the burden of suicide (13).
The objective of this study was to determine the proportion of
deaths attributable to suicides in rural Andhra Pradesh, India over a
4-year period using a verbal autopsy method. Deaths occurring in 45
villages (population 185,629) were documented from 2003 to 2007
by non-physician healthcare workers trained in the use of a verbal
autopsy tool. Causes of death were assigned by physicians trained in
the ICD, version 10. All data were entered and processed
electronically using a secure study website. Verbal autopsies were
completed for 98.2% (5,786) of the deaths (5,895) recorded. The
crude death rate was 8.0/1000; 4.8% (95% CI 4.3-5.4) of all deaths
were suicides, giving a suicide rate of 37.5/100,000 population. Of
suicides, 43% occurred in the age group 15-29 years, and 62% were in
men. In the younger age groups (10-29 years), suicides by women
(56%) were more common than by men (44%). Poisoning (40%) was
the most common method of self-harm followed by hanging (12%). In
conclusion, the suicide rate in rural Andhra Pradesh is three times
higher than the national average of 11.2/100,000, but is in line with
that reported in the Million Death Study (14).
The association between social support and suicide in a cohort of
Japanese men and women was investigated. A total of 26,672 men
and 29,865 women aged 40-69 years enrolled in the Japan Public
Health Center-based prospective study in 1993-1994 completed a
self-administered questionnaire which included four items of social
support, and were followed for death through December 2005. A
total of 180 suicidal deaths were recorded during an average of 12
years' follow-up. Men and women with the highest level of social
support had a significantly decreased risk of suicide, with HRs for the
highest vs. lowest social support group of 0.56 (95% CI 0.33-0.94) and
0.38 (95% CI 0.16-0.89) in men and women, respectively. Esteem
support and having four or more friends were associated with a
 57
L. Ben-Nun Suicide

lower risk of suicide in women (0.32, 95% CI 0.13-0.77) and in both

sexes (men 0.56, 95% CI 0.36-0.88); women 0.65 (95% CI 0.32-1.30),
respectively, whereas confident support was not. These findings
suggest that social support may be important for suicide prevention.
Avoiding social isolation may decrease the incidence of suicide in
men and women, and esteem support can provide additional benefit
for women (15).
This study aims to describe the specific characteristics of
completed suicides by violent methods and non-violent methods in
rural Chinese population, and to explore the related factors for
corresponding methods. Data of this study came from investigation
of 199 completed suicide cases and their paired controls of rural
areas in three different counties in Shandong, China, by interviewing
one informant of each subject using the method of Psychological
Autopsy. There were 78 (39.2%) suicides with violent methods and
121 (60.8%) suicides with non-violent methods. Ingesting pesticides,
as a non-violent method, appeared to be the most common suicide
method (103 cases, 51.8%). Hanging (73 cases, 36.7%) and drowning
(five cases, 2.5%) were the only violent methods observed. Storage of
pesticides at home and higher suicide intent score were significantly
associated with choice of violent methods while committing suicide.
Risk factors related to suicide death included negative life events and
hopelessness. In conclusion, suicide with violent methods has
different factors from suicide with non-violent methods. Suicide
methods should be considered in suicide prevention and intervention
strategies (16).

Assessment: in contemporary times, attempted and completed

suicide constitutes a major public health problem worldwide, with
widespread rates observed in different countries.

References
1. INSERM Collective Expertise Centre. Suicide: Psychological autopsy, a research
tool for prevention. INSERM Collective Expert Reports [Internet]. Paris: Institut
national de la santé et de la recherche médicale; 2000-2005.
2. Värnik P. Suicide in the world. Int J Environ Res Public Health. 2012;9(3):760-
71.
3. Han B, Compton WM, Gfroerer J, McKeon R. Prevalence and correlates of past
12-month suicide attempt among adults with past-year suicidal ideation in the
United States. J Clin Psychiatry. 2015;76(3):295-302.
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L. Ben-Nun Suicide

4. Centers for Disease Control and Prevention (CDC). Firearm homicides and
suicides in major metropolitan areas - United States, 2006-2007 and 2009-2010.
MMWR Morb Mortal Wkly Rep. 2013 2;62(30):597-602.
5. Fortuna LR, Perez DJ, Canino G, et al. Prevalence and correlates of lifetime
suicidal ideation and suicide attempts among Latino subgroups in the United States. J
Clin Psychiatry. 2007;68(4):572-81.
6. Bjerregaard P, Larsen CV. Time trend by region of suicides and suicidal
thoughts among Greenland Inuit. Int J Circumpolar Health. 2015;74:26053.
7. Rihmer Z, Nemeth A. Relationship between treatment of depression and
suicide mortality in Hungary - focus on the effects of the 2007 health care reform.
Neuropsychopharmacol Hung. 2014;16(4):195-204.
8. Rezaeian M. Suicide/homicide ratios in countries of the Eastern
Mediterranean Region. East Mediterr Health J. 2008;14(6):1459-65.
9. Dias D, Mendonça MC, Real FC, et al. Suicides in the Centre of Portugal:
seven years analysis. Forensic Sci Int. 2014;234:22-8.
10. Costa FA, da Trindade RF, dos Santos CB. Deaths from homicides: a historical
series. Rev Lat Am Enfermagem. 2014;22(6):1017-25.
11. Agoub M, Moussaoui D, Kadri N. Assessment of suicidality in a Moroccan
metropolitan area. J Affect Disord. 2006;90(2-3):223-6.
12. Shilubane HN, Ruiter RA, van den Borne B, et al. Suicide and related health
risk behaviours among school learners in South Africa: results from the 2002 and
2008 national youth risk behaviour surveys. BMC Public Health. 2013 Oct 4;13:926.
13. Najafi F, Hasanzadeh J, Moradinazar M, et al. An epidemiological survey of
the suicide incidence trends in the southwest Iran: 2004-2009. Int J Health Policy
Manag. 2013;1(3):219-22.
14. Joshi R, Guggilla R, Praveen D, Maulik PK. Suicide deaths in rural Andhra
Pradesh - a cause for global health action. Trop Med Int Health. 2015; 20(2):188-93.
15. Poudel-Tandukar K, Nanri A, Mizoue T, et al. Social support and suicide in
Japanese men and women - the Japan Public Health Center (JPHC)-based prospective
study. J Psychiatr Res. 2011;45(12):1545-50.
16. Sun SH, Jia CX2. Completed suicide with violent and non-violent methods in
rural Shandong, China: a psychological autopsy study. PLoS One. 2014;9(8):e104333.
 59
L. Ben-Nun Suicide

SPECIAL GROUPS

PEDIATRICS
The aim of this study was to analyze worldwide suicide rates in
children aged 10-14 years in two decades: 1990-1999 and 2000-
2009. Suicide data for 81 countries or territories were retrieved
from the WHO Mortality Database, and population data from the
World Bank data set. In the past two decades the suicide rate per
100,000 in boys aged 10-14 years in 81 countries has shown a
minor decline (from 1.61 to 1.52) whereas in girls it has shown a
slight increase (from 0.85 to 0.94). Although the average rate has
changed insignificantly, rates have decreased in Europe and
increased in South America. The suicide rates remain critical for
boys in some former USSR republics. In conclusion, the changes
may be related to economic recession and its impact on children
from diverse cultural backgrounds, but may also be due to
improvements in mortality registration in South America (1).
The aim of this study was to provide a review of studies on suicide
in children aged 14 years and younger. Articles were identified
through a systematic search of Scopus, MEDLINE and PsychINFO. Key
words were "children, suicide, psychological autopsy and case-
study". Additional articles were identified through manual search of
reference lists and discussion with colleagues. Fifteen published
articles were identified, eight psychological autopsy studies and
seven retrospective case-study series. In conclusion, suicide incidence
and gender asymmetry increases with age. Hanging is the most
frequent method. Lower rates of psychopathology are evident among
child suicides compared to adolescents. Previous suicide attempts
were an important risk factor. Children were less likely to consume
alcohol prior to suicide. Parent-child conflicts were the most common
precipitant (2).
The objective of this study was to provide an in-depth description
of children less than 13 years of age. The present study is both
retrospective and descriptive. Data were collected retrospectively
from a file containing the causes for hospitalization of each child
admitted into the Department of Child Psychiatry at the hôpital
Femme-Mère-Enfant (hospices civils de Lyon). All patients under 13
years of age who were hospitalized for a suicide attempt between
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L. Ben-Nun Suicide

2008 and 2011 were investigated. The methods used to collect the
medical records consisted of using a form made up of four major
parts: suicide attempts, social environment, medical history, and
therapy. The 26 girls and 22 boys had a mean age of 11.52 years. The
boys were younger than the girls (p=0.047) and their parents were
usually separated (p=0.034). The boys used more violent means to
commit suicide in comparison to the girls (p=0.048). On average,
children using violent means were younger (p=0.013). Boys
underwent more psychotherapy (p=0.027) and were prescribed more
psychotropic medication in comparison to girls (p=0.051).
Adjustment disorders (37.5%) and depression (27%) were the two
main diagnoses for hospitalization. Psychotherapy was organized
when leaving the hospital (98%) with legal measures (8.3%), change
of residence (12.5%), and prescription of psychotropic drugs (37.5%).
In children under 13 years of age, attempted suicide was more
frequent in girls than boys. The sample included 18 girls and 9 boys
who were 12 years old (sex ratio of 12-year-olds, 0.5). There were
more boys (16 boys/8 girls) in the children under 12 (sex ratio of 8- to
11-year-olds, 1.6). Children under 11 used more violent means
(p=0.01). Suicidal behavior in children under 11 years of age was
closer to a behavior of a person who has committed suicide than an
adolescent attempting suicide. Because of the sex ratio and non-
violent means, 12-year-old children's behavior can be considered like
that of adolescents. One factor that could explain children's
attempted suicide was family cohesion. The children in this study
were most often from broken families and had a difficult relationship
with their parents. From 1981 to 1985, more than 50% of children
who were consulted for their first suicide attempt were not
hospitalized. Therefore, hospitalization was recommended for all
children who were consulted for attempted suicide. They were
hospitalized on average 8.9-9 days. The main difference between the
treatments for adolescents and children is the importance of the
social worker who will require legal measures or changing residences
when necessary. In conclusion, the sex ratio in 6- to 12-year-olds
attempting suicide is higher than the sex ratio in adolescents
attempting suicides. Insecure attachment was found in all families in
this sample. This population is at risk since in adulthood the risk of
death by suicide is higher when there is a background of attempted
suicide by violent methods. The children should be hospitalized for a
psychological and socioenvironmental evaluation (3).
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L. Ben-Nun Suicide

The goal of the present study was to examine suicide

acceptability as a mechanism of suicide clustering in adolescents.
Data were drawn from The National Annenberg Survey of Youth, a
sample of 3,302 adolescents aged 14-22 collected between 2002
and 2004. Results indicated that beliefs of the acceptability of
suicide partially mediated the effect of exposure to suicide (defined
as knowing someone who attempted or completed suicide) on 1]
serious suicidal ideation and 2] suicide planning behaviors. The
present study demonstrated that suicide acceptability is in small
part a possible reason why suicides tend to cluster in adolescents. It
contributes not only to the knowledge of how the phenomenon of
suicide clustering might occur, but more broadly highlights the
importance of examining mediators of suicide clustering (4).
American Indian adolescents are at disproportionate risk for
suicide, and community-based studies of this population, which allow
a deeper understanding of risks and resilience to inform
interventions, are rare. This is a cross-sectional study of 71 Apache
adolescents. Strengths include the role of the community and
American Indian paraprofessionals in the design, implementation and
interpretation of findings. Participants were M = 16.0 years old, 65%
female, and 69% multiple attempters. Risks included suicidal
behavior among peers and family (68%), caregivers with substance
problems (62%), and participant substance use history namely
alcohol (91%) and marijuana (88%). Areas of resiliency included lower
depression scores (M = 23.1) and cultural activity participation. In
conclusion, a multi-tiered intervention at individual, family, and
community levels is needed (5).
Adolescents who attempt suicide are a major concern. A growing
body of literature seeks to explain this phenomenon and to identify
its predictive factors, but relatively little information is available and
children and adolescents less than 15 years of age who present to
general hospitals because of a suicide attempt. This study aimed to
describe the demographic, social, medical, and psychological
characteristics of a large sample of 517 French adolescents aged less
than 15 years, to measure psychological care in a 1-year follow-up,
and to document the reattempted rate during the follow-up.
Following the French official recommendations, a systematic 72-h
hospitalization as well as a somatic, social, and psychological
assessment was proposed to every suicide attempter after his or her
admission to the emergency department. The adolescent was
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L. Ben-Nun Suicide

followed for one year after the suicide attempt, called the index
episode. This follow-up was organized by two physicians, one of
whom was not associated with the care of any of the patients. It
consisted of seeking regular information as well as organization
and/or optimization of the patient's psychological care, which was
delivered in dedicated structures for adolescents, in outpatient care
by a psychiatrist, or in an adolescent psychiatric inpatient care unit.
In case of a repeated suicide attempt or persistence of alarming
symptoms, the follow-up was prolonged for one more year.
Experienced clinicians compiled patient data during initial assessment
and alongside the 1-year follow-up through patient self-reports
interviews with informants (family members, and social
professionals) and clinical sources (general practitioner, psychiatrist,
etc.). The areas covered were the characteristics of the index
episode, those of the population at the time of the index episode, as
well as those of the 1-year follow-up including observance to the care
and potential repetition of the suicide attempt. The mean age was 14
years with a minimum of seven years. The vast majority of the
population was female (86.1%), less than one-third lived with both
parents, and 27% had academic problems. The most frequent means
of suicide attempt was medication (83.9%), 92.6% of adolescents
were hospitalized following the index episode, while 7.5% of them
were admitted to adolescent psychiatric unit inpatient care following
the initial care. Psychiatric evaluation was documented for 93.3% of
the adolescents. Half (n=222) had at least one symptom of a
psychiatric disorder. One-year follow-up data were available for 394
adolescents: 40 had not yet completed the year and 83 were lost to
follow-up. Among the analyzable population of 391 adolescents,
35.3% were optimal observant of the care proposed and 21.4% did
not observe treatment. Fifty-nine youths (15%) were referred to the
hospital because of a repeated suicide attempt. Two patients who
repeated the suicide attempt within the year had died. In conclusion,
repetition of the suicide attempt in young adolescents is not rare
since nearly 15% of the cohort were repeaters within the year
following the index episode. Intensive care and follow-up resulted in
good attendance having a positive impact on the repetition of the
suicide attempt (6).
In many parts of the world, rates of suicidal behavior are
increasing among young people. Community surveys of suicidal
ideation have demonstrated that up to 24% of adolescents have
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L. Ben-Nun Suicide

experienced suicidal thoughts at some point in their lives. Rates of

attempted suicide are highest among young people, and increased
occurrence is reported, particularly among young males. A similar
picture emerges with regard to completed suicide, and in some
countries, rates of suicide among young males are higher than those
for older age groups. Risk factors can be grouped according to their
social/familial, individual, or environmental nature. Based on these
findings an explanatory model of suicidal behavior can be developed,
in which three criteria can be discerned: i.e. trait-dependent factors,
including those related to serotonin, personality and cognitive
psychological dysfunctions; state-dependent characteristics, such as
depression and hopelessness; and threshold factors, which may have
a risk-enhancing or protective effect, such as social support,
contagion effects, the availability of means, and the accessibility of
mental health care. Preventive actions need to be developed,
targeting the general population (through, for example, educational
programs) or populations at particular risk, such as adolescents
attempting suicide. Potential treatment approaches include the
treatment of individual psychopathological phenomena, whether or
not in school-based clinics, but particular attention has to be given to
inducting and keeping young people at risk in treatment (7).
Adolescence, when suicidal ideation and behaviors often begin,
might offer an important window to understand the causes and
prevent the progression of suicide phenomena. The need for
frameworks to organize the fragmented field has been noted, but
few studies are theoretically driven. An important recent
contribution to understanding suicidality is Joiner's (2005) IPTS.
Seventeen studies of adolescents that specifically tested or
interpreted findings in the light of Joiner's theory or the IPTS were
located. In addition, several recent reviews of the literature on
suicidality in adolescence covered information relevant to the IPTS.
There is some support for the theory in adolescence, particularly with
regard to its most novel component, the association between
acquired capability and suicide attempt. In summary, this theory is a
promising heuristic to organize the disparate studies in suicide
research. Future challenges and directions for researchers seeking to
test and elaborate the applicability of the IPTS in adolescence include
adaptations of instruments to the developmental stage, capturing
the imminent risk, and consideration of whether the current model is
underspecified. Age might moderate adult findings that give
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L. Ben-Nun Suicide

impulsivity an indirect role in suicide attempts (8).

Suicide is rare in childhood and early adolescence, and becomes
more frequent with increasing age. The latest mean worldwide
annual rates of suicide per 100,000 were 0.5 for females and 0.9 for
males among 5-14-year-olds, and 12.0 for females and 14.2 for males
among 15-24-year-olds, respectively. In most countries, males
outnumber females in youth suicide statistics. Although the rates
vary between countries, suicide is one of the commonest causes of
death among young people. Due to the growing risk for suicide with
increasing age, adolescents are the main target of suicide prevention.
Less than half of young people who have committed suicide had
received psychiatric care, and thus broad prevention strategies are
needed in healthcare and social services. Primary care clinicians are
key professionals in recognizing youth at risk for suicide. This article
reviews recent population-based psychological autopsy studies of
youth suicides and selected follow-up studies of clinical populations
and suicide attempters, analyzing risk factors for youth suicides. The
relationship between psychiatric disorders and adolescent suicide is
well established. Mood disorders, substance abuse and prior suicide
attempts are strongly related to youth suicides. Factors related to
family adversity, social alienation and precipitating problems also
contribute to the risk of suicide. The main target of effective
prevention of youth suicide is to reduce suicide risk factors.
Recognition and effective treatment of psychiatric disorders, e.g.
depression, are essential in preventing child and adolescent suicides.
In the treatment of youth depression, psychosocial treatments have
proved to be useful and efficacious. Although studies on the
effectiveness of SSRIs are limited, evidence supports their use as first-
line antidepressant medication in youth depression. Various
treatment modalities are useful in the treatment of suicidal youths,
e.g. CBT and specialized emergency room interventions. Much of the
decrease in suicide ideation and suicide attempts seems to be
attributable to nonspecific elements in treatment. For high-risk
youth, providing continuity of care is a challenge, since they are often
noncompliant and drop out or terminate their treatment. Developing
efficacious treatments for suicidal children and adolescents would
offer better possibilities to prevent suicides (9).
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L. Ben-Nun Suicide

Assessment: in many parts of the world, rates of suicidal behavior

are increasing among young people.
Suicide incidence and gender asymmetry increases with age.
Hanging is the most frequent method. Lower rates of
psychopathology are evident among child suicides compared to
adolescents. Previous suicide attempts are an important risk factor.
Parent-child conflicts are the most common precipitant.
Boys use more violent means to commit suicide than girls. For
children with suicide attempt, adjustment disorders and depression
are the two main diagnoses for hospitalization. Suicidal behavior in
children under 11 years of age is closer to a behavior of a person who
has committed suicide than an adolescent attempted suicide.
The children with attempted suicide come often from broken
families and have a difficult relationship with their parents. Suicide
acceptability is a possible reason why suicides tend to cluster in
adolescents.

References
1. Kõlves K, De Leo D. Suicide rates in children aged 10-14 years worldwide:
changes in the past two decades. Br J Psychiatry. 2014;205(4):283-5.
2. Soole R, Kõlves K, De Leo D. Suicide in Children: A Systematic Review. Arch
Suicide Res. 2015;19(3):285-304.
3. Berthod C, Giraud C, Gansel Y, et al. Suicide attempts of 48 children aged 6-12
years. Arch Pediatr. 2013;20(12):1296-305.
4. Kleiman EM. Suicide acceptability as a mechanism of suicide clustering in a
nationally representative sample of adolescents. Compr Psychiatry. 2015;59:17-20.
5. Cwik M, Barlow A, Tingey L, et al. Exploring Risk and Protective Factors with a
Community Sample of American Indian Adolescents Who Attempted Suicide. Arch
Suicide Res. 2015;19(2):172-89.
6. Giraud P, Fortanier C, Fabre G, et al. Suicide attempts by young adolescents:
epidemiological characteristics of 517 15-year-old or younger adolescents admitted
in French emergency departments. Arch Pediatr. 2013;20(6):608-15.
7. van Heeringen C. Suicide in adolescents. Int Clin Psychopharmacol. 2001;16
Suppl 2:S1-6.
8. Stewart SM, Eaddy M, Horton SE, et al. The Validity of the Interpersonal
Theory of Suicide in Adolescence: A Review. J Clin Child Adolesc Psychol. J Clin Child
Adolesc Psychol. 2015 Apr 11:1-13.
9. Pelkonen M, Marttunen M. Child and adolescent suicide: epidemiology, risk
factors, and approaches to prevention. Paediatr Drugs. 2003;5(4):243-65.
 66
L. Ben-Nun Suicide

YOUNG PEOPLE
The aim of this study was to investigate the effect of sleep
problems, depression, and cognitive processes on suicidal risk
among 460 young adults. They completed self-report
questionnaires assessing suicidal behavior, sleep quality, depressive
symptoms, emotion regulation, rumination, and impulsivity.
Suicidal participants exhibited higher rates of depressive
symptoms, sleep problems, expressive suppression, rumination,
and impulsivity. A confirmatory factor analysis model revealed
pathways to suicidal risk that showed no direct pathways between
sleep problems and suicidal risk. Instead, sleep was related to
suicidal risk via depression and rumination, which in turn increased
suicidal risk. These results suggest that addressing sleep problems
will be useful in either the treatment or prevention of depressive
and rumination symptoms and reduction in suicidal risk (1).
Suicide rates in young people have increased during the past
three decades, particularly among young males, and there is
increasing public and policy concern about the issue of youth
suicide in Australia and New Zealand. Evidence about risk factors
for suicidal behavior in young people was gathered by review of
relevant English language articles and other papers, published since
the mid-1980s. The international literature yields a generally
consistent account of the risk factors and life processes that lead to
youth suicide and suicide attempts. Risk factor domains, which may
contribute to suicidal behavior include, social and educational
disadvantage; childhood and family adversity; psychopathology;
individual and personal vulnerabilities; exposure to stressful life
events and circumstances; and social, cultural and contextual
factors. Suicidal behaviors in young people appear to be a
consequence of adverse life sequences in which multiple risk
factors increase risk of suicidal behavior. In conclusion, the
strongest risk factors for youth suicide are mental disorders (in
particular, affective disorders, substance use disorders, and
antisocial behaviors) and a history of psychopathology, indicating
that interventions reduce youth suicidal behaviors lie with
interventions focused upon the improved recognition, treatment
and management of young people with mental disorders (2).
Suicide among young people has emerged as a major public
health issue in many low- and middle-income countries. Suicidal
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L. Ben-Nun Suicide

behavior, including ideation and attempt, is the most important

predictors of completed suicide and offer critical points for
intervention. The aim of this study was to estimate the prevalence
and risk factors for suicidal behavior in young people in India. This
cross-sectional study included 3,662 youth (16-24 years) from rural
and urban communities in Goa, India. Suicidal behavior during the
recent three months and associated factors were assessed using a
structured interview. Overall, 144 3.9% (95% CI 3.3-4.6) youth
reported suicidal behavior in the previous three months. Suicidal
behavior was associated with female gender OR 6.5 (95% CI 3.9-
10.8), not attending school or college OR 1.6 (95% CI 1.01-2.6),
independent decision making OR 2.5 (95% CI 1.5-4.3), premarital
sex OR 3.2 (95% CI 1.6-6.3), physical abuse at home OR 3.3 (95% CI
1.8-6.1), life time experience of sexual abuse OR 3.3 (95% CI 1.8-
6.0) and probable common mental disorders OR 9.5 (95% CI 6.3-
14.5). Gender segregated analysis found that independent
decision-making (p=0.68 for interaction), rural residence (p=0.01
for interaction) and premarital sex (p=0.41 for interaction) were
associated with suicidal behavior only among females (p<0.05). The
population attributable fraction estimates were largest for
common mental disorders (42.8% for females, 35.9% for males);
physical abuse in one's home (12.5% for females, 12.4% for males);
sexual abuse (12.1% for females, 22.3% for males); and making
independent decisions (22.9% for females). Analyses of the risk
factors for the relatively less common outcome of suicide attempts
found a similar set of factors as for suicidal behavior; in addition,
alcohol use was an independent risk factor. In conclusion, violence
and psychological distress are independently associated with
suicidal behavior; factors associated with gender disadvantage, in
particular for rural women, may increase their vulnerabilities.
Prevention programs for youth suicide in India need to address
both the structural determinants of gender disadvantage, and the
individual experiences of violence and poor mental health (3).

Assessment: suicide rates in young people have increased during

the past three decades, particularly among young males.
Risk factors for youth suicide are mental disorders, in particular,
affective disorders, substance use disorders and antisocial behaviors.
Suicidal participants exhibit higher rates of depressive symptoms,
sleep problems, expressive suppression, rumination, and impulsivity.
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In India, suicidal behavior is associated with female gender, not

attending school or college, independent decision, premarital sex,
physical abuse at home, lifetime experience of sexual abuse, and
mental disorders.

References
1. Weis D, Rothenberg L, Moshe L, et al. The effect of sleep problems on
suicidal risk among young adults in the presence of depressive symptoms and
cognitive processes. Arch Suicide Res. 2014 Dec 17.
2. Beautrais AL. Risk factors for suicide and attempted suicide among young
people. Aust N Z J Psychiatry. 2000;34(3):420-36.
3. Pillai A, Andrews T, Patel V. Violence, psychological distress and the risk of
suicidal behaviour in young people in India. Int J Epidemiol. 2009;38(2):459-69.

ADULTS
This study examined the relationship between perception of
poor health and suicidal ideation and suicide attempt among adults
in the community. Data were drawn from the National
Comorbidity Survey (n=5,877), a representative sample of
individuals 15-54 years of age in the U.S. Perception of poor health
was associated with a significantly increased likelihood of suicidal
ideation (OR 2.14, 1.36, 3.35) and suicide attempt (OR 2.03, 1.06,
3.91), which persisted after adjusting for differences in
sociodemographic characteristics, mental disorders, and self-
reported physical illnesses. In conclusion, perception of poor health
is associated with a significantly increased likelihood of suicidal
ideation and suicide attempt among adults in the community (1).
This study described the prevalence of suicidal ideation and
attempted suicide in a representative survey among adults in
Denmark and gives the proportion of people reporting a suicide
attempt that results in contact with the health care system. The
data for the 1994 Danish national health interview survey were
collected by personal interview and a self-administered
questionnaire. A subsample of 1,362 individuals participated in the
part of the survey that addressed suicidal behavior (64% of the
random sample). The results show that 6.9% reported having had
suicidal thoughts within the past year. Averaging across all age
groups the overall prevalence of people reporting ever having
made a suicide attempt was 3.4% and the one-year prevalence was
0.5%. Suicidal ideation was more prevalent among young people
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L. Ben-Nun Suicide

than among older people, whereas ever-attempted suicide showed

no age gradient. Both suicidal ideation and ever-attempted suicide
were more prevalent among economically inactive people (e.g.
unemployed) and among unmarried or divorced people. Of suicide
attempts, 50-60% reported in a representative, national survey
become known to the healthcare system (2).
The main aim of this study was to provide an overview of the
lifetime and 12-month prevalence of suicidal ideation, suicide plans
and suicide attempts for Australian adults as a whole and for
particular sociodemographic and clinical population subgroups, and
to explore the health service use of people with suicidality. Data
came from the 2007 National Survey of Mental Health and
Wellbeing (2007), a nationally, representative household survey of
8,841 individuals aged 16-85 years. Of respondents, 13.3% had
suicidal ideation during their lifetime, 4.0% had made a suicide plan
and 3.2% had made a suicide attempt. The equivalent 12-month
prevalence rates were 2.3%, 0.6% and 0.4%, for ideation, plans and
attempts, respectively. In general, suicidality in the previous 12
months tended to be relatively more common in women, younger
people, those outside the labor force, and those with mental
disorders; and less common in those who were married or in de
facto relationships, and those with moderate levels of education. A
number of the differences in prevalence rates between
sociodemographic and clinical subgroups did not reach statistical
significance due to data availability constraints and the
conservative tests of significance that were used by necessity.
Service use for mental health problems was higher among people
with suicidality than among the general population, but significant
numbers of those experiencing suicidality did not receive
treatment. In conclusion, suicidal thoughts and behaviors are
prevalent among the Australian adult population. These thoughts
and behaviors are not only predictive of subsequent fatal suicidal
acts, but are significant public health problems in their own right.
They are associated with high levels of burden at an individual and
societal level (3).
The aim of this study was to compare the prevalence and
associated factors of lifetime suicidal ideation, plans and attempts
in the Hui and Han ethnic groups in the Ningxia Hui Autonomous
Region of China. Using a probability proportionate to size sampling
method and villages (in rural areas) or neighborhoods (in urban
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L. Ben-Nun Suicide

areas) as primary sampling units, 5,880 residents aged 18 and over

were sampled. Face-to-face interviews were conducted using a
computer-administered Chinese version of the WHO CIDI. Of the
4,789 (81.4%) persons who completed the survey, the lifetime
prevalence of suicidal ideation, suicidal plans and suicide attempts
were 5.30% (95% CI 4.66-5.93%), 1.52% (95% CI 1.17-1.86%), and
0.77% (95% CI 0.52-1.02%), respectively. The age standardized rate
of lifetime suicidal ideation and lifetime suicidal planning were
significantly higher in the largely Muslim Hui ethnic group (n=1,955)
than in the largely atheist Han ethnic group (n=2,834); the lifetime
prevalence of suicide attempt was also higher in the Hui group, but
only at the trend level (p=0.20). Factors independently associated
with lifetime suicidal ideation were female gender (OR 2.07), being
divorced or widowed (OR 2.02), rural residence (OR 1.95), mood
disorder in the prior year (OR 1.96), other mental disorder in the
prior year (OR 2.99), and self-reported poor physical health in the
prior year (OR 2.21). After adjustment for these factors, ethnicity
was not independently associated with lifetime suicidal ideation,
but stratified analyses by ethnic group found some differences in
the factors associated with lifetime suicidal ideation between Hui
and Han respondents (4).

Assessment: perception of poor health is associated with an

increased likelihood of suicidal ideation and suicide attempt among
adults. Suicidal thoughts and behaviors are predictive of subsequent
fatal suicidal acts.
The overall prevalence of people reporting ever having made a
suicide attempt is 3.4% and the 1-year prevalence is 0.5%. Suicidal
ideation is more prevalent among young people than older people,
whereas ever-attempted suicide shows no age gradient.
Factors associated with lifetime suicidal ideation include female
gender, being divorced or widowed, rural residence, mood disorder
in the prior year, other mental disorder and self-reported poor
physical health in the prior year.

References
1. Goodwin RD, Marusic A. Perception of health, suicidal ideation, and suicide
attempt among adults in the community. Crisis.2011;32(6):346-51.
2. Kjøller M, Helweg-Larsen M. Suicidal ideation and suicide attempts among
adult Danes. Scand J Public Health. 2000;28(1):54-61.
3. Johnston AK, Pirkis JE, Burgess PM. Suicidal thoughts and behaviours among
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Australian adults: findings from the 2007 National Survey of Mental Health and
Wellbeing. Aust N Z J Psychiatry. 2009;43(7):635-43.
4. Wang Z, Qin Y, Zhang Y, et al. Prevalence and correlated factors of lifetime
suicidal ideation in adults in Ningxia, China. Shanghai Arch Psychiatry. 2013;25(5):
287-94.

THE ELDERLY
Suicide is a major public health concern for older adults, who have
higher rates of completed suicide than any other age group in most
countries of the world. Older men are at greatest risk. Reduction of
suicide-related morbidity and mortality in this age group hinges on
systematic study at each point in the suicide preventive intervention
research cycle. Improvements in systems for surveillance of late-life
suicidal behavior, particularly attempted suicide, are needed to
further develop the foundation on which to evaluate differences in
the elderly subgroup, over time, and in different locations, and to
better assess changes in response to interventions (1).
This study sought to learn more about the characteristics of
suicide in the oldest-old and to use a cluster analysis to determine if
oldest-old suicide victims assort into clinically meaningful subgroups.
Data were collected from a coroner's chart review of suicide victims
in Toronto from 1998 to 2011. Two age groups (65-79 year olds,
n=335, and 80+ year olds, n=191) were compared and then a
hierarchical agglomerative cluster analysis using Ward's method to
identify distinct clusters in the 80+ group was carried out. The
younger and older age groups differed according to marital status,
living circumstances and pattern of stressors. The cluster analysis
identified three distinct clusters in the 80+ group. Cluster 1 was the
largest (n=124) and included people who were either married or
widowed who had significantly more depression and somewhat more
medical health stressors. By contrast, cluster 2 (n=50) comprised
people who were almost single and living alone with less identified
depression and slightly fewer medical health stressors. All members
of cluster 3 (n=17) lived in a retirement residence or nursing home,
and this group had the highest rates of depression, dementia, other
mental illness and past suicide attempts. In conclusion, this study
used the cluster analysis technique to identify meaningful subgroups
among suicide victims in the oldest-old. The results reveal different
patterns of suicide in the older population that may be relevant for
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clinical care (2).

Late-life suicide is a persistent threat and a reality from which no
one emerges unscathed. Family members and significant others feel
guilty and inconsequential. Assisted living residence staff is
demoralized. The residents feel frightened and confused. Although
constituting only 13% of the population in the U.S., older adults
accounted for 18% of suicide deaths in the later 1990s. There is at
present a national strategy for suicide prevention among youth under
19 years and adults aged 65 years and older. The assisted living
community that fosters independence and self-determination can be,
simultaneously, an environment in which the warning signs of
suicidal ideation and self-destruction can be missed (3).
The aim of this study was to establish the level of correlation
between the suicide item contained within the CSI, and the
presence of suicidal thoughts as assessed by the MINI and the
CSDD. Seventy elderly residents in a long-term care facility were
included in this study. All of these patients completed a CSI and a
GDS, and were interviewed using CSDD, MINI (suicide module), and
Mini-Mental State Examination. There was a significant correlation
between suicidal ideation, as assessed by item two of the CSI, and
the suicidal ideation score as assessed by MINI and CSDD (r=0.773
and r=0.626, p<0.001, respectively). The level of agreement across
all three instruments was good (Gwet's AC1 =0.907). The CSI
yielded a high level of sensitivity (100%) and specificity (90.32%) for
suicidal thoughts as measured by MINI, with an area under the
curve of 97%. When assessing predictors of the severity of suicidal
thoughts, only item 2 of the CSI predicted severity, while the
depression, GDS, and total scores obtained from the CSI did not. In
conclusion, CSI item 2 has the ability to detect suicidal ideation,
regardless of whether the patient has cognitive impairment and/or
depression or not, and is currently the best predictor of its
presence. Therefore, it shows promise as a measure for screening
the presence of suicidal thoughts among the elderly in long-term
care facilities (4).

Assessment: suicide is a major public health concern for older

adults, who have higher rates of completed suicide than any other
age group in most countries of the world.
Late-life suicide is a persistent threat and a reality from which no
one emerges unscathed. Family members and others feel guilty and
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inconsequentially. The assisted living community that fosters

independence and self-determination can be, simultaneously, an
environment in which the warning signs of suicidal ideation and self-
destruction can be missed.
CSI has the ability to detect suicidal ideation, regardless of
whether the patient has cognitive impairment and/or depression or
not, and is currently the best predictor of suicide presence.

References
1. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am.
2008;31(2):333-56.
2. Sinyor M, Tan LP, Schaffer A, et al. Suicide in the oldest old: an observational
study and cluster analysis. Int J Geriatr Psychiatry. 2015 Mar 24.
3. Mitty E, Flores S. Suicide in late life. Geriatr Nurs. 2008;29(3):160-5.
4. Wongpakaran T, Wongpakaran N. Detection of suicide among the elderly in a
long term care facility. Clin Interv Aging. 2013;8:1553-9.

OTHER GROUPS
INDIVIDUALS WITH EATING DISORDERS
In patients with AN, (SMR) for suicide ranges from 1.0 to 5.3,
whereas suicide rates do not appear to be elevated in BN. By
contrast, suicide attempts occur in approximately 3-20% of patients
with AN and in 25-35% of patients with BN. Clinical correlates of
suicidality in EDs include purging behaviors, depression, substance
abuse, and a history of childhood physical and/or sexual abuse.
Patients with EDs, particularly those with comorbid disorders, should
be assessed routinely for suicidal ideation, regardless of the severity
of ED or depressive symptoms (1).
Suicide is a major cause of death among individuals with ED. This
study examined risk of suicide among females with EDs based on
population-based military data. Data on diagnoses of EDs from the
pre-induction screening for psychopathology and diagnoses assigned
during military service were merged with data on later suicide from
the nationwide Israeli Death Registry. Risk of suicide in 1,356 females
with EDs was compared to a population-based control group of
females without EDs over a mean follow-up period of 8.5 ± 5.34
years. Females with EDs had a higher rate of suicide (0.22%, n=3)
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compared to females without EDs (03%, n=166). Having a moderate-

severe ED was associated with increased risk of suicide (RR 12.50,
95% CI 3.86-38.09), whereas none of the females diagnosed as having
a mild ED died by suicide. In conclusion, females with moderate-
severe EDs are at risk of suicide should be monitored for suicidal
intent (2).
The aim of this study was to explore the prevalence of hospital-
treated suicide attempts in a large clinical population of ED patients.
Follow-up study of adults (n=2462, 95% women, age 18-62 years)
admitted to the ED Clinic of Helsinki University Central Hospital in the
period 1995-2010 was conducted. For each patient, four controls
were selected and matched for age, sex and place of residence.
Patients (n=156) with ED (6.3%) and 139 controls (1.4%) had required
hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37
(26.6%) had more than one attempt. The RR for suicide attempt in
patients with ED was 4.70 (95% CI 1.41-15.74). In AN, RR was 8.01
(95% CI 5.40-11.87), and in BN, it was 5.08 (95% CI 3.46-7.42). In ED
patients with a history of suicide attempt, the risk of death from any
cause was 12.8%, suicide being the main cause in 45% of the deaths.
In conclusion, suicide attempts and repeated attempts are common
among patients with ED. Suicidal ideation should be routinely
assessed from patients with EDs (3).
The main aim of this study was to evaluate whether the
prevalence of lifetime suicide attempts/completions was higher in
women with a lifetime history of an ED than in women without ED
and assessed whether ED features, comorbid psychopathology, and
personality characteristics were associated with suicide attempts in
women with AN, ANR, ANBP, lifetime history of ANBN, BED, and PD.
Participants were part of the Swedish Twin study of Adults: Genes
and Environment (n=13,035) cohort. Lifetime suicide attempts were
identified using diagnoses from the Swedish National Patient and
Cause of Death Registers. General linear models were applied to
evaluate whether ED category (ANR, ANBP, ANBN, BN, BED, PD, or no
ED) was associated with suicide attempts and to identify factors
associated with suicide attempts. Relative to women with no ED,
lifetime suicide attempts were significantly more common in women
with all types of ED. None of the ED features or personality variables
was significantly associated with suicide attempts. In the ANBP and
ANBN groups, the prevalence of comorbid psychiatric conditions was
higher in individuals with than without a lifetime suicide attempt. The
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odds of suicide were highest in presentations that included purging

behavior (ANBN, ANBN, BN, and PD), but were elevated in all patients
with ED. To improve outcomes and decrease mortality, it is critical to
be vigilant for suicide and identify indices for those who are at
greatest risk (4).
Suicide is a common cause of death in AN and suicide attempts
occur often in both AN and BN. No studies have examined predictors
of suicide attempts in a longitudinal study of eating disorders with
frequent follow-up intervals. The objective of this study was to
determine predictors of serious suicide attempts in women with ED.
In a prospective longitudinal study, women diagnosed with either
DSM-IV AN (n=136) or BN (n=110) were interviewed and assessed for
suicide attempts and suicidal intent every 6-12 months over 8.6
years. Fifteen percent of subjects reported at least one prospective
suicide attempt over the course of the study. Significantly, more
anorexic (22.1%) than bulimic subjects (10.9%) made a suicide
attempt. Multivariate analyses indicated that the unique predictors
of suicide attempt for AN included the severity of both depressive
symptoms and drug use over the course of the study. For BN, a
history of drug use disorder at intake and the use of laxatives during
the study significantly predicted suicide attempts. In conclusion,
women with AN or BN are at considerable risk to attempt suicide.
Clinicians should be aware of this risk, particularly in anorexic
patients with substantial co-morbidity (5).

Assessment: suicide is a major cause of death among individuals

with EDs, especially in AN. Females with ED have a higher rate of
suicide compared to females without ED.

References
1. Franko DL, Keel PK. Suicidality in eating disorders: occurrence, correlates, and
clinical implications. Clin Psychol Rev. 2006;26(6):769-82.
2. Goldberg S, Werbeloff N, Shelef L, et al. Risk of suicide among female
adolescents with eating disorders: a longitudinal population-based study. Eat Weight
Disord. 2015 Jan 18. [Epub ahead of print]
3. Suokas JT, Suvisaari JM, Grainger M, et al. Suicide attempts and mortality in
eating disorders: a follow-up study of eating disorder patients. Gen Hosp Psychiatry.
2014;36(3):355-7.
4. Pisetsky EM, Thornton LM, Lichtenstein P, et al. Suicide attempts in women with
eating disorders. J Abnorm Psychol. 2013;122(4):1042-56.
5. Franko DL, Keel PK, Dorer DJ, et al. What predicts suicide attempts in women
with eating disorders? Psychol Med. 2004;34(5):843-53.
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VETERANS
Veterans attending an urgent care psychiatric clinic (n=473)
completed a survey on suicidal ideation and other acute risk warning
signs. More than half the sample (52%) reported suicidal ideation
during the prior week. Of these, more than one-third (37%) had
active ideation which included participants with a current suicide
plan (27%) and those who had made preparations to carry out their
plan (12%). Other warning signs were also highly prevalent, with the
most common being: sleep disturbances (89%), intense anxiety
(76%), intense agitation (75%), hopelessness (70%), and desperation
(70%). Almost all participants (97%) endorsed at least one warning
sign. Participants with depressive syndrome and/or who screened
positive for PTSD endorsed the largest number of warning signs.
Those with both depressive syndrome and PTSD were more likely to
endorse intense affective states than those with either disorder
alone. In conclusion, these major findings are the strikingly high
prevalence of past suicidal ideation, suicide attempts, current suicidal
ideation and intense affective states in veterans attending an urgent
care psychiatric clinic; and the strong associations were observed
between co-occurring PTSD and depressive syndrome with intense
affective states (1).
Many deployed women Veterans have experienced similar
combat exposure as their male counterparts in wars since 1990.
Upon reintegration, many Veterans visit civilian health facilities with
behavioral health issues, sometimes voicing and/or attempting
suicide. Effective nursing assessment and actions are needed to
specifically care for this unique population. Any suicide variables
(e.g., ideation, attempts, and completed) are concerning; therefore,
all women Veterans from the Vietnam, Gulf I, Iraq, and Afghanistan
wars should be assessed. The first priority is always patient safety.
Timely and frequent screening for a variety of risk factors,
documented for both men and women Veterans, and women
specifically, are important. Symptomatology may not become evident
for 3-15 months into reintegration. Applicable dialogue can recognize
changing thoughts, judgment, and behavior patterns (2).

Assessment: veterans have a current suicide plan and

preparations to carry out their plan. Warning signs include sleep
disturbances, intense anxiety, intense agitation, hopelessness, and
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desperation. Suicide variables such as ideation, attempts, completed

are suspicious. Applicable dialogue can recognize changing thoughts,
judgment, and behavior patterns.

References
1. McClure JR, Criqui MH, Macera CA, et al. Prevalence of suicidal ideation and
other suicide warning signs in veterans attending an urgent care psychiatric clinic.
Compr Psychiatry. 2014 Sep 16. pii: S0010-440X(14)00266-1.
2. Conard PL, Armstrong ML, Young C, Hogan LM. Suicide assessment and action
for women veterans. J Psychosoc Nurs Ment Health Serv. 2015; 53(4):33-42.

STROKE SURVIVORS
Stroke is a dramatic event and is associated with potentially
severe consequences, including disability, mortality, and social costs.
Stroke may occur at any age; however, most strokes occur in
individuals aged 65 years and older. The aim of the current review is
to investigate the relationship between suicide and stroke in order to
determine which stroke patients are at elevated risk for suicide.
Moreover, the literature is reviewed in order to provide
pharmacological treatment strategies for stroke patients at high risk
of suicide. A search was performed to identify articles and book
chapters focused on this issue, selecting only English-language
articles published from 1990 to 2014 that addressed the issue of
suicide after stroke and its pharmacological management. Twelve
clinical trials that explored the relationship between stroke and
suicidal ideation and/or suicidal plans and 11 investigating suicide as
the cause of death after stroke were found. Stroke was identified as a
significant risk factor for both suicide and suicidal ideation, especially
among younger adult depressed patients, providing further support
for the association between post-stroke and suicidality. Suicide risk is
particularly high in the first five years following stroke. Depression,
previous mood disorder, prior history of stroke, and cognitive
impairment were the most important risk factors for suicide. SSRIs
represent the treatment of choice for stroke survivors with suicide
risk, and studies in rats have suggested that carbolithium is a
promising treatment in these patients. Early identification and
treatment of post-stroke depression may significantly reduce suicide
risk in stroke patients (1).
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Attempted and completed suicides after stroke were examined to

determine whether they were associated with socioeconomic status,
other patient characteristics, or time after stroke. This nationwide
cohort study included stroke patients from Riksstroke from 2001 to
2012. Personal identification numbers were used to link the
Riksstroke data with other national registers. Suicide attempts were
identified by a record of hospital admission for intentional self-harm
(ICD-10: X60-X84), and completed suicides were identified in the
national Cause of Death Register. Of 220,336 stroke patients with a
total follow-up time of 860,713 PY, there were 1,217 suicide
attempts, of which 260 were fatal. This was approximately double
the rate of the general Swedish population. Patients with lower
education or income (HR 1.37, 95% CI 1.11-1.68) for primary vs.
university and patients living alone (HR 1.73, 95% CI 1.52-1.97) had
an increased risk of attempted suicide, while patients born outside of
Europe had a lower risk compared to patients of European origin.
Male sex, young age, severe stroke, and poststroke depression were
other factors associated with an increased risk of attempted suicide
after stroke. The risk was highest during the first two years after
stroke. In conclusion, both clinical and socioeconomic factors
increase the risk of poststroke suicide attempts. This suggests a need
for psychosocial support and suicide preventive interventions in high-
risk groups of stroke patients (2).

Assessment: stroke is a dramatic event and is associated with

disability, mortality, and social costs. Stroke may occur at any age;
however, most strokes occur in individuals aged 65 years and older.
Stroke is a significant risk factor for both suicide and suicidal ideation,
especially among younger adult depressed patients. Clinical and
socioeconomic factors increase the risk of poststroke suicide
attempts.

References
1. Pompili M, Venturini P, Lamis DA, et al. Suicide in stroke survivors:
epidemiology and prevention. Drugs Aging. 2015;32(1):21-9.
2. Eriksson M, Glader EL, Norrving B, Asplund K. Poststroke suicide attempts and
completed suicides: A socioeconomic and nationwide perspective. Neurology.
2015;84(17):1732-8.
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PATIENTS WITH CANCER

The purpose of this study was to characterize suicide rates among
patients with cancer in the U.S. and identify patient and disease
characteristics associated with higher suicide rates. Patients in the
study were residents of geographic areas served by the SEER program
who were diagnosed with cancer from 1973 to 2002. Comparisons
with the general U.S. population were based on mortality data
collected by the National Center for Health Statistics. This was a
retrospective cohort study of suicide in persons with cancer. Among
3,594,750 SEER registry patients observed for 18,604,308 PY, 5,838
suicides were identified, for an age-, sex-, and race-adjusted rate of
31.4/100,000 PY. By contrast, the suicide rate in the general U.S.
population was 16.7/100,000 PY. Higher suicide rates were
associated with male sex, white race, and older age at diagnosis. The
highest suicide risks were in patients with cancers of the lung and
bronchus (SMR 5.74, 95% CI 5.30-6.22), stomach (SMR 4.68, 95% CI
3.81-5.70), oral cavity and pharynx (SMR 3.66, 95% CI 3.16-4.22), and
larynx (SMR 2.83, 95% CI 2.31-3.44). SMRs were highest in the first
five years after diagnosis with cancer. In conclusion, patients with
cancer in the U.S. have nearly twice the incidence of suicide of the
general population, and suicide rates vary among patients with
cancers of different anatomic sites (1).
Approximately 70% of all suicides in patients aged >60 years are
attributed to physical illness, with higher rates noted in patients with
cancer. The purpose of the current study was to characterize suicide
rates among patients with genitourinary cancers and identify factors
associated with suicide in this specific cohort. Patients with prostate,
bladder, kidney, testis, and penile cancer were identified in the
Surveillance, Epidemiology, and End Results database (1988-2010).
There were 2,268 suicides identified among 1,239,522 individuals
with genitourinary malignancies observed for 7,307,377 PY. The
SMRs for patients with cancer were 1.37 for prostate cancer (95% CI
0.99-1.86), 2.71 for bladder cancer (95% CI 2.02-3.62), 1.86 for kidney
cancer (95% CI 1.32-2.62), 1.23 for testis cancer (95% CI 0.88-1.73),
and 0.95 for penile cancer (95% CI 0.65-1.35). On multivariable
analysis, male sex was associated with odds of suicide among
patients with bladder cancer (OR 6.63), and kidney cancer (OR 4.98).
Increasing age was associated with suicide for patients with prostate,
bladder, and testis cancer (OR range, 1.03-1.06). Distant disease was
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associated with suicide in patients with prostate, bladder, and kidney

cancer (OR range, 2.82-5.43). Among patients with prostate, bladder,
and kidney cancer, African American patients were less likely to
commit suicide compared with white individuals (OR range 0.26-
0.46). In conclusion, suicide in patients with genitourinary
malignancies poses a public health dilemma, especially among men,
the elderly, and those with aggressive disease. Clinicians should be
aware of risk factors for suicide in these patients (2).
Depression, anxiety and aggression are documented in testis
cancer patients and can result in death from suicides; however, their
risk of suicide is not defined. Suicide rates among testis cancer
patients in the U.S. are reported and factors associated with higher
rates are determined. The SEER database maintained by the National
Cancer Institute was used to identify patients diagnosed with testis
cancer between 1995 and 2008. Multivariate analysis was used to
assess factors affecting suicide rate. Among 23,381 patients followed
for 126,762 PY, suicide rate was 26.0 per 100,000 PY, with the
average corresponding rate in the US population aged 25-44 years
being 21.5 per 100,000 PY; the calculated SMR for death by suicide
was 1.2 (95% CI 1.1-2.1). The SMR for suicide was 1.5 (95% CI 1.1-2.1)
in ages less than 30 years, and 1.8 (95% CI 1.3-2.4) in men of races
other than White and Black. Other patient and disease characteristics
were not predictive. In conclusion, patients with testis cancer have a
20% increase in the risk of suicide over that of the general
population, and races other than White and Black and younger
patients may commit suicide at higher rates (3).

Assessment: patients with malignancy are at increased risk for

suicide.

References
1. Misono S, Weiss NS, Fann JR, et al. Incidence of suicide in persons with cancer.
J Clin Oncol. 2008;26(29):4731-8.
2. Klaassen Z, Jen RP, DiBianco JM, Reinstatler L, et al. Factors associated with
suicide in patients with genitourinary malignancies. Cancer. 2015;121(11):1864-72.
3. Alanee S, Russo P. Suicide in men with testis cancer. Eur J Cancer Care (Engl).
2012;21(6):817-21.
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DOCTORS/NURSES
In this study, physicians' suicide rate ratios were estimated with a
meta-analysis and systematic quality assessment of recent studies.
Studies of physicians' suicide rates were located in MEDLINE,
PsycINFO, AARP Ageline, and the EBM Reviews: Cochrane Database
of Systematic Reviews with the terms "physicians," "doctors,"
"suicide," and "mortality." Studies were included if they were
published in or after 1960 and gave estimates of age-standardized
suicide rates of physicians and their reference population or reported
extractable data on physicians' suicide; 25 studies met the criteria.
Reviewers extracted data and scored each study for quality. The
studies were tested for heterogeneity and publication bias and were
stratified by publication year, follow-up, and study quality. Effect
sizes were pooled by using fixed-effects (women) and random-effects
(men) models. The aggregate suicide rate ratio for male physicians,
compared to the general population, was 1.41 (95% CI 1.21-1.65). For
female physicians the ratio was 2.27 (95% CI 1.90-2.73). Visual
inspection of funnel plots from tests of publication bias revealed
randomness for men but some indication of bias for women, with a
relative, insignificant lack of studies in the lower right quadrant. In
conclusion, studies on physicians' suicide collectively show modestly
(men) to highly (women) elevated suicide rate ratios. Larger studies
should help clarify whether female physicians' suicide rate is truly
elevated or can be explained by publication bias (1).
The objective of this systematic literature search was to
determine whether there are gender differences in the incidence of
suicide in physicians, and whether there are differences in the
methods used by male and female physicians to commit suicide. A
literature search was performed in the electronic literature databases
PubMed and PsycInfo. After exclusion based on title, abstract or
missing data, nine studies remained. All these studies met quality
criteria that were set up in advance. The studies were assessed by
two researchers. Suicide among male physicians occurred at the
same or at a slightly lower rate, than in the general population. Even
after correction for age, female physicians committed suicide more
often. The gender difference in suicide in the general population, i.e.
suicide attempts by men are more successful than those by women
was not found in physicians. Male and female physicians often used
medication as their preferred method of suicide, and at twice the
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rate than that people in the general population did. In conclusion,

female physicians are at higher risk of committing suicide than their
male counterparts, although this situation is perhaps changing now
that they are less of a minority. With respect to prevention, one
might consider paying more attention to depression in physicians and
those in training, and to constructing a more open professional
culture in which mistakes are condemned less (2).
The medical profession represents one of the groups of people
who are not reached by the present help system for suicidal
behavior. The suicide rate of male physicians is slightly higher than
that of the general population, while that of their female colleagues
is clearly higher. This tendency is most pronounced in female
psychiatrists and anesthetists. In addition to the usual preventive
measures such as the treatment of depression and addiction, the
necessity of a qualified, professional treatment especially for doctors
must be recognized because there is often a penchant for ineffective
self-treatment. The symptoms are played down and even in acute
crises, the urgently needed help is not enlisted (3).
This study provides an overview of the research on suicide rates
and suicidal tendencies of physicians. Original articles on this topic
since 1980 were analyzed. Empirical studies indicate an increased
suicide rate in physicians compared to the general population.
Possible causes are the increased prevalence rate of depressive
disorders as well as the presumably increased rate of substance
abuse in physicians. In addition to this, there are job-related stressors
as reasons for the high suicide risk in physicians. In conclusion, in
terms of preventive measures it seems reasonable to systematically
inform medical students about stressors they will be exposed to in
their later practice and to discuss coping strategies and prevention.
Thus, a suitable emotional preparation for future work stress can be
assured. For working physicians, seminars and professional training
on education and prevention as well as supervision should
continuously be offered (4).
The aim of this article was to review the knowledge currently
available on the risk of suicide among nurses and on contributory risk
factors. A search was conducted in electronic databases using
keywords related to prevalence and risk factors of suicide among
nurses. The abstracts were analyzed by reviewers according to
selection criteria. Selected articles were submitted to a full-text
review and their key elements were summarized. Only nine articles
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were eligible for inclusion in this review. The results of this literature
review highlight both the troubling high prevalence of suicide among
nurses as well as the persistent lack of studies that examine this
issue. In conclusion, considering that the effects of several factors
related to nurses' work and work settings are associated with high
stress, distress, or psychiatric problems, the relevance of
investigating work-related factors associated with nurses' risk of
suicide is highlighted (5).

Assessment: studies on physicians' suicide collectively show

modestly (men) to highly (women) elevated suicide rate ratios. The
suicide rate of male physicians is slightly higher than that of the
general population, while that of their female colleagues is clearly
higher. This tendency is pronounced in female psychiatrists,
anesthetists, and among nurses.

References
1. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative
and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295-302.
2. Lagro-Janssen AL, Luijks HD. Suicide in female and male physicians. Ned
Tijdschr Geneeskd. 2008;152(40):2177-81.
3. Wolfersdorf M. Suicide and suicide prevention for female and male physicians.
MMW Fortschr Med. 2007;149(27-28):34-6.
4. Reimer C, Trinkaus S, Jurkat HB. Suicidal tendencies of physicians - an
overview. Psychiatr Prax. 2005;32(8):381-5.
5. Alderson M, Parent-Rocheleau X, Mishara B. Critical Review on Suicide Among
Nurses. Crisis. 2015 Feb 23:1-11.

DRIVERS
A case-control study was conducted to determine whether
adolescents and young adults who have been in a motor vehicle
crash or hospitalized for unintentional and intentional injury are at
greater risk for suicide. Cases were 700 Washington State residents
aged 16-35 years with a driver's license who died of suicide during
1987-1989. Controls were 3,494 licensed drivers matched by age, sex,
and zip code. Using two different databases, the past incidence of in-
state injury hospitalizations and motor vehicle crashes for all subjects
were determined. Overall, the incidence of suicide was tenfold higher
among those with a past hospitalization for injury. Many of these
admissions were for suicide attempts (OR 56, 95% CI 27-120), but the
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risk of suicide was higher among those hospitalized for unintentional

injuries (OR 5.0, 95% CI 2.2-11.5) and assaults (OR 4.5, 95% CI 1.1-18).
The relative risk for suicide was 2.7 (95% CI 2.0-3.5) for those with
prior injury as a driver in a motor vehicle crash and 2.9 (95% CI 2.2-
3.8) for those with involvement in a single vehicle crash. Many
unintentional injury hospitalizations and a proportion of motor
vehicle crashes in younger adults may represent unrecognized suicide
attempts (1).
Around the world, a substantial proportion of motor vehicle crash
deaths are recognized as "hidden" suicides. This project sought to
progress understandings of drivers who used a motor vehicle to die
by suicide in Queensland, Australia, during the period 1990 to 2007.
Data for this study were derived from the Queensland Suicide
Register and forensic crash investigation case records. Analysis
focused on life circumstances, events preceding the death, physical
and mental illnesses, past suicidality, and indication of suicide intent
(e.g., suicide notes or statements). Compared to cases using other
methods, confirmed driver suicides were more likely to be males
aged between 25 and 44 years who were employed at the time of
death. A large proportion of driver suicides had consumed alcohol
immediately prior to the crash and experienced a number of life
events, including relationship conflict, legal or criminal issues, and
financial problems. In conclusion, these exploratory results indicate
the need to educate crash investigators about the characteristics of
those who use a motor vehicle to die. Improving the information
available on the mental and physical health and background life-
related factors of crash victims can help coroners and researchers
determine whether these deaths were intentional (2).
Many authors have suggested that some road traffic crashes are
disguised suicide attempts. A case report and literature review is
used to explore this claim and to examine the frequency and risk
factors associated with driver suicide. The methodological difficulty
of establishing the driver's intent of suicide accounts for an under-
estimation of the frequency of this event and many cases of driver
suicide go unrecognized. Familiarity with the risk factors associated
with driver suicide may assist in the identification of cases of failed
driver suicide and referral to psychiatric services (3).
This study focused on driver suicides in Finland. The first aim was
to find out what the prevalence of these suicides was during the
years 1974-2006. The second aim was to find out whether there were
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differences between northern and southern Finland in regards to the

number of cases and the backgrounds of the drivers who committed
suicide. All case reports of fatal motor vehicle accidents from the
years 2005-2006 were investigated (n=528). Results were compared
to the years previously investigated: 1974-1975, 1984-1985, 1987-
1988, 1991-1992, 1993-1994 and 1997-1998 (n=3482). As driver
suicides were classified, only those crashes in which the driver's
intention had notably influenced the progress of the crash and the
driver's background information clearly supported suicide. Driver
suicides in northern and southern Finland were compared. Driver
suicides were related to both the number of fatal motor vehicle
accidents and the number of inhabitants. Driver suicides increased
during the period under study. However, both the number and the
proportion of driver suicides have been quite constant since the
beginning of the 1990s, averaging 20 per year, which is 8% of all fatal
motor vehicle accidents in Finland. There were no differences in
northern and southern Finland regarding driver suicides. In
conclusion, driver suicides represent a small proportion (2%) of all
suicides committed in Finland every year. However, the proportion of
driver suicides of all fatal motor vehicle accidents is greater, around
8-9%. As a majority of driver suicides is collisions, they affect an even
larger group of people (4).

Assessment: some road traffic crashes are disguised suicide

attempts, with substantial proportion of motor vehicle crash deaths
recognized as "hidden" suicides.
Driver suicides represent a small proportion of all suicides. These
drivers consume alcohol immediately prior to the crash and
experience a number of life events, including relationship conflict,
legal or criminal issues, and financial problems.

References
1. Grossman DC, Soderberg R, Rivara FP. Prior injury and motor vehicle crash as
risk factors for youth suicide. Epidemiology. 1993;4(2):115-9.
2. Milner A, De Leo D. Suicide by motor vehicle "accident" in Queensland. Traffic
Inj Prev. 2012;13(4):342-7.
3. Henderson AF, Joseph AP. Motor vehicle accident or driver suicide?
Identifying cases of failed driver suicide in the trauma setting. Injury. 2012;43(1):18-
21.
4. Hernetkoski KM, Keskinen EO, Parkkari IK. Driver suicides in Finland--are they
different in northern and southern Finland? Int J Circumpolar Health. 2009;68(3):
249-60.
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L. Ben-Nun Suicide

PRISONERS
Self-harm among prisoners is high, and suicide rates are
increasing. Assessment of depressive characteristics is easy. To
what extent are these linked with previous self-harm? The aim of
this study was to compare depressive characteristics of prisoners
who report previous self-harm with those who do not. Twenty-four
new arrivals at an adult male category B local prison who reported
previous episodes of suicidal behavior (including self-harm and/or
explicit attempted suicide) were assessed using the BHS, the BDI-II,
and the Beck Scale for Suicide Ideation. A further 24 new arrivals
were matched as closely as possible with them on
sociodemographic and offending characteristics. Mean scores on
the BHS, the BDI-II, and the Beck Scale for Suicide Ideation were
significantly higher among the prisoners with a history of self-harm.
In conclusion, prisoners with a previous history of self-harm are
more likely than those without to show a range of depressive
symptoms than their imprisoned peers without such a history,
suggesting a continued vulnerability to self-harm and perhaps
suicide (1).
Suicide in detention environment is a phenomenon that affects
both prisoners and operators, especially prison service. Currently, in
terms of suicide prevention, the interest is shifting from an etiology
essentially endogenous to exogenous factors, seeing as the criticality
of system has its origin in the lack of knowledge of the "detained
person". This work neglects statistics and detection models to look at
all those behaviors that are part of suicide, although the suicidal act
is not genuine. This view allows identifying areas of risk and it is not
just for have a look over "the death event". Aware that no definition
is enough to shed light on this phenomenon where subjectivity is
elusive, we must always bear in mind the behaviors that precede it
and exogenous and endogenous factors. To better understand the
phenomenon of suicide in prison it is necessary to be aware of the
action that a "totalizing institution" has on the individual (2).
Released prisoners have high suicide rates compared with the
general population, but little is known about risk factors and possible
causal pathways. A population-based cohort study was conducted to
investigate rates and risk factors for suicide in people previously
imprisoned. Individuals released from prison in Sweden between
January 1, 2005, and December 31, 2009, through linkage of national
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L. Ben-Nun Suicide

population-based registers were identified. Released prisoners were

followed from the day of release until death, emigration, new
incarceration, or December 31, 2009. Survival analyses were
conducted to compare incidence rates and psychiatric morbidity with
nonconvicted population controls matched on gender and year of
birth. Among 26,985 prisoners, 38,995 releases were identified (7.6%
female) during 2005-2009. Overall, 127 suicides occurred, accounting
for 14% of all deaths after release, n=920. The mean suicide rate was
204 per 100,000 PY, yielding an incidence RR of 18.2 (95% CI 13.9-
23.8) compared with general population controls. Previous substance
use disorder (HR 2.1, 95% CI 1.4-3.2), suicide attempt (HR 2.5, 95% CI
1.7-3.7), and being born in Sweden vs. abroad (HR 2.1; 95% CI 1.2-
3.6) were independent risk factors for suicide after release. In
conclusion, released prisoners are at high suicide risk and have a
slightly different pattern of psychiatric risk factors for suicide
compared with the general population. Results suggest appropriate
allocation of resources to facilitate transition to life outside prison
and increased attention to prisoners with both a previous suicide
attempt and substance use disorder (3).
Recently released prisoners are at markedly higher risk of suicide
than the general population. The aim of this study was to identify key
risk factors for suicide by offenders released from prisons in England
and Wales. All suicides committed by offenders within 12 months of
their release from prison in England and Wales, between 2000 and
2002, were identified. One control matched on gender and date of
release from prison was recruited for each case. Of 256.920 released
prisoners, 384 suicides occurred within a year of release. Factors
significantly associated with post-release suicide were increasing age
over 25 years, released from a local prison, a history of alcohol
misuse or self-harm a psychiatric diagnosis, and requiring Community
Mental Health Services follow-up after release from prison. Non-
white ethnicity and a history of previous imprisonment were
protective factors. In conclusion, there is a need to improve the
continuity of care for people who are released from prison and for
community health, offender and social care agencies to coordinate
care for these vulnerable individuals (4).
The objective of this study was to determine the risk of suicide
and drug overdose death among recently released prisoners. This
retrospective cohort study included 85,203 adult offenders who had
spent some time in full-time custody in prisons in New South Wales
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L. Ben-Nun Suicide

between 1 January 1988 and 31 December 2002. Of 844 suicides

(795 men, 49 women), 724 (86%) occurred after release. Men had a
higher rate of suicide than women both did in prison (129 vs. 56 per
100,000 PY) and after release (135 vs. 82 per 100,000 PY). The suicide
rate in men in the two weeks after release was 3.87 (95% CI 2.26-
6.65) times higher than the rate after six months. Male prisoners
admitted to the prison psychiatric hospital had a threefold higher risk
than non-admitted men both in prison and after release. No suicides
among women were observed in the two weeks after release. No
increased risk of suicide was observed among Aboriginal Australians
in the first two weeks after release. Of 1,674 deaths due to overdose,
1,627 (97%) occurred after release. Drug-related mortality in men
was 9.30 (95% CI 7.80-11.10) times higher, and in women 6.42 (95%
CI 3.88-10.62) times higher, in the two weeks after release than after
six months. In conclusion, prisoners are at a heightened risk of
suicide and overdose death in the immediate post-release period.
After six months post-release, the suicide rate approaches the rate
observed in custody (5).

Assessment: self-harm among prisoners is high, and suicide rates

are increasing. Released prisoners are at high suicide risk and have a
slightly different pattern of psychiatric risk factors for suicide
compared with the general population. Factors significantly
associated with post-release suicide include released from a local
prison, a history of alcohol misuse or self-harm, a psychiatric
diagnosis, and requiring Community Mental Health Services follow-
up after release.

References
1. Palmer EJ, Connelly R. Depression, hopelessness and suicide ideation among
vulnerable prisoners. Crim Behav Ment Health. 2005;15(3):164-70.
2. Anselmi N, Alliani D, Ghini F. Psychophysiology of suicide in prison: a
contribution in terms of prevention. Riv Psichiatr. 2014;49(6):288-91.
3. Haglund A, Tidemalm D, Jokinen J, et al. Suicide after release from prison: a
population-based cohort study from Sweden. J Clin Psychiatry. 2014;75(10):1047-53.
4. Pratt D, Appleby L, Piper M, Webb R, Shaw J. Suicide in recently released
prisoners: a case-control study. Psychol Med. 2010;40(5):827-35.
5. Kariminia A, Law MG, Butler TG, et al. Suicide risk among recently released
prisoners in New South Wales, Australia. Med J Aust. 2007;187(7):387-90.
 89
L. Ben-Nun Suicide

MILITARY
Suicide of soldiers has its own specifics, because not only it
represents the tragedy for the individuals and their family, but also
has great psychological effect on social environment and military unit
in which it occurs. Suicide can be caused by variety of factors. The
case reviewed in this article presents multilateral determination of
suicide, with particular stress on the character of each individual and
social interaction of soldiers. Psychological complex of basic
inferiority, low educational level, family problems, and poor
integration into military unit could be considered as the leading
determinants of this suicide. This emphasizes the importance of
certain preventive measures such as more rigorous psychological
selection for specific military duty, and the education of non-
commissioned officers for better recognition and understanding of
pre-suicidal syndrome (1).
This study examined recent-onset (i.e., acute) and persistent (i.e.,
chronic) life stressors among 54 acutely suicidal U.S. Army Soldiers
and examined their relationship to persistence of suicidal crises over
time. Soldiers with a history of multiple suicide attempts reported
the most severe suicide ideation (p=0.021) and the greatest number
of chronic stressors (p=0.009). Chronic but not acute stressors were
correlated with severity of suicide ideation (p=0.026). Participants
reporting low-to-average levels of chronic stress resolved suicide
ideation during the 6-month follow-up, but participants reporting
high levels of chronic stress did not (p=0.032). Soldiers who are
multiple attempters report a greater number of chronic stressors.
Chronic, but not acute-onset, stressors are associated with more
severe and longer-lasting suicidal crises (2).
In order to best tailor suicide prevention initiatives and programs,
it is critical to gain an understanding of how service members‫ ׳‬suicide
risk factors may differ by gender. The aim of this study was to
understand gender differences in suicide and suicide attempts among
soldiers, including demographic, military, mental health, and other
risk factors. Risk factors uniquely associated with suicide and suicide
attempts were examined. A retrospective study of 1,857 U.S. Army
soldiers who died by suicide or attempted suicide was conducted
between 2008 and 2010 and had a Department of Defense Suicide
Event Report. Female and male soldiers had more similarities than
differences when examining risk factors associated with suicide. The
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L. Ben-Nun Suicide

only gender difference approaching significance was workplace

difficulties, which was more strongly associated with suicide for
female soldiers, compared to their male counterparts. Among suicide
decedents, the most common risk factor was having a failed intimate
relationship in the 90 days prior to suicide. Among those who
attempted suicide, the most common risk factor was a major
psychiatric diagnosis (3).
A pressing question in military suicide prevention research is
whether deployment in support of OEF or OIF relates to suicide risk.
Prior smaller studies report differing results and often have not
included suicides that occurred after separation from military service.
The objective of this study was to examine the association between
deployment and suicide among all 3.9 million US military personnel
who served during OEF or OIF, including suicides that occurred after
separation. This retrospective cohort design used administrative
data to identify dates of deployment for all service members
(October 7, 2001, to December 31, 2007) and suicide data (October
7, 2001, to December 31, 2009) to estimate rates of suicide-specific
mortality. Deployment was not associated with the rate of suicide
(HR 0.96, 99% CI 0.87-1.05). There was an increased rate of suicide
associated with separation from military service (HR1.63, 99% CI
1.50-1.77), regardless of whether service members had deployed or
not. Rates of suicide were also elevated for service members who
separated with less than four years of military service or who did not
separate with an honorable discharge. In conclusion, findings do not
support an association between deployment and suicide mortality in
this cohort. Early military separation (<4 years) and discharge that is
not honorable were suicide risk factors (4).
The main objective of this study was to determine whether
exposure to particular types of traumatic events was differentially
associated with suicide attempts in a representative sample of active
military personnel. Data came from the Canadian Community Health
Survey: Mental Health and Well-Being Canadian Forces Supplement,
a cross-sectional survey that provided a comprehensive examination
of mental disorders, health, and the well-being of currently active
Canadian military personnel (n=8,441, aged 16 to 54 years, response
rate 81.1%). Respondents were asked about exposure to 28
traumatic events that occurred during their lifetime. Suicide attempts
were measured using a question about whether the person ever
"attempted suicide or tried to take (his or her) own life". The
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L. Ben-Nun Suicide

prevalence of lifetime suicide attempts for currently active Canadian

military men and women was 2.2% and 5.6%, respectively. Sexual
and other interpersonal traumas (for example, rape, sexual assault,
spousal abuse, child abuse) were significantly associated with suicide
attempts for both men (AOR 2.31-4.43) and women (AOR 1.73- 3.71),
even after adjusting for sociodemographics and mental disorders.
Additionally, the number of traumatic events was positively
associated with increased risk of suicide attempts, indicating a dose-
response effect of exposure to trauma. The current study
demonstrates that sexual and other interpersonal traumatic events
are associated with suicide attempts in a representative sample of
active Canadian military men and women (5).
Soldier suicide rates, unfortunately, continue to rise in military
services. Military personnel are highly vulnerable to multiple
psychopathologies due to a lack of social support system,
traumatizing life events and deprived sense of control. Serious
psychopathologies such as PTSDs, other anxiety disorders (i.e., GAD)
and depression may increase the risk of suicide. In addition,
malingering may be a serious problem that can affect valid treatment
due to an intentional production of false or grossly exaggerated
physical or psychological symptoms, motivated by external incentive
such as avoiding military duty or obtaining financial compensation.
Hispanic soldiers are at a higher risk for such psychopathologies due
to extreme marginalization conditions by military peers, lack of
bilingual language management and discrimination that can severely
affect their quality of life. It is important to recognize those problems
in order to prevent them. Primary Preventive Interventions can help
to reduce the incidence of psychiatric disorders due to an early
identification of the mental conditions associated with serious
outcome, such as suicide. It is important to develop and validate a
battery of screening instruments that address the previous
conditions in the military personnel, especially in the Hispanic/Latino
soldier and/or veteran as plans of interventions. This implies the
creation, adaptation and administration of a Psychological Battery
that will be culturally sensitive for Hispanic/Latino soldiers in which
the screening of the previously mentioned pathologies and
conditions can be identified. This can help to prevent serious
psychological situations and irreversible damage, such as suicide (6).
This article examined the factors associated with suicide during
America's Civil War and the years immediately following the
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L. Ben-Nun Suicide

cessation of armed conflict. Contemporary newspaper reports,

complemented by book and journal articles, provide an
understanding of the incidence and motivations of suicide. The rate
of suicide in the general population dramatically increased in the
years following the war's end. During the Civil War, suicides occurred
nearly every month, reliably peaking in the spring of each year.
Depression and alcohol abuse were major factors associated with
military suicides. Emotional disorders and alcohol misuse, when
combined with the hardships of war, contributed to a steady rate of
suicides during the Civil War (7).
The suicide rate among U.S. Army soldiers has increased
substantially in recent years. The objective of this study was to
estimate the lifetime prevalence and sociodemographic, Army
career, and psychiatric predictors of suicidal behaviors among
nondeployed U.S. Army soldiers. This study included a representative
cross-sectional survey of 5,428 nondeployed soldiers participating in
a group self-administered survey. The lifetime prevalence estimates
of suicidal ideation, suicide plans, and suicide attempts are 13.9%,
5.3%, and 2.4%. Most reported cases (47.0%-58.2%) had pre-
enlistment onsets. Pre-enlistment onset rates were lower than in a
prior national civilian survey (with imputed/simulated age at
enlistment), whereas post-enlistment onsets of ideation and plans
were higher, and post-enlistment first attempts were equivalent to
civilian rates. Most reported onsets of plans and attempts among
ideators (58.3%-63.3%) occur within the year of onset of ideation.
Post-enlistment attempts are positively related to being a woman
(with an OR of 3.3, 95% CI 1.5-7.5), lower rank (OR 5.8, 95% CI 1.8-
18.1) and previously deployed (OR  2.4-3.7) are negatively related to
being unmarried (OR  0.1-0.8) and assigned to Special Operations
Command (OR  0.0, 95% CI 0.0-0.0). Five mental disorders predicted
post-enlistment first suicide attempts in multivariate analysis: pre-
enlistment panic disorder (OR  0.1, 95% CI 0.0-0.8), pre-enlistment
PTSD (OR  0.1, 95% CI 0.0-0.7), post-enlistment depression (OR 3.8,
95% CI 1.2-11.6), and both pre- and post-enlistment intermittent
explosive disorder (OR  3.7-3.8). Four of these five ORs (PTSD is the
exception) predict ideation, whereas only post-enlistment
intermittent explosive disorder predicts attempts among ideators.
The population-attributable risk proportions of lifetime mental
disorders predicting post-enlistment suicide attempts are 31.3% for
pre-enlistment onset disorders, 41.2% for post-enlistment onset
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L. Ben-Nun Suicide

disorders, and 59.9% for all disorders. In conclusion, the fact that
approximately one-third of post-enlistment suicide attempts are
associated with pre-enlistment mental disorders suggests that pre-
enlistment mental disorders might be targets for early screening and
intervention. The possibility of higher fatality rates among Army
suicide attempts than among civilian suicide attempts highlights the
potential importance of means control (i.e., restricting access to
lethal means [such as firearms]) as a suicide prevention strategy (8).
Analyses of suicide risk factors enable to undertake appropriate
preventive measures within the Suicide Prevention Program in
Military Environment, which was fully applied in 2003 in the Serbian
Army Forces. The aim of this study was to identify the most
important suicide risk factors in soldiers within the period from 1998
to 2007. Analysis of suicide risk factors was carried out based on data
obtained by psychological suicide autopsy. The control group was
matched with adapted soldiers by socio-demographic factors. A
descriptive statistical analysis was used. A total of 35 soldiers aged
22-49 years (21.76 +/- 1.76 years on average) committed suicide
within the period 1999-2007, the 2/3 within, and 1/3 out of a military
compound. More than one-half soldiers committed suicide after
transferring to a different post. Soldiers who committed suicide had
come from uncompleted and dysfunctional families (p<0.05). In
comparison with the adapted soldiers, in premilitary period they had
more interpersonal problems with their comrades (p<0.001) and
problems with law (p<0.05). During military service, alcohol
consumption was less presented; they used to have fewer separation
problems (p <0.05) and to be rarely awarded (p<0.001) in comparison
with the adapted soldiers. Soldiers who committed suicide were
emotionally and socially immature persons. The commonest motives
for suicide were decreased capacity of adaptation to military service,
actual psychic disturbance, emotional interruption, fear of
environment judgment, actual family problems, but in the one-fifth
motive stayed unrecognized. Suicide risk factors in soldiers are
primary in their immature personality organization, its relation with
family and military environment factors which, in coexistence with
actual life accidents, result in suicide. A suicide prevention program
should be designed to prevent multiple suicide risk factors (9).
The present study compared characteristics of combatant and
non-combatant Israeli soldiers (ages 18-21), who committed suicide
(n=429) with others who did not commit suicide (n=499). Measures
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L. Ben-Nun Suicide

of pre-military psychological characteristics and data reflecting

adjustment to service were extracted from army records. Findings
indicate that in comparison to non-suicide soldiers (non-suicide-
soldiers) soldiers who committed suicide (suicide soldiers) had
greater behavioral adjustment and motivation to serve. In addition,
as compared to non-combatant suicide soldiers, combatant suicide
soldiers had fewer referrals for psychological evaluation, higher sense
of duty and autonomy scores and fewer unit changes. Excessive
motivation to excel in the army and the tendency to be autonomous
and independent may account for suicide among combatant suicide
soldiers, whereas personality weaknesses may have an impact on
suicide among non-combatants (10).

Assessment: suicide of soldiers has its own specifics, because not

only it represents the tragedy for the individuals and their family, but
also has great psychological effect on social environment and military
unit in which it occurs. Psychological complex of basic inferiority, low
educational level, family problems, and poor integration into military
unit are the leading determinants of suicide.
Military personnel are highly vulnerable to multiple
psychopathologies due to a lack of social support system,
traumatizing life events and deprived sense of control. Serious
psychopathologies such as PTSDs, GAD, and depression may increase
the risk of suicide.
The commonest motives for suicide are decreased capacity of
adaptation to military service, actual psychic disturbance, emotional
interruption, fear of environment judgment, and family problems.
Suicide risk factors in soldiers are primary in their immature
personality organization, its relation with family and military
environment factors which, in coexistence with actual life accidents,
result in suicide therefore.
The number of traumatic events is associated with increased risk
of suicide attempts. Soldiers who are multiple attempters report a
greater number of chronic stressors. Chronic, but not acute-onset,
stressors are associated with more severe and longer-lasting suicidal
crises.
Among suicide decedents, the most common risk factor is a failed
intimate relationship in the 90 days prior to suicide. Among those
who attempted suicide, the most common risk factor was a major
 95
L. Ben-Nun Suicide

psychiatric diagnosis. Early military separation (<4 years) and

discharge that is not honorable are also suicide risk factors.
Depression and alcohol abuse are major factors associated with
military suicides. Emotional disorders and alcohol misuse, when
combined with the hardships of war, contributed to a steady rate of
suicides during the American Civil War.
Was suicide associated with military situation in characters
studied in this research? In Samson and King Saul, factors in military
suicide include – the humiliating defeat in the battle, refusal to
surrender to their enemies, the impossibility to escape, hopelessness,
and despair, while in proud Abimelech's case, he was humiliated and
defeated by a simple stone cast by a woman. There was no
possibility of being saved and cured.

References
1. Cabarkapa M, Panid M. Suicide in the military environment. Vojnosanit Pregl.
2004;61:199-203.
2. Bryan CJ, Clemans TA, Leeson B, Rudd MD. Acute vs. chronic stressors,
multiple suicide attempts, and persistent suicide ideation in US soldiers. J Nerv Ment
Dis. 2015;203(1):48-53.
3. Maguen S, Skopp NA, Zhang Y, Smolenski DJ. Gender differences in suicide
and suicide attempts among US Army soldiers. Psychiatry Res. 2015;225(3):545-9.
4. Reger MA, Smolenski DJ1, Skopp NA, et al. Risk of Suicide Among US Military
Service Members Following Operation Enduring Freedom or Operation Iraqi
Freedom Deployment and Separation From the US Military. JAMA Psychiatry. 2015
Apr 1.
5. Rodríguez JR, Quiñones-Maldonado R, Alvarado-Pomales A. Military suicide:
factors that need to be taken into consideration to understand the phenomena. Bol
Asoc Med P R. 2009;101:33-41.
6. Belik SL, Stein MB, Asmundson GJ, Sareen J. Relation between traumatic
events and suicide attempts in Canadian military personnel. Can J Psychiatry.
2009;54:93-104.
7. Lande RG. Felo De Se. Soldier suicides in America's Civil War. Mil Med. 2011;
176:531-6.
8. Nock MK, Stein MB, Heeringa SG, et al.; Army STARRS Collaborators.
Prevalence and correlates of suicidal behavior among soldiers: results from the Army
Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA
Psychiatry. 2014;71(5):514-22.
9. Dedid G, Panid M. Soldiers suicides risk factors in the Serbian Army Forces.
Vojnosanit Pregl. 2010;67:548-57.
10. Bodner E, Ben-Artzi E, Kaplan Z. Soldiers who kill themselves: the
contribution of dispositional and situational factors. Arch Suicide Res. 2006;10:29-43.
 96
L. Ben-Nun Suicide

PERSONS WITH MENTAL DISORDERS

A prospective research study attempted to identify persons who
would subsequently commit or attempt suicide. The sample
consisted of 4,800 patients who were consecutively admitted to the
inpatient psychiatric service of a Veterans Administration hospital.
They were examined and rated on a wide range of instruments and
measures, including most of those previously reported as predictive
of suicide. Many items were found to have positive and substantial
correlations with subsequent suicides and/or suicide attempts.
However, all attempts to identify specific subjects were unsuccessful,
including use of individual items, factor scores, and a series of
discriminant functions. Each trial missed many cases and identified
far too many false positive cases to be workable. Identification of
particular persons who will commit suicide is not currently feasible,
because of the low sensitivity and specificity of available
identification procedures and the low base rate of this behavior (1).
The literature on inpatient suicides was systematically reviewed.
English, German, and Dutch articles were identified by means of the
electronic databases PsycInfo, Cochrane, Medline, EMBASE
psychiatry, CINAHL, and British Nursing Index. In total, 98 articles
covering almost 15,000 suicides were reviewed and analyzed. Rates
and demographic features connected to suicides varied substantially
between articles, suggesting distinct subgroups of patients
committing suicide (e.g., depressed vs. schizophrenic patients) with
their own suicide determinants and patterns. Early in the admission is
clearly a high-risk period for suicide, but risk declines more slowly for
patients with schizophrenia. Suicide rates were associated with
admission numbers, and as expected, previous suicidal behavior was
a robust predictor of future suicide. The methods used for suicide are
linked to availability of means. Timing and location of suicides seem
to be associated with absence of support, supervision, and the
presence of family conflict. Although there is a strong notion that
suicides cluster in time, clear statistical evidence for this is lacking.
For prevention of suicides, staff needs to engage with patients' family
problems, and reduce absconding without locking the door (2).
The aim of this study was to evaluate characteristics and
predictors for in-patient suicides. All in-patient suicides registered
by the psychiatric basic documentation for the period 1989 - 1999
were described. Thirty in-patient suicides were found among
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39,372 cases, corresponding to a mean annual suicide rate of 76

per 100,000 admissions. All suicides were committed using violent
methods and took place outside the hospital in more than 75% of
the cases. Nearly 85% of the patients were on leave or an outing.
According to the logistic regression, the risk of hospital suicides is
significantly increased for patients with schizophrenia, a higher
cumulative length of stay and a previous suicide attempt, but not
suicidality or suicide attempt before index admission. In conclusion,
schizophrenic patients represent the high-risk group for suicide in
psychiatric hospital. An especially focused prevention on this group
could reduce in-patient suicide rates (3).

References
1. Pokorny AD. Prediction of suicide in psychiatric patients. Report of a
prospective study. Arch Gen Psychiatry. 1983;40(3):249-57.
2. Bowers L, Banda T, Nijman H. Suicide inside: a systematic review of
inpatient suicides. J Nerv Ment Dis. 2010;198(5):315-28.
3. Spiessl H, Cording C. Suicides in psychiatric in-patient treatment. Psychiatr
Prax. 2001;28(7):330-4.

DEPRESSION. Depression is the most common psychiatric

disorder in people who die by suicide. Awareness of risk factors for
suicide in depression is important for clinicians. In a systematic
review of the international literature, cohort and case-control
studies identified people with depression in which suicide was an
outcome, and meta-analyses of potential risk factors were
conducted. Nineteen studies (28 publications) were included.
Factors significantly associated with suicide were: male gender (OR
1.76, 95% CI 1.08-2.86), family history of psychiatric disorder (OR
1.41, 95% CI 1.00-1.97), previous attempted suicide (OR 4.84, 95%
CI 3.26-7.20), more severe depression (OR 2.20, 95% CI 1.05-4.60),
hopelessness (OR 2.20, 95% CI 1.49-3.23), comorbid disorders,
including anxiety (OR 1.59, 95% CI 1.03-2.45) and misuse of alcohol
and drugs (OR 2.17, 95% CI 1.77-2.66). In conclusion, the factors
identified should be included in clinical assessment of risk in
depressed patients (1).
Few studies have investigated risk factors for suicidal ideation
and attempts, or possible variations in them, among representative
samples of psychiatric patients with MDD. As part of the Vantaa
Depression Study in Vantaa, Finland, 269 patients with DSM-IV
MDD, diagnosed by interview using semistructured WHO Schedules
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for Clinical Assessment in Neuropsychiatry, version 2.0, and

Structured Clinical Interview for DSM-III-R Personality Disorders,
were thoroughly investigated. Information was gathered on
patients' levels of depression, anxiety, hopelessness, perceived
social support, social and occupational functioning, and alcohol use.
Suicidal behavior was assessed by interviews, including the Scale
for Suicidal Ideation, and by information from psychiatric records.
Data were gathered from Feb. 1, 1997, to May 31, 1998. During the
current MDD episode, 58% of all patients had experienced suicidal
ideation; among the 15% of the total who had attempted suicide,
almost all (95%) had also had suicidal ideation. In nominal
regression models predicting suicidal ideation, hopelessness,
alcohol dependence or abuse, low level of social and occupational
functioning, and poor perceived social support were significant
independent risk factors (p<0.05). High severity of depression and
current alcohol dependence or abuse in particular, younger age and
low level of social and occupational functioning, predicted suicide
attempt. In conclusion, suicidal ideation is prevalent and appears to
be a precondition for suicide attempts among psychiatric patients
with MDD. The risk factors for suicidal ideation and attempts locate
in several clinical and psychosocial domains. While these risk
factors largely overlap, the overall level of psychopathology of
suicide attempters is higher compared with that in patients with
ideation, and substance use disorders and severity of depression
may be of particular importance in predicting suicide attempts (2).
The aim was to assess determinants of suicidality (suicidal
ideation and suicide attempts) in a general population cohort with
depressive spectrum disorders, and to compare determinants for
suicidal ideation and determinants for suicide attempts in this
cohort. The Netherlands Mental Health Survey and Incidence Study
is an epidemiologic survey in the adult population (n=7,076), using
the CIDI. In a cohort of 586 persons with a depressive spectrum
disorder, 97 (16.6%) reported suicidal ideation and 19 (3.2%)
suicide attempts in a period of two years. In a multivariate model,
male gender (OR 0.54, 95% CI 0.30-0.99, p=0.05), longer (>13
months) duration of depression (OR 2.86, 95% CI 1.21-6.73, p=0.02;
OR 2.71, 95% CI 1.24-5.91, p=0.01), anhedonia (OR 2.00, 95% CI
1.01-5.91, p=0.05), feeling worthless (OR 1.99, 95% CI 1.05-3.74,
p=0.03), comorbid anxiety (OR 2.46, 95% CI 1.38-4.40, p<0.01),
previous suicidal ideation (OR 3.50, 95% CI 1.96-6.24, p<0.001), and
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use of professional care (OR 1.96, 95% CI 1.01-3.79, p=0.05) were

significantly related to suicidality. Determinants of suicidal ideation
differed from determinants of suicide attempts. In conclusion,
features of depression were the most important determinants of
suicidality in a depressive spectrum cohort. Determinants for
suicidal ideation differed from suicide attempts. These findings
could be helpful in identifying those who need more intense
treatment strategies in order to prevent suicidality and eventually
suicide (3).
MDD is a major risk factor for suicide. However, not all individuals
with MDD commit suicide. Impulsive and aggressive behaviors have
been proposed as risk factors for suicide, but it remains unclear
whether their effect on the risk of suicide is at least partly explained
by axis I disorders commonly associated with suicide, such as MDD.
With a case-control design, a comparison of the level of impulsive
and aggressive behaviors and the prevalence of associated
psychopathology was carried out with control for the presence of
primary psychopathology. One hundred and four male suicide
completers who died during MDE and 74 living depressed male
comparison subjects were investigated with proxy-based interviews
by using structured diagnostic instruments and personality trait
assessments. Current (6-month prevalence) alcohol
abuse/dependence, current drug abuse/dependence, and cluster B
personality disorders increased the risk of suicide in individuals with
major depression. Higher levels of impulsivity and aggression were
associated with suicide. These risk factors were more specific to
younger suicide victims (ages 18-40). A multivariate analysis indicated
that current alcohol abuse/dependence and cluster B personality
disorder were two independent predictors of suicide. In conclusion,
impulsive-aggressive personality disorders and alcohol
abuse/dependence were two independent predictors of suicide in
MDD, and impulsive and aggressive behaviors seem to underlie these
risk factors (4).

Assessment: depression is the most common psychiatric disorder

in people who die by suicide. Suicidal behavior is related to male
gender, longer (>13 months) duration of depression, anhedonia,
feeling worthless, comorbid anxiety, previous suicidal ideation, and
use of professional care.
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Impulsive-aggressive personality disorders and alcohol

abuse/dependence are predictors of suicide in MDD. While impulsive
and aggressive behaviors seem to underlie these risk factors.
Can bipolar disorder be linked to suicide in King Saul's case?
Although King Saul suffered from bipolar disorder I, this mental
disorder cannot be related to his suicidal behavior. His suicide was
associated with a situation when the battle on Mount Gilboa was lost
and there was no chance of escape. King Saul, having a strong
character, died likes a hero.
The medical record of other characters studied in this research
shows no signs of some type of depression such as MDD, brief
depressive episodes, or very brief depressive episodes. In addition,
no signs of comorbidity of MDD with PTSD are recorded. Thus, the
defeat in military cannot be related to the development of
depression.
Can impulsivity be associated with suicide in the cases of Samson,
King Saul, Ahithopel, King Zimri, and Abimelech? Was their
impulsivity associated with the defeat? Can the King Saul's
impulsivity be linked to severe behavioral complications of bipolar
disorder?
It is likely that the relationship between impulsivity and
hopelessness in the face of defeat led to suicide in these individuals.

References
1. Hawton K, Casañas I Comabella C, et al. Risk factors for suicide in individuals
with depression: a systematic review. J Affect Disord. 2013;147(1-3):17-28.
2. Sokero TP, Melartin TK, Rytsälä HJ, et al. Suicidal ideation and attempts among
psychiatric patients with major depressive disorder. J Clin Psychiatry. 2003;64(9):
1094-100.
3. Spijker J, de Graaf R, Ten Have M, et al. Predictors of suicidality in depressive
spectrum disorders in the general population: results of the Netherlands Mental
Health Survey and Incidence Study. Soc Psychiatry Psychiatr Epidemiol. 2010;45(5):
513-21.
4. Dumais A, Lesage AD, Alda M, et al. Risk factors for suicide completion in
major depression: a case-control study of impulsive and aggressive behaviors in men.
Am J Psychiatry. 2005;162(11):2116-24.
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MOOD DISORDERS
About one-half to two-thirds of all suicides are by people who
suffer from mood disorders; preventing suicides among those who
suffer from them is thus central for suicide prevention.
Understanding factors underlying suicide risk is necessary for
rational preventive decisions. The literature on risk factors for
completed and attempted suicide among subjects with depressive
and bipolar disorders was reviewed. Lifetime risk of completed
suicide among psychiatric patients with mood disorders is likely
between 5-6%, with bipolar disorders, and possibly somewhat
higher risk than patients with MDD. Longitudinal and psychological
autopsy studies indicate that suicidal acts usually take place during
MDEs or mixed illness episodes. Incidence of suicide attempts is
about 20- to 40-fold, compared with euthymia, during these
episodes, and duration of these high-risk states is therefore an
important determinant of overall risk. Substance use and cluster B
personality disorders also markedly increase risk of suicidal acts
during mood episodes. Other major risk factors include
hopelessness and presence of impulsive-aggressive traits. Both
childhood adversity and recent adverse life events are likely to
increase risk of suicide attempts, and suicidal acts are predicted by
poor perceived social support. Understanding suicidal thinking and
decision making is necessary for advancing treatment and
prevention. In conclusion, among subjects with mood disorders,
suicidal acts usually occur during MDEs or mixed episodes
concurrent with comorbid disorders. Nevertheless, illness factors
can only in part explain suicidal behavior. Illness factors, difficulty
controlling impulsive and aggressive responses, plus predisposing
early exposures and life situations result in a process of suicidal
thinking, planning, and acts (1).
The aim of this review is to highlight the traditional and newly
recognized suicide risk factors in patients with mood disorders.
Current research findings clearly suggest that suicidal behavior in
patients with mood disorder is a 'state-dependent' phenomenon.
There is, however, a growing body of evidence that besides the well
accepted clinically explorable suicide risk factors in mood disorders
(e.g., severe depression, prior suicide attempt, comorbid anxiety,
substance use, personality disorders, and so on), mixed state of
depression could also be an important precursor of suicidal
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behavior. This might be particularly true in unrecognized cases of

bipolar depressives, when antidepressant monotherapy
(unprotected by mood stabilizers or atypical antipsychotics) can
worsen the clinical picture and rarely induce an aggressive or self-
destructive behavior. In the majority of patients with mood
disorders, suicidal behavior is predictable and preventable, with a
good chance. A careful and systematic exploration of suicide risk
factors in patients with mood disorder helps clinicians to identify
patients at high suicide risk. A successful, acute and long-term
treatment of these patients substantially reduces the suicidal
behavior even in this high-risk population (2).
This article reviews the evidence for the major risk factors
associated with suicidal behavior in bipolar disorder. Review of the
literature studies was conducted on bipolar disorder, suicidal
behavior and suicidal ideation. Bipolar disorder is strongly
associated with suicide ideation and suicide attempts. In clinical
samples, between 14-59% of the patients have suicide ideation and
25-56% present at least one suicide attempt during lifetime.
Approximately 15-19% of patients with bipolar disorder die from
suicide. The causes of suicidal behavior are multiple and complex.
Some strong predictors of suicidal behavior have emerged in the
literature such as current mood state, severity of depression,
anxiety, aggressiveness, hostility, hopelessness, comorbidity with
others Axis I and Axis II disorders, lifetime history of mixed states,
and history of physical or sexual abuse. In conclusion, bipolar
disorder is the psychiatric condition associated with highest lifetime
risk for suicide attempts and suicide completion (3).
In the Jorvi Bipolar Study, psychiatric inpatients and outpatients
were screened for bipolar disorders with the Mood Disorder
Questionnaire from January 1, 2002, to February 28, 2003.
According to Structured Clinical Interviews for DSM-IV Axis I and II
Disorders, 191 patients were diagnosed with bipolar disorders
(bipolar I, n=90; bipolar II, n=101). Suicidal ideation was measured
using the Scale for Suicidal Ideation. Prevalence of and risk factors
for ideation and attempts were investigated. During the current
episode, 39 (20%) of the patients had attempted suicide and 116
(61%) had suicidal ideation; all attempters also reported ideation.
During their lifetime, 80% of patients (n=152) had had suicidal
behavior and 51% (n=98) had attempted suicide. In nominal
regression models, severity of depressive episode and hopelessness
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were independent risk factors for suicidal ideation, and

hopelessness, comorbid personality disorder, while previous
suicide attempt were independent risk factors for suicide attempts.
There were no differences in prevalence of suicidal behavior
between bipolar I and II disorder; the risk factors were overlapping
but not identical. In conclusion, over their lifetime, the vast
majority (80%) of psychiatric patients with bipolar disorders have
either suicidal ideation or ideation plus suicide attempts.
Depression and hopelessness, comorbidity, and preceding suicidal
behavior are key indicators of risk. The prevalence of suicidal
behavior in bipolar I and II disorders is similar, but the risk factors
for it may differ somewhat between the two (4).
The purpose of this descriptive review of the past ten years of
scientific literature on suicidality in youths with bipolar disorder was
to identify the risk and protective factors associated with this
phenomenon, and to discuss the implications for research and clinical
practice. Searches on Medline and PsycINFO databases for the period
from early 2002 to mid-2012 yielded 16 relevant articles, which were
subsequently explored using an analysis grid. A consensus analysis
approach was used at all stages of the review. Four primary
categories of risk factors for suicidality in youths with bipolar disorder
were identified: demographic (age and gender), clinical (depression,
mixed state or mixed features specifier, mania, anxiety disorders,
psychotic symptoms, and substance abuse), psychological
(cyclothymic temperament, hopelessness, poor anger management,
low self-esteem, external locus of control, impulsivity and
aggressiveness, previous suicide attempts, and history of suicide
ideation, non-suicidal self-injurious behaviors and past psychiatric
hospitalization), and family/social (family history of attempted
suicide, family history of depression, low quality of life, poor family
functioning, stressful life events, physical/sexual abuse, and social
withdrawal). Youths with bipolar disorder who experienced more
complex symptomatic profiles were at greater risk of suicidality. Few
protective factors associated with suicidality have been studied
among youths with bipolar disorder. One protective factor was
found: the positive effects of dialectical behavior therapy (5).

Assessment: bipolar disorder is strongly associated with suicide

ideation and suicide attempts. Severity of depressive episode and
hopelessness are factors for suicidal ideation, while hopelessness,
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comorbid personality disorder, and previous suicide attempt are

independent risk factors for suicide attempts.
Among characters studied in this research, only King Saul suffered
from bipolar I disorder. Can bipolar disorder be linked to suicide in
King Saul's case? Although King Saul suffered from bipolar disorder I,
this mental disorder cannot be related to his suicidal behavior. His
suicide was associated with a military situation when the battle on
Mount Gilboa was lost and there was no chance of escape. His
situation was hopeless and desperate, with no possibility of breaking
through surrounding enemy or escaping over Mount Gilboa. His
hopelessness was therefore was due to the circumstances of the
battle rather than bipolar I disorder.

References
1. Isometsä E. Suicidal behaviour in mood disorders-who, when, and why? Can
J Psychiatry. 2014;59(3):120-30.
2. Rihmer Z. Suicide risk in mood disorders. Curr Opin Psychiatry.
2007;20(1):17-22.
3. Abreu LN, Lafer B, Baca-Garcia E, Oquendo MA. Suicidal ideation and suicide
attempts in bipolar disorder type I: an update for the clinician. Rev Bras Psiquiatr.
2009;31(3):271-80.
4. Valtonen H, Suominen K, Mantere O, et al. Suicidal ideation and attempts in
bipolar I and II disorders. J Clin Psychiatry. 2005;66(11):1456-62.
5. Halfon N, Labelle R, Cohen D, et al. Juvenile bipolar disorder and suicidality:
a review of the last 10 years of literature. Eur Child Adolesc Psychiatry. 2013;
22(3):139-51.

GENERALIZED ANXIETY DISORDER

The main aim of this study was to examine whether anxiety
disorders are risk factors for suicidal ideation and suicide attempts in
a large population-based longitudinal study. Data come from the
Netherlands Mental Health Survey and Incidence Study, a
prospective population-based survey with a baseline and two follow-
up assessments over a 3-year period. The CIDI was used to assess
DSM-III-R mental disorders. Lifetime diagnoses of anxiety disorders
(social phobia, simple phobia, GAD, panic disorder, agoraphobia, and
OCD) were assessed at baseline. Multiple logistic regression analyses
were used to examine whether anxiety disorders were associated
with suicidal ideation and attempts at baseline (n=7,076) and
whether anxiety disorders were risk factors for subsequent onset of
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suicidal ideation and attempts (n=4,796). After adjusting for

sociodemographic factors and all other mental disorders assessed in
the survey, baseline presence of any anxiety disorder was
significantly associated with suicidal ideation and suicide attempts in
both the cross-sectional analysis (AOR for suicidal ideation 2.29, 95%
CI 1.85-2.82; AOR for suicidal attempts 2.48, 95% CI 1.70-3.62) and
longitudinal analysis (AOR for suicidal ideation 2.32, 95% CI 1.31-
4.11; AOR for suicide attempts 3.64, 95% CI 1.70-7.83). Further
analyses demonstrated that the presence of any anxiety disorder in
combination with a mood disorder was associated with a higher
likelihood of suicide attempts in comparison with a mood disorder
alone. In conclusion, a preexisting anxiety disorder is an independent
risk factor for subsequent onset of suicidal ideation and attempts.
Comorbid anxiety disorders amplify the risk of suicide attempts in
persons with mood disorders (1).
The objective of this study was to determine whether the
presence of an anxiety disorder was a risk factor for future suicide
attempts. Data were drawn from the 13-year follow-up Baltimore
Epidemiological Catchment Area survey (n=1,920). Multiple logistic
regression analysis was used to determine the association between
baseline anxiety disorders (social phobia, simple phobia, OCD, panic
attacks, or agoraphobia) and subsequent onset suicide attempts. The
presence of one or more anxiety disorders at baseline was
significantly associated with subsequent onset suicide attempts (AOR
2.20, 95% CI 1.04-4.64) after controlling for sociodemographical
variables and all baseline mental disorders assessed in the survey.
These findings suggest that anxiety disorders are independent risk
factors for suicide attempts, and underscore the importance of
anxiety disorders as a serious public health problem (2).
The aim of this study was to examine whether depressed veterans
with comorbid anxiety had higher risks of suicide death. Using
Veterans Affairs administrative databases, 887,859 patients with
depression were identified. In multivariate analyses, the odds of
completed suicide were significantly increased for patients with panic
disorder (OR 1.26, 95% CI 1.04-1.53), GAD (OR 1.27, 95% CI 1.09-
1.47), and anxiety disorder, not otherwise specified (OR 1.25, 95% CI
1.12-1.38). The odds of completed suicide were also greater among
patients who received any antianxiety medication (OR 1.71, 95% CI
1.55-1.88), and were further increased among those who received
high dose treatment (OR 2.26, 95% CI 1.98-2.57). Odds of completed
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suicide were decreased among patients with comorbid PTSD (OR

0.87, 95% CI 0.77-0.97), and there was insignificant relationship
between social phobia, OCD, and all other anxiety disorders and
suicide. In conclusion, these findings emphasize the importance of
comorbid anxiety disorders and symptoms in increasing suicide risk
among depressed patients and may inform suicide prevention efforts
among these patients (3).
The aims of the present study were to examine the prevalence of
suicidal ideation and behaviors, as well as factors associated with
suicide risk in patients with anxiety disorders in primary care. Data
from a large scale RCS were analyzed to assess prevalence of suicidal
thoughts and behaviors, as well as factors associated with suicide
risk. Results revealed that suicidal ideation and behaviors were
relatively common in this group. When examining mental and
physical health factors jointly, presence of depression, mental health-
related impairment, and social support each uniquely accounted for
variance in suicide risk score. Results highlight the complex
determinants of suicidal behavior and the need for more nuanced
suicide assessment in this population, including evaluation of
comorbidity and general functioning (4).

Assessment: any anxiety disorder is associated with suicidal

ideation and suicide attempts. Comorbid anxiety disorders amplify
the risk of suicide attempts in persons with mood disorders, and
suicide risk among depressed patients.
The medical record of the characters studied in this research
indicates no GAD. Their situation was hopeless and desperate due to
specific circumstances. Thus, suicide in these cases was not
associated with GAD.

References
1. Sareen J, Cox BJ, Afifi To, et al. Anxiety disorders and risk for suicidal ideation and
suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry.
2005;62(11):1249-57.
2. Bolton JM, Cox BJ, Afifi To, et al. Anxiety disorders and risk for suicide attempts:
findings from the Baltimore Epidemiologic Catchment area follow-up study. Depress
Anxiety. 2008;25(6):477-81.
3. Pfeiffer PN, Ganoczy D, Ilgen M, et al. Comorbid anxiety as a suicide risk factor
among depressed veterans. Depress Anxiety. 2009;26(8):752-7.
4. Bomyea J, Lang AJ, Craske MG, Chavira D, et al. Suicidal ideation and risk factors
in primary care patients with anxiety disorders. Psychiatry Res. 2013; 209(1):60-5.
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OBSESSIVE-COMPULSIVE DISORDER
One hundred consecutive DSM-IV OCD subjects attending the
specialty OCD clinic and the inpatient services of a major psychiatric
hospital in India from November 1, 2003, to October 31, 2004,
formed the sample of this study. Subjects were assessed
systematically by using structured interviews and various rating
scales. The Scale for Suicide Ideation-worst ever (lifetime) and -
current measured suicidal ideation was used. The 24-item HAM-D
measured severity of depression, and the BHS measured
hopelessness. Assessments at study entry were conducted. The rates
of suicidal ideation, worst ever and current, were 59% and 28%,
respectively. History of suicide attempt was reported in 27% of the
subjects. For past suicide attempt, worst ever suicidal ideation
(p<0.001) was the only significant predictor, with an overall
prediction of 89%, and accounted for 60% of the variance. For worst
ever suicidal ideation, MDD (p=0.043), HAM-D score (p=0.013), BHS
score (p=0.011), and history of attempt (p=0.009) were significant
predictors, with an overall prediction of 82% and variance of 56%.
Somewhat similar predictors emerged as significant for current
suicidal ideators, with an overall prediction of 85% and variance of
50%. In the structural equation model, too, presence of depression
and high BHS score contributed to suicidal ideation. In conclusion,
OCD is associated with a high risk for suicidal behavior. Depression
and hopelessness are the major correlates of suicidal behavior. It is
vital that patients with OCD undergo detailed assessment for suicide
risk and associated depression. Aggressive treatment of depression
may be warranted to modify the risk for suicide (1).
The objective of this study was to explore the association between
OCPD and suicidal behavior. Subjects referred for a psychiatric
consultation were evaluated with structured interviews for mood and
personality disorders (the Structured Clinical Interview for DSM-III-R
and the Structured Clinical Interview for DSM-III-R Axis II Disorders), a
history of suicidal behavior, and levels of coping. A total of 311
subjects were investigated using a 3-group design to test the
association between OCPD and suicidal behavior, controlling for the
presence of depression. Subjects with OCPD and a history of
depression were compared to depressed subjects without any Axis II
diagnosis and to subjects without depression or personality
disorders. The study was conducted at Verdun Community
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Psychiatric Clinic, Douglas Hospital, McGill University, in Montreal,

Quebec, Canada, and subjects were recruited from 2003 until 2005.
Subjects in the comorbid OCPD-depression group presented
increased current and lifetime suicide ideation compared to the
groups with depression alone or without depression or personality
disorders (p=0.004); they also had increased history of suicide
attempts (p=0.04), which were often multiple attempts (p=0.01).
They scored lower on the RFL and the Death Anxiety Questionnaire.
Comorbid OCPD-depression patients differed from patients with
depression alone on the Moral Objections items of the RFL, on which
individuals with OCPD-depression scored lowest. In conclusion, OCPD
is a factor increasing risk for nonfatal suicidal behavior independently
of risk conferred by depressive disorders (2).
The objective of this study was to describe the occurrence of
persistent suicidal ideation and suicide attempts in a sample of OCD
patients followed-up prospectively during one to six years, and to
determine the existence of predictors of suicide behavior. Two
hundred and eighteen outpatients with DSM-IV OCD, recruited from
a specialized OCD Unit in Barcelona, Spain, between February 1998
and December 2007, were included in the study. Suicide ideation was
assessed by item there of the HAM-D. Suicide attempts were
evaluated by the Beck Suicide Intent Scale. Patients with and without
persistent suicidal thoughts and suicide attempters and non-
attempters were compared on sociodemographic and clinical
variables. Patients completed a mean follow-up period of treatment
of 4.1 years (SD 1.7, range 1-6 years). During this period, 18 patients
(8.2%) reported persistent suicidal ideation, two patients (0.91%)
committed suicide and 11 (5.0%) attempted suicide. Being
unmarried, presenting higher basal scores in the HAM-D, current or
previous history of affective disorders and symmetry/ordering
obsessions were independently associated with suicidal behaviors.
Patients were recruited from a specialized OCD clinic and received
exhaustive treatment. Influence of variables including social support,
life events, hopelessness and substance abuse/dependence was not
assessed. In conclusion, suicide behavior is not a highly common
phenomenon in OCD, but it should not be disregarded, especially in
unmarried patients, with comorbid depression and
symmetry/ordering obsessions and compulsions, who appear to be at
a greater risk for suicide act (3).
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Assessment: OCD is associated with a high risk for suicidal

behavior. Depression and hopelessness are the major correlates of
suicidal behavior.
Being unmarried, higher basal scores in the HAM-D, current or
previous history of affective disorders and symmetry/ordering
obsessions are independently associated with suicidal behaviors.
The medical record of the characters studied in this research
shows no signs of OCD. Thus, this cause of suicide can be dropped.

References
1. Kamath P, Reddy YC, Kandavel T. Suicidal behavior in obsessive-compulsive
disorder. J Clin Psychiatry. 2007;68(11):1741-50.
2. Diaconu G, Turecki G. Obsessive-compulsive personality disorder and
suicidal behavior: evidence for a positive association in a sample of depressed
patients. J Clin Psychiatry. 2009;70(11):1551-6.
3. Alonso P, Segalàs C, Real E, et al. Suicide in patients treated for obsessive-
compulsive disorder: a prospective follow-up study. J Affect Disord. 2010;
124(3):300-8.

PERSONALITY DISORDERS
BPD is a serious public health problem. It is associated with high
levels of mental health service utilization, an important degree of
psychosocial impairment and a high rate of suicide (10%). BPD is a
common psychiatric disorder and the most frequent personality
disorders. Approximately, 15% to 50% of psychiatric inpatients and
11% of psychiatric outpatients meet current criteria for BPD.
Recurrent suicidal threats, gestures or behavior or self-mutilation are
common in patients suffering from BPD. However, despite their
similarities, self-mutilation behavior differs from suicide attempts by
the lack of systematic suicidal intentions. The purpose of this study is
to examine the relationships between self-mutilations, suicide and
related therapeutic approach. The literature published from January
1980 to October 2006, using the following keywords: self-mutilation,
suicide, borderline personality (44 articles) with five other additional
articles was reviewed. Self-mutilation refers to the deliberate, direct
destruction or alteration of one's body tissue without conscious
suicidal intent. This pattern of behavior is common in BPD (50 to 80%
of cases) and is frequently repetitive (more than 41% of patients
make more than 50 self-mutilations). The most common form of self-
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mutilation behavior is cutting, but bruising, burning, head banging or

biting are not unusual. The functions of self-mutilation are variable: it
provides relief from negative mood states, reduces distress, obtains
care from other people as well as therapists and expresses emotions
in a symbolic fashion. The rate of suicide in clinical samples of BPD is
of around 5% to 10%. This rate is about 400 times than that of the
general population. Of borderline patients, 40% to 85% carry out
suicide attempts that are usually multiple (average=3). The
relationships between self-mutilation and suicide are paradoxical.
Some authors identify self-mutilation as a protective factor against
suicide. Self-mutilation behavior can be defined as an attenuated
form of suicide ("focal suicide"). In this way, self-mutilation plays the
role of an anti-suicide act, allowing patients to emerge from their
dissociation and to feel that they are living again. The risk of suicide
will not increase so long as self-mutilation produces the expected
relief. Nevertheless, self-mutilation is a risk factor of completed
suicide. Thus, borderline patients with history of self-mutilation
behavior have about twice the rate of suicide than those without.
Repetitive self-mutilations may increase dysphoria, which will only be
relieved by suicidal gestures. Self-mutilating suicide attempters may
be at greater risk for suicide for several reasons: they experience
more feeling of depression and hopelessness, they are more
aggressive and display more affective instability, they underestimate
the lethality of their suicidal behavior and finally, they are troubled
by suicidal thoughts for longer and more frequent periods. Treatment
of these patients requires a multidisciplinary approach.
Psychoanalytic/psychodynamic therapy and dialectal behavior
therapy lower rates of attempted suicide among BPD patients.
Pharmacotherapy focuses on key symptoms: aggression, irritability
and depressed mood (SSRIs), behavioral dyscontrol and affective
dysregulation (mood stabilizers), anxiety, psychoticism and hostility
(antipsychotics). In conclusion, these findings highlight the possibility
of self-mutilation as a risk factor of suicide in BPD (1).
Identifying personality disorder risk factors for suicide attempts is
an important consideration for research and clinical care alike.
However, most prior research has focused on single personality
disorders or categorical personality disorder diagnoses without
considering unique influences of different personality disorders or of
severity (sum) of personality disorder criteria on the risk for suicide-
related outcomes. This has usually been done with cross-sectional or
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retrospective assessment methods. Rarely are dimensional models of

personality disorders examined in longitudinal, naturalistic
prospective designs. It is important to consider divergent risk factors
in predicting the risk of ever making a suicide attempt vs. the risk of
making an increasing number of attempts within the same model.
This study examined 431 participants who were followed for 10 years
in the Collaborative Longitudinal Personality Disorders Study.
Baseline assessments of personality disorder criteria were summed
as dimensional counts of personality pathology and examined as
predictors of suicide attempts reported at annual interviews
throughout the 10-year follow-up period. Consistent with prior
research, BPD was uniquely associated with ever attempting.
However, only narcissistic personality disorder was uniquely
associated with an increasing number of attempts. These findings
highlight the relevance of both borderline and narcissistic personality
pathology as unique contributors to suicide-related outcomes (2).
A prospective cohort study was conducted to examine risk
factors for suicide attempts in a treated sample of patients with
BPD. One hundred eighty participants with BPD were followed over
a yearlong course of dialectical behavior therapy or general
psychiatric management and then for two more years in
naturalistic follow-up. Participants were assessed for suicidal and
self-injurious behaviors at baseline, every four months over the 1-
year treatment phase, and every six months over a 2-year follow-
up period. Participants were classified as suicide or non-suicide
attempters based on their behavior at the end of the 1-year
treatment phase and after the 2-year follow-up period. Groups
were then compared on baseline clinical and demographic
variables. Nearly 26% of participants made a suicide attempt during
the 1-year treatment phase, while 16.7% reported a suicide
attempt over the 2-year follow-up period. Baseline number of
suicide attempts during the four months prior to study and severity
of childhood sexual abuse predicted suicide attempts during the
treatment year. Similarly, baseline suicide attempts, severity of
childhood sexual abuse, and number of hospitalizations in the four
months prior to study entry predicted suicide attempts during the
2-year follow-up. In conclusion, risk factors for suicide attempts in
this treated sample of patients with BPD were fairly stable, largely
non-modifiable, and unrelated to psychopathology or psychosocial
functioning at baseline (3).
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Efforts to identify reliable predictors of suicidal behavior in BPD

have been confounded by the marked dimensional heterogeneity of
the disorder, frequent comorbidity with other high-risk disorders,
debilitating social and vocational consequences of BPD over time.
Using survival analyses, the predictive association between risk
factors in each of these symptom domains and suicide attempts were
assessed in BPD subjects followed for 12 months, 18-24 months and
2-5 years. The suicide attempt rate was 19% in the first year, 24.8%
through the second year. The risk of suicidal behavior among 137
BPD subjects completing the first 12 months was increased by
comorbid MDD and poor social adjustment. Outpatient treatment
decreased short-term risk. Among 133 subjects completing 18-24
months in the study, the relative risk of a suicide attempt was
increased by hospitalization (prior to any attempt), and poor social
adjustment. Among 122 subjects followed for 2-5 years, increased
risk was associated with hospitalization and medication visits (prior
to any attempt), an attempt in the first year, and a low GAS score at
baseline. Long-term risk was decreased by "any outpatient
treatment." Predictors of suicidal behavior in BPD change over time.
MDD has a short-term effect on suicide risk, while poor social
adjustment may increase risk throughout each follow-up interval.
Assessing and supporting family, work, and social relationships may
decrease suicidal behavior in BPD, and should be a principal focus of
long-term treatment (4).
The primary aim of this study was to examine clinically relevant
predictors of suicide threats in this patient group. Two-hundred and
ninety inpatients meeting Revised Diagnostic Interview for
Borderlines and DSM-III-R criteria for BPD were assessed during their
index admission using a series of semistructured interviews and a
self-report measure. These subjects were then reassessed using the
same instruments every two years for 16 years. All variables in the
bivariate analyses were significant. In multivariate analyses, four
predictors were significant: feeling abandoned and hopeless, and
being demanding and manipulative. The results of this study suggest
that suicide threats are often related to emotions connected with
interpersonal relationships. Suicide threats may function, albeit
maladaptively, to regulate these emotions aroused by interpersonal
relationships and bring needed support (5).
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Assessment: recurrent suicidal threats, gestures or behavior or

self-mutilation are common in patients suffering from BPD. Self-
mutilating suicide attempters are at greater risk for suicide for
several reasons: they experience more feeling of depression and
hopelessness, they are more aggressive and display more affective
instability, they underestimate the lethality of their suicidal
behaviour and finally, they are troubled by suicidal thoughts for
longer and more frequent periods.
Self-mutilation is a risk factor of suicide in borderline personality
disorder. Suicide threats are often related to emotions connected
with interpersonal relationships.
MDD has a short-term effect on suicide risk, while poor social
adjustment may increase risk throughout each follow-up interval.
The medical record of the characters studied in this research
shows no signs of BPD. Thus, this diagnosis of suicide can be
removed.

References
1. Oumaya M, Friedman S, Pham A, et al. Borderline personality disorder, self-
mutilation and suicide: literature review. Encephale. 2008; 34(5):452-8.
2. Ansell EB, Wright AG, Markowitz JC, et al. Personality disorder risk factors
for suicide attempts over 10 years of follow-up. Personal Disord. 2015;6(2):161-7.
3. Links PS, Kolla NJ, Guimond T, McMain S. Prospective risk factors for suicide
attempts in a treated sample of patients with borderline personality disorder. Can
J Psychiatry. 2013;58(2):99-106.
4. Soloff PH, Fabio A. Prospective predictors of suicide attempts in borderline
personality disorder at one, two, and two-to-five year follow-up. J Pers Disord.
2008;22(2):123-34.
5. Wedig MM, Frankenburg FR, Bradford Reich D, et al. Predictors of suicide
threats in patients with borderline personality disorder over 16 years of
prospective follow-up. Psychiatry Res. 2013;208(3):252-6.

SCHIZOPHRENIA
Schizophrenia and schizoaffective disorder are diagnostic
categories that are particularly at risk for suicide. A number of risk
factors have been proposed to play a role in vulnerability to suicide,
but it is unclear whether these are specific to certain diagnostic
groups at risk for suicide or generalizable across disorders. It remains
to be better understood what differentiates schizophrenic from non-
schizophrenic suicides and whether or not these two groups share a
common suicide liability. Of 527 consecutive suicides, 43 met criteria
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for schizophrenia and schizoaffective disorder, and were investigated

by means of proxy-based interviews using structured diagnostic
instruments and personality trait assessments. Compared to other
suicides, schizophrenic and schizoaffective suicides presented
comparably elevated levels of impulsive aggressive traits. They also
had comparable levels of family history of suicidal behavior among
first-degree relatives. Overall, schizophrenics and schizoaffective
suicides met criteria for fewer psychiatric disorders, and were less
likely to meet criteria for more than one disorder. Compared to
suicides without schizophrenia or schizoaffective disorders, lower
levels depressive disorders, of current and lifetime comorbid alcohol
abuse, and personality disorders were found within those suicides
who met criteria for schizophrenia and schizoaffective disorders. In
conclusion, elevated levels of impulsive-aggressive personality traits,
indicative of an elevated risk for suicide in other diagnostic
categories, characterize schizophrenic and schizoaffective suicide
completers. Elevated levels of impulsive aggressive behaviors may
serve as a common liability to suicide across major
psychopathological categories, including schizophrenia and
schizoaffective disorder (1).
A systematic review of all original studies concerning suicide in
schizophrenia published since 2004 was conducted. Fifty-one data-
containing studies (from 1281 studies screened) met the inclusion
criteria, and ranked these by standardized quality criteria. Estimates
rates of suicide and risk factors associated with later suicide were
identified, and the risk factors were grouped according to type and
strength of association with suicide. Consensus on the lifetime risk of
suicide was a rate of approximately 5%. Risk factors with a strong
association with later suicide included being young, male, and with a
high level of education. Illness-related risk factors were important
predictors, with number of prior suicide attempts, depressive
symptoms, active hallucinations and delusions, and the presence of
insight all having a strong evidential basis. A family history of suicide,
and comorbid substance misuse were positively associated with later
suicide. The only consistent protective factor for suicide was delivery
of and adherence to effective treatment. Prevention of suicide in
schizophrenia will rely on identifying individuals at risk, and treating
comorbid depression and substance misuse, as well as providing best
available treatment for psychotic symptoms (2).
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Assessment: schizophrenia and schizoaffective disorder patients

are particularly at risk for suicide. Elevated levels of impulsive-
aggressive personality traits are found among schizophrenic and
schizoaffective suicide completers. Risk factors with a strong
association with later suicide include being young, male, and a high
level of education. Illness-related risk factors are important
predictors, with number of prior suicide attempts, depressive
symptoms, active hallucinations and delusions, and the presence of
insight all having a strong evidential basis. A family history of suicide
and comorbid substance misuse is associated with later suicide.
The medical record of the characters studied in this research
shows no signs of schizophrenia or schizoaffective disorder. Thus, this
diagnosis of suicide is irrelevant in these cases.

References
1. McGirr A, Turecki G. What is specific to suicide in schizophrenia disorder?
Demographic, clinical and behavioural dimensions. Schizophr Res. 2008;98(1-3): 217-
24.
2. Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and
risk factors. J Psychopharmacol. 2010;24(4 Suppl):81-90.

EMERGENCY DEPARTMENT VISITS

The aim was to study whether number of visits to emergency
department is associated with suicide, taking into consideration
known risk factors. This was a population-based case-control study
nested in a cohort. Computerized database on attendees to
emergency department (during 2002-2008) was record linked to
nation-wide death registry to identify 152 cases, and randomly
selected 1,520 controls. The study was confined to patients attending
the emergency department, who were subsequently discharged, and
not admitted to hospital ward. Suicide cases had on average
attended the emergency department four times, while controls
attended twice. The OR for attendance due to mental and behavioral
disorders was 3.08 (95% CI 1.61-5.88), 1.60 (95% CI 1.06-2.43) for
non-causative diagnosis, and 5.08 (95% CI 1.69-15.25) for poisoning.
The ORs increased gradually with increasing number of visits.
Adjusted for age, gender, and the above-mentioned diagnoses, the
OR for three attendances was 2.17, for five attendances 2.60, for
seven attendances 5.97, and for nine attendances 12.18 compared
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with those who had one visit. In conclusion, number of visits to the
emergency department is an independent risk factor for suicide
adjusted for other known and important risk factors. The prevalence
of four or more visits was 40% among cases compared with 10%
among controls. This new risk factor may open new venues for
suicide prevention (1).
The feasibility and concurrent validity of adolescent suicide risk
screening in medical emergency departments has been documented.
The objectives of this short-term prospective study were: 1] to
examine adolescents' rate of suicidal behavior during the 2 months
following their emergency departments visits and compare it with
reported rates for psychiatric samples; and 2] to identify possible
predictors of acute risk for suicidal behavior in this at-risk sample.
Participants were 81 adolescents, ages 14-19 years, seeking services
for psychiatric and nonpsychiatric chief complaints, who screened
positive for suicide risk because of recent suicidal ideation, a suicide
attempt, and/or depression plus alcohol or substance misuse. A
comprehensive assessment of suicidal behavior, using the Columbia-
Suicide Severity Rating Scale, was conducted at baseline and 2-month
follow-up. Six adolescents (7.4%) reported a suicide attempt and 15
(18.5%) engaged in some type of suicidal behavior (actual, aborted,
or interrupted suicide attempt; preparatory behavior) during the two
months following their number of visits to the emergency
department, an independent risk factor for suicide adjusted for other
known and important risk factors visit. This screen identified a high-
risk sample. Adolescents who screened positive for suicidal ideation
and/or attempt plus depression and alcohol/substance misuse were
most likely to engage in future suicidal behavior (38.9%). In
conclusion, use of a higher screen threshold (multiple suicide risk
factors) showed promise for identifying highly elevated acute risk for
suicidal behavior (2).
This cross-sectional study was designed to examine 1] the
concurrent validity and utility of an adolescent suicide risk screen for
use in general medical emergency departments and 2] the
prevalence of positive screens for adolescent males and females
using two different sets of screening criteria. Participants were 298
adolescents seeking pediatric or psychiatric emergency services (50%
male; 83% white, 16% black or African American, and 5.4% Hispanic).
The inclusion criterion was age 13 to 17 years. Exclusion criteria were
severe cognitive impairment, no parent or legal guardian present to
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provide consent, or abnormal vital signs. Parent or guardian consent

and adolescent assent were obtained for 61% of consecutively
eligible adolescents. Elevated risk was defined as 1] Suicidal Ideation
Questionnaire-Junior core of ≥31 or suicide attempt in the past three
months or 2] alcohol abuse plus depression (Alcohol Use Disorders
Identification Test-3 score of ≥3, Reynolds Adolescent Depression
Scale-2 score of ≥76). The BHS and Problem Oriented Screening
Instrument for Teenagers were used to ascertain concurrent validity.
Of 48 adolescents, 16% screened positive for elevated suicide risk.
Within this group, 98% reported severe suicide ideation or a recent
suicide attempt (46% attempt and ideation, 10% attempt only, 42%
ideation only) and 27% reported alcohol abuse and depression. Of
adolescents who screened positive, 19% presented for nonpsychiatric
reasons. One-third of adolescents with positive screens were not
receiving any mental health or substance use treatment.
Demonstrating concurrent validity, the BHS scores of adolescents
with positive screens and the POSIT scores of those with positive
screens due to alcohol abuse and depression indicated substantial
impairment. The addition of alcohol abuse with co-occurring
depression as a positive screen criterion did not result in improved
case identification. Among the subgroup screening positive due to
depression plus alcohol abuse, all but one (>90%) reported severe
suicide ideation and/or a recent suicide attempt. This subgroup
(approximately 17% of adolescents who screened positive) reported
significantly more impulsivity than other adolescents who screened
positive. In conclusion, the suicide risk screen showed evidence of
concurrent validity. It demonstrated utility in identifying 1]
adolescents at elevated risk for suicide who presented to the
emergency department with unrelated medical concerns and 2] a
subgroup of adolescents who may be at highly elevated risk for
suicide due to the combination of depression, alcohol abuse,
suicidality, and impulsivity (3).
The present study was conducted to assess the epidemiology of
suicide and its associated risk factors in Sistan and Balouchestan
Province, southeast of Iran. A total of 369 suicide cases admitted to
the emergency department of Zahedan Khatam- Al- Anbia hospital
between March 2010 and February 2012 were examined. Data were
collected from the hospital information system using a semi-
structured questionnaire. A greater proportion of the study subjects
(65%) were female. They were more likely to be young (43.5% in the
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age group of 16 to 25 years) and illiterate or have a primary school

education (20.9% and 48.8%, respectively). Housewives, self-
employed individuals and those with a low or medium income
dominated the suicide cases. The most common method of suicide
was burning (53.4%) followed by drug ingestion (23.8%). The case
fatality rate was 49.6% and it was significantly associated with low
income, summer time suicides, burning as a method of suicide. In
conclusion, this study highlights the burden of suicide and its
potential socio-demographic risk factors in Sistan and Blouchestan
Province (4).

Assessment: the number of visits to the emergency department is

an independent risk factor for suicide.
The suicide risk screen can identify adolescents at elevated risk for
suicide who present to the emergency department with unrelated
medical concerns and a subgroup of adolescents with the
combination of depression, alcohol abuse, suicidality, and impulsivity.
In southeast Iran emergency department, housewives, self-
employed individuals and those with a low or medium income
dominate the suicide cases. The most common method of suicide is
burning followed by drug ingestion.

References
1. Kvaran RB, Gunnarsdottir OS, Kristbjornsdottir A, et al. Number of visits to the
emergency department and risk of suicide: a population-based case-control study.
BMC Public Health. 2015 Mar 7;15:227.
2. King CA, Berona J, Czyz E, et al. Identifying adolescents at highly elevated risk
for suicidal behavior in the emergency department. J Child Adolesc
Psychopharmacol. 2015;25(2):100-8.
3. King CA, O'Mara RM, Hayward CN, Cunningham RM. Adolescent suicide risk
screening in the emergency department. Acad Emerg Med. 2009;16(11):1234-41.
4. Behmanehsh Poor F, Tabatabaei SM, Bakhshani NM. Epidemiology of suicide
and its associated socio-demographic factors in patients admitted to emergency
department of Zahedan Khatam-Al-Anbia hospital. Int J High Risk Behav Addict. 2014;
3(4):e22637.
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HOSPITALIZED PATIENTS
Few studies have been devoted to in-patients' suicides. This
covers all suicides that occurred during hospitalization, whatever the
place (inside or outside the institution) and often, for psychiatric in-
patients, and suicides carried out within 24 hours after leaving the
institution. However, the incidence of suicide in hospital is high,
higher than that observed in the general population. It is 250 per
100,000 admissions in psychiatric hospitals and 1.8 per 100,000
admissions in general hospitals, which is four to five times more than
in general population. Five to 6.5% of suicides are committed in the
hospital: 3% to 5.5% occur in psychiatric hospitals and about 2% in
general hospitals. Risk factors for suicide were identified in this
context. The accessibility to one or more means of suicide (water,
rail, high floor [third floor or beyond], knives, and possibility of
hanging...) is a recognized factor in psychiatric institutions. In the
psychiatric environment, hospitalization period also determines the
risk of suicide: it is highest during the 1st week of hospitalization and
within two weeks after leaving. The same is true for the conditions of
care: inadequate supervision, the underestimation of the risk of
suicide by teams, poor communication within the teams and the lack
of intensive care unit promote suicide risk. The controlled studies
conducted in a psychiatric environment distinguish two periods for
identifying risk factors. The first period is the time of hospitalization.
Recognized risk factors include: the existence of suicidal personal
history (but also family) and attempted suicide shortly before
admission, the diagnosis of schizophrenia or mood disorder (non-
controlled studies also emphasize the importance of alcoholic
comorbidity), being hospitalized without consent, living alone, and
absence from the service without permission. The second period
covers the time-period immediately following the hospitalization. For
this period, risk factors are: the existence of personal history of
suicide and suicidal ideation or attempt of suicide shortly before
admission (but also attempt of suicide during hospitalization), the
existence of relational difficulties, the existence of stress or loss of
employment, living alone, a decision on leaving the hospital
unplanned and lack of contact with nursing in the immediate
postdischarge period. In general hospitals, the chronicity and severity
of the somatic disease, the personality of the patient and the
existence of a psychiatric comorbidity are the suicidal factors most
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often quoted. Only a low rate of psychiatric consultation during the

hospitalization of patient who will commit suicide was found. Among
the countries, which have a national program of suicide prevention,
only England registered the question of the in-patients suicide among
its priorities. The elements of a prevention policy appear however in
certain scientific publications and some programs of local or regional
initiative. These elements can be grouped under five items: securing
the hospital environment, optimization of the care of the patients at
suicidal risk, training of the medical teams in the detection of the risk
and in the care of the suicidal subjects, involvement of the families in
the care and implementation of post-event procedures following a
completed suicide or an attempt (1).
Suicide in inpatient psychiatric settings is a critical problem. A
comprehensive literature review was performed to determine risk
factors for inpatient suicide, instruments for assessing suicide, and
treatment of hospitalized suicidal patients. Findings suggested that
root causes of inpatient suicide were factors related to the treatment
environment, failure to assess patient behavioral characteristics, and
staff reliance on no-suicide contracts. Recommendations include
assessing suicide risk regularly throughout hospitalization, including
on admission, during changes in a patient's mental or physical status,
after a change in observation level, and before discharge. Orientation
and inservice education for all staff and additional research on the
psychometric properties of available suicide assessment instruments
are also essential (2).
The objective of this Nested case-control design study was to
explore suicide risk according to time since admission, diagnosis,
length of hospital treatment, and number of prior hospitalizations.
Individual data are drawn from various Danish longitudinal registers.
All 13,681 male and 7,488 female suicides committed in Denmark
from January 1, 1981, to December 31, 1997, and 423,128 population
control subjects were matched for sex, age, and calendar time of
suicide. This study demonstrates that there are two sharp peaks of
risk for suicide around psychiatric hospitalization, one in the first
week after admission and another in the first week after discharge;
suicide risk is significantly higher in patients who received less than
the median duration of hospital treatment; affective disorders have
the strongest impact on suicide risk in terms of its effect size and
population attributable risk; and suicide risk associated with affective
and schizophrenia spectrum disorders declines quickly after
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treatment and recovery, while the risk associated with substance

abuse disorders declines relatively slower. An admission history
increases suicide risk relatively more in women than in men; and
suicide risk is substantial for substance disorders and for multiple
admissions in women but not in men. In conclusion, suicide risk peaks
in periods immediately after admission and discharge. The risk is
particularly high in persons with affective disorders and in persons
with short hospital treatment. These findings should lead to
systematic evaluation of suicide risk among inpatients before
discharge and corresponding outpatient treatment, while family
support should be initiated immediately after the discharge (3).

Assessment: the incidence of suicide in psychiatric hospital is

high, higher than that observed in the general population.
In psychiatric institutions, risk factors for suicide include the
accessibility to ` or more means of suicide; the risk of suicide is
highest during the 1st week of hospitalization and within two weeks
after leaving.
Factors related to suicide include the treatment environment,
failure to assess patient behavioral characteristics, and staff reliance
on no-suicide contracts. The risk is particularly high in persons with
affective disorders and in persons with short hospital treatment.

References
1. Martelli C, Awad H, Hardy P. In-patients suicide: epidemiology and prevention.
Encephale. 2010;36 Suppl 2:D83-91.
2. Lynch MA, Howard PB, El-Mallakh P, Matthews JM. Assessment and
management of hospitalized suicidal patients. J Psychosoc Nurs Ment Health Serv.
2008;46(7):45-52.
3. Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization:
evidence based on longitudinal registers. Arch Gen Psychiatry. 2005;62(4):427-32.

METHODS OF SUICIDE
In different countries, there are variations in the methods of
suicide. These variations can be related to the culture of each
country, and its understanding of life and death, the social
acceptability of suicide, access to a lethal weapon, and acceptance of
death as an inevitable part of life. Differing methods of suicide
include hanging, strangulation, or suffocation, gassing, jumping from
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a height, gunshot, using a firearm or explosive, drowning, cutting,

poisoning, helium, cannabis, suicide on subways or railways, and
pesticide use. Other methods are suicide bombing, complex suicide,
double suicide, seppuku (Hara-kiri), massive suicide, and "Kamikaze"
attacks (1).
Samson, who was chained to the middle pillars of a temple,
pushed them apart, and caused the collapse of the building. Samson
died together with the thousands people inside. Ahithophel hanged
himself; King Zimri committed suicide by setting fire to his house;
Abimelech committed assisted suicide by asking his armor-bearer to
kill him with a sword; King Saul and his armor-bearer performed a
double suicide. King Saul's suicide resembles the characteristics of
Japanese Hara-kiri (literally means "stomach cutting", a painful
method of self-destruction when victim falls on the sword and in this
way ends his life (1).

Reference
1. Ben-Nun L. In: Ben-Nun L (ed.). How did biblical King Saul die? B.N. Publication
House. Israel. 2012.

RISK FACTORS
Factors that affect the risk of suicide include psychiatric disorders,
drug misuse, psychological states, cultural, family and social
situations, and genetics (1). Strong suicidal intent and psychiatric
illness are indicators of high suicide risk (2).
Mental illness and substance misuse frequently co-exist (3). Other
risk factors include previous attempted suicide (4), the ready
availability of a means to commit the act, a family history of suicide,
or the presence of TBI (5). For example, suicide rates were greater in
households with firearms than those without them (6). Socio-
economic problems such as unemployment, poverty, homelessness,
and discrimination may trigger suicidal thoughts (7,8). About 15-40%
of people leave a suicide note (9). Genetics appears to account for
between 38% and 55% of suicidal behaviors (10). War veterans have
a higher risk of suicide due in part to higher rates of mental illness
and physical health problems related to war (11).
The reasons for intentional self-harm among youths include:
seeking attention, the releasing of negative emotions and conflicts
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within the family, relationships and sexual problems (12). Many of

these youths suffer from depression, anxiety, impulsivity, low self-
esteem and suicidal ideation (12). Risk for suicide also includes older
men who live alone and have a history of depression and alcohol use
(13). Older women are at increased risk, particularly if they are
recently widowed, divorced, or separated and have multiple medical
problems (13). Female sex, childhood trauma, and a family history of
suicidal behavior are each independent and non-interacting risk
factors for attempting suicide (14).
Unlike most causes of death, suicide occurs due to a combination
of psychiatric disorders such as depression, substance misuse,
schizophrenia, and impulsive behavior in moments of crisis in the
context of serious physical illness, unemployment, divorce (15), or
being unmarried (16).
Suicide is amongst the top ten causes of death for all age groups
in most countries of the world. It is the second most important cause
of death in the younger age group (15-19 years), second only to
vehicular accidents. Attempted suicides are ten times the successful
suicide figures, and 1-2% attempted suicides become successful
suicides every year. Male sex, widowhood, single or divorced marital
status, addiction to alcohol or drugs, concomitant chronic physical or
mental illness, past suicidal attempt, adverse life events, staying in
lodging homes or staying alone, or in areas with a changing
population, all these conditions predispose people to suicides. The
key factor probably is social isolation. WHO Study established that
out of 6,003 suicides, 98% had a psychiatric disorder. Hence, mental
health professionals have an important role to play in the prevention
and management of suicide. Social disintegration increases suicides,
as was witnessed in the Baltic States following collapse of the Soviet
Union. Hence, reducing social isolation, preventing social
disintegration and treating mental disorders must be the crux of any
public health program to reduce/prevent suicide. This requires an
integrated effort on the part of mental health professionals (including
crisis intervention and medication/psychotherapy), governmental
measures to tackle poverty and unemployment, and social attempts
to reorient value systems and prevent sudden disintegration of
norms and mores. Suicide prevention and control are a movement,
which involves the state, professionals, non-governmental
organizations, volunteers and an enlightened public. The Global
Burden of Diseases Study has projected a rise of more than 50% in
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mental disorders by the year 2020 (from 9.7% in 1990 to 15% in

2020). One third of this rise will be due to MDD. One of the
prominent causes of preventable mortality is suicidal attempts made
by patients of MDD. Therefore, facilities to tackle this condition need
to be set up globally on a war footing by governments, non-
governmental organizations and health care delivery systems, if
morbidity and mortality of the world population has to be seriously
controlled. The need is to identify suicide prevention as public health
policy, just as in terms of Malaria or Polio eradication, or have
achieved smallpox eradication (17).
Suicide is an act of intentionally causing one's own death. Number
of suicidal incidences is proportional to attempted suicide cases
hence if attempt cases are reduced, number of suicidal death can
also be decreased and for that purpose risk factors should be
identified and reduced. Therefore, this study is planned to identify
risk factors among lower socioeconomic rural population of
surrounding areas of Hyderabad in India. This was a prospective
study in which all the suicide attempt cases were included at Bhaskar
Medical College and General Hospital. The study period was from
January 2013 to July 2013. Patients undergone a detailed psychiatric
interview, including their demographic details, and complete suicide
risk assessment was done using Beck's suicide intent scale. Females
in the age group of 20-30 years, uneducated, married and daily
laborers by occupation had higher incidence of suicidal attempts.
Depressive disorder is the most common associated psychiatric
disorder in both the genders, followed by alcohol use related
problems. Family disputes were the other major risk factors. Most
common mode for attempt was organophosphorous poisoning
followed by ingestion of calotropis. In conclusion, risk of suicide
attempt is almost equal in terms of medium and high category of
suicide assessment scale in both genders. All individuals with alcohol
related disorders must be screened for suicidal ideation so that
appropriate methods can be adopted to reduce the risk (18).
This review aimed to identify the evidence for predictors of
repetition of suicide attempts, and more specifically for subsequent
completed suicide. A literature search of PubMed and Embase was
conducted between January 1, 1991 and December 31, 2009, and
studies investigating only special populations (e.g., male and female
only, children and adolescents, elderly, a specific psychiatric
disorder) and studies with sample size fewer than 50 patients were
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excluded. The strongest predictor of a repeated attempt is a

previous attempt, followed by being a victim of sexual abuse, poor
global functioning, having a psychiatric disorder, being on
psychiatric treatment, depression, anxiety, and alcohol abuse or
dependence. For other variables examined (Caucasian ethnicity,
having a criminal record, having any mood disorders, bad family
environment, and impulsivity) there are indications for a putative
correlation as well. For completed suicide, the strongest predictors
are older age, suicide ideation, and history of suicide attempt.
Living alone, male sex, and alcohol abuse are weakly predictive
with a positive correlation for poor impulsivity and a somatic
diagnosis. In conclusion, it is difficult to find predictors for
repetition of nonfatal suicide attempts, and even more difficult to
identify predictors of completed suicide. Suicide ideation and
alcohol or substance abuse/dependence, which are, along with
depression, the most consistent predictors for initial nonfatal
attempt and suicide, are not consistently reported as strong
predictors for nonfatal repetition (19).
The aim of this review was to perform a critical appraisal of
reports on suicide attempts published in 2009, looking for features
and predictors of suicidal behavior. Psychinfo, Embase, and
Pubmed in the period from 1 December 2008 to 31 December 2009
looking for papers on suicide attempt were searched. Rates of
suicide attempts are in line with previous data and confirm a north-
south gradient in the suicide attempt rate. Previous attempts are
the strongest risk factors for further attempt. The importance of
mood disorders (in particular depression) and personality
disorders, unemployment, and a medium age as risk factors was
pointed out. In adolescence, the repetition rate seems to overlap
the adult population, though the samples are very small. Even in
this case, the presence of a previous suicide attempt increases the
risk for repeated suicide attempt. By contrast, the role of
psychiatric and demographic variables is less clear. A personality
disorder increases the risk for further attempt, but this correlation
is significantly less strong for fatal repetition. In depressed patients,
the presence of anxiety perhaps acts as a protective factor. In
conclusion, the risk for a suicide attempt is higher for people who
had previously attempted. Having a psychiatric diagnosis and more
specifically a mood disorder is also a strong predictor for both fatal
and nonfatal suicide attempt (20).
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Suicide is the tenth leading cause of death in the U.S., and its rate
has risen by 16% in the past decade. Deliberate self-poisoning is the
leading method of attempted suicide. Unlike more violent methods,
which are almost universally fatal, survival following self-poisoning is
common, providing an opportunity for secondary prevention.
However, the long-term risk of suicide following a first episode of
self-poisoning is unknown. The objective of this study was to
determine the risk of suicide and mortality from other causes
following a first self-poisoning episode. Population-based cohort
study was conducted using multiple linked health care databases. All
individuals with a first self-poisoning episode in Ontario, Canada,
from April 1, 2002, through December 31, 2010 were identified, and
all surviving participants were followed up until December 31, 2011,
or death, whichever occurred first. For each individual with a
deliberate self-poisoning episode, one control was randomly selected
from the same population with no such history, matched for age
(within three months), sex, and calendar year. The primary analysis
examined the risk of suicide following discharge after self-poisoning.
The secondary analyses explored factors associated with suicide and
examined the risk of death caused by accidents or any other cause. A
total of 65,784 patients (18,482, 28.1%) younger than 20 years were
discharged after a first self-poisoning episode. During a median
follow-up of 5.3 years (IQR, 3.1-7.6 years), 4,176 died, including 976
(23.4%) by suicide. The risk of suicide following self-poisoning was
markedly increased relative to controls (HR 41.96, 95% CI 27.75-
63.44), corresponding to a suicide rate of 278 vs. seven per 100,000
PY, respectively. The median time from hospital discharge to
completed suicide was 585 days (IQR, 147-1301 days). Older age,
male sex, multiple intervening self-poisoning episodes, higher
socioeconomic status, depression, and recent psychiatric care were
strongly associated with suicide. Patients with a self-poisoning
episode were also more likely to die because of accidents (HR 10.45,
95% CI 8.10-13.47) and all causes combined (HR 5.55, 95% CI 5.12-
6.02). In conclusion, a first self-poisoning episode is a strong
predictor of subsequent suicide and premature death. Most suicides
occur long after the index poisoning, emphasizing the importance of
longitudinal, sustained secondary prevention initiatives (21).
Research into environmental factors associated with suicide has
historically focused on meteorological variables. Recently, a
heightened risk of suicide related to short-term exposure to airborne
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particulate matter was reported. The associations between short-

term exposure to nitrogen dioxide, particulate matter, and sulfur
dioxide and completed suicide in Salt Lake County, Utah (n=1,546)
from 2000 to 2010 were examined. A time-stratified case-crossover
design to estimate AORs for the relationship between suicide and
exposure to air pollutants on the day of the suicide and during the
days preceding the suicide was used. Maximum heightened odds of
suicide were associated with IQR increases in nitrogen dioxide during
cumulative lag three (average of the three days preceding suicide, OR
1.20, 95% CI 1.04-1.39) and fine particulate matter (diameter ≤2.5
μm) on lag day 2 (day 2 before suicide, OR 1.05, 95% CI 1.01-1.10).
Following stratification by season, an increased suicide risk was
associated with exposure to nitrogen dioxide during the spring/fall
transition period (OR 1.35, 95% CI 1.09-1.66) and fine particulate
matter in the spring (OR 1.28, 95% CI 1.01-1.61) during cumulative
lag 3. Positive associations between air pollution and suicide appear
to be consistent across study locations with vastly different
meteorological, geographical, and cultural characteristics (22).
Suggestive associations of suicide with air pollutant
concentrations have been reported. Recognizing regional and
temporal variability of pollutant concentrations and suicide, a
detailed meta-analysis of completed suicides in relation to five major
pollutants over six years in the 16 administrative regions of the
Republic of Korea was carried out, while controlling for other
established influences on suicide rates. Of the five major pollutants
examined, ozone concentrations had a powerful association with
suicide rate, extending back to four weeks. Over the range of 2 SDs
around the annual mean ozone concentration, the adjusted suicide
rate increased by an estimated 7.8% of the annual mean rate.
Particulate matter pollution also had a significant effect, strongest
with a 4-week lag, equivalent to 3.6% of the annual mean rate over
the same 2 SD range that approximated the half of annual observed
range. These results suggest deleterious effects of ozone and
particulate matter pollution on the major public health problem of
suicide (23).
The objective of this cohort study was to assess the associations
between different antidepressant treatments and the rates of suicide
and attempted suicide or self-harm in people with depression.
Patients registered with UK general practices contributing data to the
QResearch database. Participants included 238,963 patients aged 20
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to 64 years with a first diagnosis of depression between 1 January

2000 and 31 July 2011, followed up until 1 August 2012. Exposures
included antidepressant class (tricyclic and related antidepressants,
SSRI, and other antidepressants), dose, and duration of use, and
commonly prescribed individual antidepressant drugs. During follow-
up, 87.7% (n=209,476) of the cohort received one or more
prescriptions for antidepressants. The median duration of treatment
was 221 days (IQR 79-590 days). During the first five years of follow-
up 198 cases of suicide and 5,243 cases of attempted suicide or self-
harm occurred. The difference in suicide rates during periods of
treatment with tricyclic and related antidepressants compared with
SSRI was insignificant (AHR 0.84, 95% CI 0.47-1.50), but the suicide
rate was significantly increased during periods of treatment with
other antidepressants (AHR 2.64, 95% CI 1.74-3.99). The HR for
suicide was significantly increased for mirtazapine compared with
citalopram (AHR 3.70, 95% CI 2.00-6.84). Absolute risks of suicide
over one year ranged from 0.02% for amitriptyline to 0.19% for
mirtazapine. There was insignificant difference in the rate of
attempted suicide or self harm with tricyclic antidepressants (AHR
0.96, 95% CI 0.87-1.08) compared with SSRIs , but the rate of
attempted suicide or self-harm was significantly higher for other
antidepressants (AHR 1.80, 95% CI 1.61-2.00). The AHRs for
attempted suicide or self-harm were significantly increased for three
of the most commonly prescribed drugs compared with citalopram:
venlafaxine (AHR 1.85, 95% CI 1.61-2.13), trazodone (AHR 1.73, 95%
CI 1.26-2.37), and mirtazapine (AHR 1.70, 95% CI 1.44-2.02), and
significantly reduced for amitriptyline (AHR 0.71, 95% CI 0.59-0.85).
The absolute risks of attempted suicide or self-harm over one year
ranged from 1.02% for amitriptyline to 2.96% for venlafaxine. Rates
were highest in the first 28 days after starting treatment and
remained increased in the first 28 days after stopping treatment. In
conclusion, rates of suicide and attempted suicide or self-harm were
similar during periods of treatment with SSRIs and tricyclic and
related antidepressants. Mirtazapine, venlafaxine, and trazodone
were associated with the highest rates of suicide and attempted
suicide or self-harm, but the number of suicide events was small
leading to imprecise estimates. As this is an observational study, the
findings may reflect indication biases and residual confounding from
severity of depression and different characteristics of patients
prescribed these drugs. The increased rates in the first 28 days of
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starting and stopping antidepressants emphasize the need for careful

monitoring of patients during these periods (24).
Government agencies have issued warnings about the use of
antidepressant medications in children, adolescents, and young
adults since 2003. The statements warn that such medications may
cause de novo 'suicidality' in some people. This review explores the
data on the treatment of depression that led to these warnings and
subsequent data that are relevant to the warnings. It also addresses
the effectiveness of antidepressant treatment in general and the
relationship of suicide rates to antidepressant treatment. It
concludes that the decisions for the 'black box' warnings were based
on biased data and invalid assumptions. The decisions were
unsupported by the observational data regarding suicide in young
people that existed in 2003. The following recommendations would
seem to follow from these observations. Drug authorities should re-
evaluate the basis for their imposed warnings on antidepressant
medicines, and analyze the actual public health consequences the
warnings have had. In the absence of substantial evidence supporting
the warnings, they should be removed. Physicians and other
providers with prescription privileges should continue to be educated
regarding the importance of aggressively treating depression in
young people, using antidepressants when indicated. Physicians and
other professionals who treat depressed young people must always
be aware of the risk of suicide (albeit quite low) and observe them
closely for any signs of increased risk of suicide. This is necessary
regardless of the type of treatment being provided (25).
In 2003, public health advisories in North America and Europe
regarding suicidality associated with SSRIs led to the addition of black
box warnings to antidepressant package inserts in 2004.
Subsequently, a series of events appeared to result from these
regulatory actions. This review provides an overview of the temporal
associations of regulatory agencies' actions in North America and
Europe with rates of depression diagnoses, pediatric antidepressant
prescription rates, follow-up visits to physicians prescribing
antidepressants, and rates of completed suicide and suicidal ideation
in children and adolescents. Key advancements in the study of young
patients at risk for suicide and innovations in current research
methodology, to more accurately identify suicidality and the
relationship to antidepressant use within this vulnerable patient
population should be considered. Until more data are available,
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however, closely monitored antidepressant treatment in

combination with CBT may provide the most benefit (26).
A growing body of literature indicates that insomnia is related to
suicidality. However, the mechanism through which insomnia
correlates with suicide risk is unclear. The goal of the present
research was to determine whether hopelessness, a robust predictor
of suicidality, mediates the relation between insomnia and suicidal
ideation. The present study used archival data from community-
dwelling adults. Participants (n=766) completed a Health Survey, two
weeks of daily sleep diaries, and five measures of daytime
functioning, including the BDI. BDI item two was used to assess
hopelessness, and BDI item nine was used to assess suicidal ideation.
Criteria from the DSM-5 as well as quantitative criteria were used to
identify participants with insomnia (n=135). The analyses revealed
that hopelessness is a significant mediator of the relation between
insomnia and suicidal ideation. After adding depression as an
additional mediator, hopelessness remained a significant predictor of
suicidal ideation. In conclusion, there is the need for clinicians to
routinely screen clients who have insomnia for hopelessness and
suicidal ideation, and to treat hopelessness when it is present (27).
The objective of this study was to assess risk and protective
factors for suicidality at 6-month follow-up in adolescent inpatients
after a suicide attempt. One hundred seven adolescents from five
inpatient units who had a suicide attempt were seen at 6-month
follow-up. Baseline measures included sociodemographics, mood and
suicidality, dependence, borderline symptomatology, temperament
and character inventory, reasons for living, spirituality, and coping
scores. At 6-month follow-up, 41 (38%) subjects relapsed from
suicidal behaviors. Among them, 15 (14%) had repeated a suicide
attempt. Higher depression and hopelessness scores, the occurrence
of a new suicide attempt, or a new hospitalization belonged to the
same factorial dimension (suicidality). Derived from the best-fit
structural equation modelling for suicidality as an outcome measure
at 6-month follow-up, risk factors among the baseline variables
included: MDD, high depression scores, and high scores for
temperament and character inventory self-transcendence. Only one
protective factor emerged: coping-hard work and achievement. In
conclusion, in this very high-risk population, some established risk
factors (for example, a history of suicide attempts) may not predict
suicidality. Adolescents who retain high scores for depression or
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hopelessness, who remain depressed, or who express a low value for

life or an abnormally high connection with the universe are at higher
risk for suicidality and thus should be targeted for more intense
intervention. Improving adolescent motivation in school and in work
may be protective. Given the sample size, the model should be
regarded as exploratory (28).
The aim of this study was to assess determinants of suicidality
(suicidal ideation and suicide attempts) in a general population
cohort with depressive spectrum disorders, and to compare
determinants for suicidal ideation and determinants for suicide
attempts in this cohort. The Netherlands Mental Health Survey and
Incidence Study is an epidemiologic survey in the adult population
(n=7,076), using the CIDI. In a cohort of 586 persons with a
depressive spectrum disorder, 97 (16.6%) reported suicidal ideation
and 19 (3.2%) suicide attempts in a period of two years. In a
multivariate model, male gender (OR 0.54, 95% CI 0.30-0.99, p=0.05),
longer (>13 months) duration of depression (OR 2.86, 95% CI 1.21-
6.73, p=0.02; OR 2.71, 95% CI 1.24-5.91, p=0.01), anhedonia (OR
2.00, 95% CI 1.01-5.91, p=0.05), feeling worthless (OR 1.99, 95% CI
1.05-3.74, p=0.03), comorbid anxiety (OR 2.46, 95% CI 1.38-4.40,
p<0.01), previous suicidal ideation (OR 3.50, 95% CI 1.96-6.24,
p<0.001), and use of professional care (OR 1.96, 95% CI 1.01-3.79,
p=0.05) were significantly related to suicidality. Determinants of
suicidal ideation differed from determinants of suicide attempts. In
conclusion, features of depression were the most important
determinants of suicidality in a depressive spectrum cohort.
Determinants for suicidal ideation differed from suicide attempts.
These findings could be helpful in identifying those who need more
intense treatment strategies in order to prevent suicidality and
eventually suicide (29).
Older adults worldwide are at a greater risk of suicide than other
age groups. A prospective cohort of senior Taipei City residents
between 2005 and 2009 (n=101,764) were examined. Male sex (HR
3.41, p<0.001), lower education (HR=3.31, p<0.001) and lower
income (HR=2.52, p=0.01) were associated with an increased risk of
suicide, as well as depressed mood (HR=1.44, p=0.02; per unit
increase in a 4-point scale) and insomnia (HR=1.30, p=0.03; per unit
increase in a 4-point scale). The derived prediction score yielded a
sensitivity of 0.63, a specificity of 0.73, and an area under curve of
0.73. Removing depressed mood from the prediction model altered
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insignificantly suicide predictability (p=0.11). In conclusion, prediction

of suicide based on factors recorded in a routine health screen of
elderly people was unsatisfactory; the strongest predictors were
factors that cannot be easily altered. Understanding of how the
socioeconomic condition of seniors contributes to suicide may
provide valuable insights for intervention targeting this growing
population-at-risk (30).

Assessment: the risk of suicide includes mental disorders, alcohol

or substance abuse/dependence, drug misuse, cultural, family,
socioeconomic problems, genetics, pesticide poisoning, air pollution,
different antidepressant treatments, history of suicide attempt,
deliberate self-poisoning, concomitant chronic physical or mental
illness, sexual problems, adverse life events, and staying in lodging
homes.
In general population, male gender, longer (>13 months) duration
of depression, anhedonia, feeling worthless, comorbid anxiety,
previous suicidal ideation and use of professional care are
significantly related to suicidality.
In older people, male sex, lower education and lower income, and
depressed mood are associated with an increased risk of suicide.

References
1. Hawton, K; Saunders, KE; O'Connor, RC. Self-harm and suicide in adolescents.
Lancet. 2012;379 (9834): 2373–82.
2. Skegg K. Self-harm. Lancet. 2005; 366(9495):1471-83.
3. Vijayakumar L, Kumar MS, Vijayakumar V. Substance use and suicide. Curr
Opin Psychiatry. 2911;24(3):197–202.
4. Chang B, Gitlin D; Patel R. The depressed patient and suicidal patient in the
emergency department: evidence-based management and treatment strategies.
Emerg Med Pract. 2011;13(9):1–23; quiz 23–4.
5. Simpson G, Tate R. Suicidality in people surviving a traumatic brain injury:
prevalence, risk factors and implications for clinical management. Brain Inj.
2007;21(13–14): 1335–51.
6. Miller M, Azrael D, Barber C. Suicide mortality in the United States: the
importance of attending to method in understanding population-level disparities in
the burden of suicide. Annu Rev Public Health. 2012;33:393–408.
7. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic,
demographic, psychiatric, and familial factors: a national register-based study of all
suicides in Denmark, 1981–1997. Am J Psychiatry 2003;160(4):765–72.
8. Centers for Disease Control and Prevention, (CDC). Suicide among adults aged
35-64 years - United States, 1999-2010. MMWR. Morbidity and Mortality Weekly
Report. 2013;62(17):321–5.
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9. Gilliland Richard K, James, Burl E. Crisis intervention strategies (7th ed.).

Belmont, CA: Brooks/Cole. 2012, p. 215. ISBN 978-1-111-18677-7.
10. Brent DA, Melhem N. Familial transmission of suicidal behavior. The Psychiatr
Clin North Am. 2008;31 (2): 157–77.
11. Rozanov V, Carli V. Suicide among war veterans. Int J Environ Res Public
Health. 2012;9(7):2504–19.
12. Lowenstein LF. Youths who intentionally practice self-harm. Review of the
recent research 2001-2004. Int J Adolesc Med Health. 2005;17(3):225-30.
13. Lantz MS. Suicide in later life. Identifying and managing at-risk older patients.
Geriatrics. 2001;58:47-8.
14. Roy A, Janal M. Family history of suicide, female sex, and childhood trauma:
separate or interacting risk factors for attempts at suicide? Acta Psychiatr Scand.
2005;112(5):367-71.
15. Gunnel D, Lewis G. Studying suicide from the life course perspective:
implications for prevention. Br J Psychiatry. 2005;187:206-8.
16. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic,
demographic, psychiatric, and familial factors: a national register-based study of all
suicide in Denmark, 1981-1997. Am J Psychiatry. 2003;160:765-72.
17. Singh AR, Singh SA. Towards a suicide free society: identify suicide
prevention as public health policy. Mens Sana Monogr. 2004;2(1):21-33.
18. Kosaraju SK, Vadlamani LN, Mohammed Bashir MS, et al. Risk factors for
suicidal attempts among lower socioeconomic rural population of telangana region.
Indian J Psychol Med. 2015;37(1):30-5.
19. Beghi M, Rosenbaum JF, Cerri C, Cornaggia CM. Risk factors for fatal and
nonfatal repetition of suicide attempts: a literature review. Neuropsychiatr Dis Treat.
2013;9:1725-36.
20. Beghi M, Rosenbaum JF. Risk factors for fatal and nonfatal repetition of
suicide attempt: a critical appraisal. Curr Opin Psychiatry. 2010;23(4):349-55.
21. Bakian AV, Huber RS, Coon H, et al. Acute air pollution exposure and risk of
suicide completion. Am J Epidemiol. 2015;181(5):295-303.
22. Kim Y, Myung W, Won HH, et al. Association between air pollution and
suicide in South Korea: a nationwide study. PLoS One. 2015;10(2): e0117929.
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Effectiveness Research Network (CDSERN). Risk of Suicide Following Deliberate Self-
poisoning. JAMA Psychiatry. 2015 Apr 1.
24. Coupland C, Hill T, Morriss R, et al. Antidepressant use and risk of suicide and
attempted suicide or self harm in people aged 20 to 64: cohort study using a primary
care database. BMJ. 2015 Feb 18;350:h517.
25. Isacsson G, Rich CL. Antidepressant drugs and the risk of suicide in children
and adolescents. Paediatr Drugs. 2014;16(2):115-22.
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use and suicidality in pediatric depression. Expert Opin Pharmacother.
2012;13(15):2119-30.
27. Woosley JA, Lichstein KL, Taylor DJ, et al. Hopelessness mediates the relation
between insomnia and suicidal ideation. J Clin Sleep Med. 2014;10(11):1223-30.
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at 6-Month Follow-up in Adolescent Inpatients Who Attempted Suicide: An
Exploratory Model. Can J Psychiatry. 2015;60(2 Suppl 1):S27-36.
29. Spijker J, de Graaf R, Ten Have M, et al. Predictors of suicidality in depressive
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spectrum disorders in the general population: results of the Netherlands Mental

Health Survey and Incidence Study. Soc Psychiatry Psychiatr Epidemiol. 2010;45(5):
513-21.
31. Hung GC, Kwok CL, Yip PS, et al. Predicting suicide in older adults - a
community-based cohort study in Taipei City, Taiwan. J Affect Disord. 2014;172C:
165-70.

INTERNET
The association between excessive video game/internet use and
teen suicidality was investigated. Data were obtained from the 2007
and 2009 Youth Risk Behavior Survey, a high school-based, nationally
representative survey (n=14,041 and n=16,410, respectively). Teens
who reported five hours or more of video games/Internet daily use,
in the 2009 Youth Risk Behavior Survey, had a significantly higher risk
for sadness (adjusted and weighted OR 95% CI I2.1, 1.7-2.5), suicidal
ideation (95% CI 1.7, 1.3-2.1), and suicide planning (95% CI 1.5, 1.1-
1.9). The same pattern was found in the 2007 survey. These findings
support an association between excessive video game and Internet
use and risk for teen depression and suicidality (1).
The main aim of this study was to systematically review research
on how people use the Internet for suicide-related reasons and its
influence on users. This review summarizes the main findings and
conclusions of existing work, the nature of studies that have been
conducted, their strengths and limitations, and directions for future
research. An online search was conducted through PsycINFO,
PubMed, Ovid MEDLINE and CINAHL databases for papers published
between 1991 and 2014. Papers were included if they examined how
the Internet was used for suicide-related reasons, the influence of
suicide-related Internet use, and if they presented primary data,
including case studies of Internet-related suicide attempts and
completions. Findings of significant relationships between suicide-
related search trends and rates of suicide suggest that search trends
may be useful in monitoring suicide risk in a population. Studies that
examine online communications between people who are suicidal
can further understanding of individuals' suicidal experiences. While
engaging in suicide-related Internet use was associated with higher
levels of suicidal ideation, evidence of its influence on suicidal
ideation over time was mixed. There is a lack of studies directly
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recruiting suicidal Internet users. Only case studies examined the

influence of suicide-related Internet use on suicidal behaviors, while
no studies assessed the influence of pro-suicide or suicide prevention
websites. Online professional services can be useful to suicide
prevention and intervention efforts, but require more work in order
to demonstrate their efficacy. In conclusion, individuals use the
internet to search for suicide-related information and to discuss
suicide-related problems with one another. However, the causal link
between suicide-related internet use and suicidal thoughts and
behaviors is still unclear. More research is needed, particularly
involving direct contact with Internet users, in order to understand
the impact of both informal and professionally moderated suicide-
related Internet use (2).
There is concern that the internet is playing an increasing role in
self-harm and suicide. In this study, research literature was
systematically reviewed and analyzed to determine whether there is
evidence that the internet influences the risk of self-harm or suicide
in young people. An electronic literature search was conducted using
the PsycINFO, MEDLINE, EMBASE, Scopus, and CINAHL databases.
Articles of interest were those that included empirical data on the
internet, self-harm or suicide, and young people. The articles were
initially screened based on titles and abstracts, then by review of the
full publications, after which those included in the review were
subjected to data extraction, thematic analysis and quality rating.
Youth who self-harm or are suicidal often make use of the internet. It
is most commonly used for constructive reasons such as seeking
support and coping strategies, but may exert a negative influence,
normalizing self-harm and potentially discouraging disclosure or
professional help seeking. The internet has created channels of
communication that can be misused to 'cyber-bully' peers; both
cyber-bullying and general internet use have been found to correlate
with increased risk of self-harm, suicidal ideation, and depression.
Correlations have been found between Internet exposure and violent
methods of self-harm. In conclusion, Internet use may exert both
positive and negative effects on young people at risk of self-harm or
suicide. Careful high quality research is needed to better understand
how internet media may exert negative influences and should focus
on how the internet might be utilized to intervene with vulnerable
young people (3).
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Most striking in the recent rise of suicide in Japan are the increase
in suicide among young Japanese and the emergence of Internet
suicide pacts. Ethnography of suicide-related Web sites reveals a
distinctive kind of existential suffering among visitors that is not
reducible to categories of mental illness and raises questions
regarding the meaning of an individual "choice" to die, when this
occurs in the context of an intersubjective decision by a group of
strangers, each of whom is too afraid to die alone. Anthropology's
recent turn to subjectivity enables analyses of individual suffering in
society that provide a more nuanced approach to the apparent
dichotomy between agency and structure and that connect the
phenomenon of suicide in Japan to Japanese conceptions of selfhood
and the afterlife. The absence of ikigai [the worth of living] among
suicide Web site visitors and their view of suicide as a way of healing
show that analyses of social suffering must be expanded to include
questions of meaning and loss of meaning and, also, draw attention
to Japanese conceptions of self in which relationality in all things,
including the choice to die, is of utmost importance (4).

Assessment: there is an association between excessive video

game and Internet use and risk for teen depression and suicidality.
Individuals use the Internet to search for suicide-related
information and to discuss suicide-related problems with one
another. Internet use may exert both positive and negative effects
on young people at risk of self-harm or suicide.

References
1. Messias E, Castro J, Saini A, et al. Sadness, suicide, and their association with
video game and internet overuse among teens: results from the youth risk behavior
survey 2007 and 2009. Suicide Life Threat Behav. 2011;41(3):307-15.
2. Mok K, Jorm AF, Pirkis J. Suicide-related Internet use: A review. Aust N Z J
Psychiatry. Aust N Z J Psychiatry. 2015;49(8):697-705.
3. Daine K, Hawton K, Singaravelu V, et al. The power of the web: a systematic
review of studies of the influence of the internet on self-harm and suicide in young
people. PLoS One. 2013;8(10):e77555.
4. Ozawa-de Silva C. Too lonely to die alone: internet suicide pacts and
existential suffering in Japan. Cult Med Psychiatry. 2008;32(4):516-51.
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PROTECTIVE FACTORS
The objective of this study was to examine whether protective
factors in the Protection for Adolescent Depression Study moderate
the impact of stressful events on depression and suicidal behavior in
the community and a clinical setting; and to study the influence of
sex. Participants were 283 adolescents from the community and 119
from a mood disorder clinic in Montreal. The participants were
evaluated on six instruments measuring individual risk and protective
factors. Risk factors predicted higher levels of depression and
presence of suicidal behavior, and protective factors predicted lower
levels of depression and absence of suicidal behavior, as expected
under the vulnerability-resilience stress model. Several sex
differences were observed in terms of the predictive power of risk
factors (for example, hopelessness among girls and keep to
themselves among boys) and protective factors (for example,
focusing on the positive among girls and self-discovery among boys).
In conclusion, protective factors moderate the impact of stress on
depression and suicidal behavior. Developing protection appears
important in the presence of chronic conditions, such as depressive
disorders, to reduce the likelihood of further episodes. The influence
of sex makes it the more relevant to target different factors for boys
and girls to increase protection and decrease risk in prevention and
intervention programs (1).
Few studies have investigated the association between religiosity
and self-injurious thoughts and behaviors specifically in adolescents,
yielding inconsistent results. Self-injurious thoughts and behaviors,
as well as depression, were assessed in a nationally representative
sample of Jewish adolescents (n=620) and their mothers, using the
Development and Well-Being Assessment Inventory structured
interview. Degree of religiosity was obtained by a self-report
measure. Using multivariate analysis, level of religiosity was inversely
associated with self-injurious thoughts and behaviors (p=0.047),
decreasing the likelihood of occurrence by 55% (OR=0.45, 95% CI 0.2-
0.99), after adjusting for depression and socio-demographic factors.
This model (adjusted R(2)=0.164; likelihood ratio (p<0.047) was able
to correctly classify 95.6% of the patients as belonging either to the
high or low risk groups. In conclusion, religiosity has a direct
independent protective effect against self-injurious thoughts and
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behaviors in Jewish adolescents. This finding has clinical implications

regarding risk assessment and suicide prevention (2).
Suicide is common among the elderly worldwide. The purpose of
this study was to explore young-old outpatients' reasons for not
killing themselves in Taiwan. Data for this qualitative descriptive
study were extracted from a large research series. From the 83
elderly outpatients in the original sample, 31 were chosen for this
study because they were young-old (65-74 years old) and from two
randomly selected medical centers in northern Taiwan. Data on
participants' reasons for not killing themselves in unhappy situations
were collected in individual interviews using a semi-structured guide
and analyzed by content analysis. Analysis of interview data
identified six major themes: satisfied with one's life, suicide cannot
resolve problems, fear of humiliating one's children, religious beliefs,
never thought about suicide, and living in harmony with nature. In
conclusion, these identified protective factors (reasons for living)
could be added to suicide-prevention programs for the elderly. The
findings may serve as a reference for geriatric researchers in western
countries with increasing numbers of elderly ethnic minority
immigrants (3).

Assessment: protective factors moderate the impact of stress on

depression and suicidal behavior. Protection is important in the
presence of chronic conditions, such as depressive disorders,
reducing the likelihood of further episodes.
Religiosity has a direct independent protective effect against self-
injurious thoughts and behaviors in Jewish adolescents.
Protection factors in young-old adults (65-74 years old) include
satisfaction with one's life, suicide cannot resolve problems, fear of
humiliating one's children, religious beliefs, never thought about
suicide, and living in harmony with nature.

References
1. Breton JJ, Labelle R, Berthiaume C, et al. Protective factors against depression
and suicidal behaviour in adolescence. Can J Psychiatry. 2015;60 (2 Suppl 1):S5-S15.
2. Amit BH, Krivoy A, Mansbach-Kleinfeld I, et al. Religiosity is a protective factor
against self-injurious thoughts and behaviors in Jewish adolescents: findings from a
nationally representative survey. Eur Psychiatry. 2014;29(8):509-13.
3. Chen YJ, Tsai YF, Lee SH, Lee HL. Protective factors against suicide among
young-old Chinese outpatients. BMC Public Health. 2014 Apr 16;14:372.
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L. Ben-Nun Suicide

JEWISH PERSPECTIVE
Suicide is a significant cause of death, constituting an alarming
public health problem. Many countries, therefore, have
acknowledged the necessity to create special centers for the
prevention of suicide. There is a moral conflict between the principle
of autonomy and the value of life in the case of suicide. This can be
resolved in several ways: 1] autonomy should be considered as a
categorical imperative and as an absolute principle, hence overriding
even the value of life; 2] suicide should be regarded, prima facie, as a
noncompetent decision, thus being in no conflict with the principle of
autonomy; 3] the value of life nullifies the principle of autonomy;
thus, when free will is used for the destruction of life, it should be
entirely relinquished. Judaism endorses the last interpretation of the
relationship between free will and destruction of life. It strictly
forbids suicide, based on theological considerations, regarding such
an act as one of the gravest of sins. The educational impact of such a
philosophy may favorably contribute to the efforts devoted to the
prevention of suicide. By contrast, those attributing absolute
importance to the principle of autonomy may have contributed to
the increasing rate of suicide in the Western world. The degree of
rationality of the suicide act depends on the degree of the philosophy
guiding the person's deliberations (1).
The Bible considers human life to be a divine gift but suicide per
se in neither condemned nor approved. Those suffering from suicidal
thoughts are treated with respect and support is offered (2).
According to Jewish tradition, the shortening of life through suicide,
assisted suicide, or euthanasia is categorically forbidden (3).
We see that there is no condemnation of the suicide of any of the
biblical character evaluated in this research.

References
1. Steinberg A. A comparative moral approach to suicide - a Jewish perspective.
Isr J Med Sci. 1987;23(7):850-2.
2. Koch. Suicides and suicide ideation in the Bible: and empirical study. Acta
Psychiatr Scand. 2005;112(3):167-72.
3. Kinzbrunner BM. Jewish medical ethics and end-of-life care. J Palliat Med.
2004;7(4):558-73.
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PREVENTION
Every year, suicide is among the top 20 leading causes of death
globally for all ages. Unfortunately, suicide is difficult to prevent, in
large part because the prevalence of risk factors is high among the
general population. Prevention strategies are effective in suicide
prevention including means restriction, responsible media coverage,
and general public education, as well identification methods such as
screening, gatekeeper training, and primary care physician education.
Although the treatment for preventing suicide is difficult, follow-up
that includes pharmacotherapy, psychotherapy, or both may be
useful. However, prevention methods cannot be restricted to the
individual. Community, social, and policy interventions will be
essential (1).
The public health approach to health problems provides a strong
framework and rationale for developing and implementing suicide
prevention programs. This approach consists of health-event
surveillance to describe the problem, epidemiologic analysis to
identify risk factors, the design and evaluation of interventions, and
the implementation of prevention programs. Suggestions for
improving surveillance include encouraging the use of appropriate
coding, reviewing suicide statistics at the local level, collecting more
etiologically useful information, and placing greater emphasis on
analysis of morbidity data. For epidemiologic analysis, greater use
could be made of observational studies, and uniform definitions and
measures should be developed and adopted. Efforts to develop
interventions must include evaluating both the process and the
outcome. Community suicide prevention programs should include
more than one strategy and, where appropriate, should be strongly
linked with the community's mental health resources. With adequate
planning, coordination, and resources, the public health approach
can help reduce the emotional and economic costs imposed on
society by suicide and suicidal behavior (2).
The suicide rates in Denmark have been declining during the last
two decades. The decline was relatively larger among women than
among men. All age groups experienced a decline except the very
young with stable rates and the very old with increasing rates. The
Universal, Selective, Indicated model recommended by Institute of
Medicine was used as a framework for the thesis. Universal
preventive interventions are directed toward the entire population;
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selective interventions are directed toward individuals who are at

greater risk for suicidal behavior; and indicated preventions are
targeted at individuals who have already begun self-destructive
behavior. At the universal level, a review was carried out to highlight
the association between availability of methods for suicide and
suicide rate. There were mostly studies of firearms, and restricted
access to lethal means was associated with decline in suicide with
that specific method, and in many cases with overall suicide
mortality. Restricting access is especially important for methods with
high case fatality rate. There is a beneficial effect on suicide rates of
restrictions in access to barbiturates, dextropropoxyphen, domestic
gas and car exhaust with high content of carbon monoxide. Although
a range of other factors in the society might be of importance,
restrictions in access to dangerous means for suicide are likely to play
an important role in reducing suicide rates in Denmark, especially for
women. At the selective level, there are several important risk groups
such as psychiatric patients, persons with alcohol and drug abuse,
persons with newly diagnosed severe physical illness, all who
previously attempted suicide, and groups of homeless,
institutionalized, prisoners and other socially excluded persons. The
thesis focused on homeless persons and psychiatric patients,
especially patients with schizophrenia and related disorders. The
thesis contains a review of the risk of suicide in homeless. In all the
studies included, increased suicide mortality was found, and in the
studies that evaluated suicide risk in different age groups, the excess
suicide mortality was most dominant in younger age groups. An
increased risk of suicide was associated with shortest stay in hostel
less than 11 days and more than one stay during one year. The thesis
also contains a review of the risk of suicide in first-episode patients
with schizophrenia, and it was concluded based on the identified
studies that long-term risk of suicide was not 10% as previously
accepted, but lower. Risk factors for suicide among patients with
schizophrenia were evaluated in case control studies, in nested case
control studies, and in prospective studies. The following risk factors
were the most important and frequently observed predictors: male
gender, young age, short duration of illness, many admissions during
last year, current inpatient, short time since discharge, previous and
recent suicide attempt, co-morbid depression, drug abuse, poor
compliance with medication, poor adherence to treatment, high IQ,
and suicidal ideations. The results of analyses of psychotic symptoms
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as risk factor for suicide were contradictory, but a recent meta-

analysis concluded that both hallucinations and delusions seemed to
be protective; however, there was insignificant tendency that
command hallucinations were associated with higher suicide risk.
Prevention of suicide in schizophrenia must especially focus on
improving assessment of risk of suicide during inpatient treatment
and the first week after discharge, special attention must be paid to
patients with one or more of the identified risk factors. Effect of
integrated treatment on attempted suicide was not found, but there
was an effect on hopelessness and a trend toward lower prevalence
of depression among patients in the integrated treatment. There
were four suicides and one probable suicide (drowning) in standard
treatment and one suicide in integrated treatment at 2-year follow-
up, but the study did not have sufficient power to detect these
differences in proportion to who committed suicide; more than 1000
patients should have been in each treatment condition in order for
these differences in proportion to be significant. At the indicated
prevention level, a literature review was carried out regarding risk of
suicide attempt and suicide in short-term, medium-term and long-
term follow-up of persons who attempted suicide. It was concluded
that the risk of repetition in short- and medium-term follow-up
studies was approximately 16%, with lower risk among "first-evers"
compared to repeaters. There was a large variation in repetition rate.
The proportion who committed suicide in medium-term follow-up
studies was 2.8% and in long-term follow-up studies was 3.5%
(weighted mean) with clearly higher proportions in the Nordic studies
than in the studies from UK. Risk factors for attempted suicide were
previous suicide attempt, alcohol and drug abuse, depression,
schizophrenia, previous inpatient treatment, self-discharge before
evaluation, sociopathy, unemployment, frequent change of address,
hostility, and living alone. Several of the predictors are overlapping
and most of them were already identified in early studies of factors
predictive of repetition of suicide attempt. Predictors of suicide were
male gender, increasing age, previous suicide attempt, serious
suicide attempt, alcohol and substance abuse, somatic disease,
mental illness, and planning suicide attempt, high suicidal intent
score, violent suicide attempt or suicide attempt with severe
lethality, and ongoing or previous psychiatric treatment. In a follow-
up study from Bispebjerg Hospital, the risk of suicide during a 10-year
follow-up period among patients admitted in 1980 after self-
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poisoning was 30 times greater than in the general population.

Increased mortality by all other causes of death was found.
Predictors of suicide were several previous suicide attempts, living
alone and increasing age. There are not many randomized clinical
trials of psychosocial interventions aiming to reduce risk of repetition
among suicide attempters. A Cochrane review concluded that
evidence was lacking to indicate the most effective forms of
treatment for deliberate self-harm patients. A recent RCS showed a
positive influence of CBT on repetition rate. A quasi-experimental
study of effectiveness of two weeks' inpatient treatment in a special
unit of young persons who had severe suicidal thoughts or who had
attempted suicide showed that risk of repetition was reduced in the
intervention group, and the intervention group obtained a
significantly greater improvement in BDI, Hopelessness Scale,
Rosenberg Self-Esteem Scale and CAGE-score. The study of
emergency outreach indicates that there are many persons in the
community that experience a suicidal crisis, and that this group is an
important target group for psychiatric emergency outreach. In a
study of registration and referral practice in Copenhagen Hospital
Cooperation, not all suicide attempts were registered in the National
Patient Register - in fact, only 37%. The quality of the Danish Patient
Register must be improved with regard to registration of suicide
attempt. Psychiatric evaluation was planned in relation to almost all
suicide attempts, and it must be recommended to pay attention to
escorting patients to psychiatric emergency in order to ensure that
the patient actually attends the planned consultation. Of patients
who were referred after psychiatric evaluation to psychiatric
treatment at outpatient facilities, only approximately two-thirds of
the cases received the planned treatment. Similarly to other data,
outpatient facilities should adopt an assertive approach to patients
who have attempted suicide (4).
Native peoples living in Alaska have one of the highest rates of
suicide in the world. This represents a significant health disparity for
indigenous populations living in Alaska. This research was part of a
larger study that explored qualitatively the perceptions of Alaska
Native university students from rural communities regarding suicide.
This analysis explored the resilience that arose from participants'
experiences of traditional ways, including subsistence activities.
Previous research has indicated the importance of traditional ways in
preventing suicide and strengthening communities. Semi-structured
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interviews were conducted with 25 university students who had

migrated to Fairbanks, Alaska, from rural Alaskan communities. An
interview protocol was developed in collaboration with cultural and
community advisors. Interviews were audio-recorded and
transcribed. Participants were asked specific questions concerning
the strengthening of traditional practices towards the prevention of
suicide. Transcripts were analyzed using the techniques of grounded
theory. Participants identified several resilience factors against
suicide, including traditional practices and subsistence activities,
meaningful community involvement and an active lifestyle.
Traditional practices and subsistence activities were perceived to
create the context for important relationships, promote healthy living
to prevent suicide, contrast with current challenges and transmit
important cultural values. Participants considered the strengthening
of these traditional ways as important in suicide prevention efforts.
However, subsistence and traditional practices were viewed as a
diminishing aspect of daily living in rural Alaska. In conclusion, many
college students from rural Alaska have been affected by suicide but
were strong enough to cope with such events. Subsistence living and
traditional practices were perceived as important social and cultural
processes with meaningful lifelong benefits for participants (5).
Suicide is a leading cause of death among post-secondary
students worldwide. Suicidal thoughts and planning are common
among post-secondary students. Previous reviews have examined the
effectiveness of interventions for symptomatic individuals; however,
many students at high risk of suicide are undiagnosed and untreated.
The effect on suicide and suicide-related outcomes of primary suicide
prevention interventions that targeted students within the post-
secondary setting was evaluated. The following sources up to June
2011: Specialized Registers of 2 Cochrane Groups, Cochrane Central
Register of Controlled Trials, and nine other databases, trial registers,
conference proceedings, and websites of national and international
organizations were searched. Reference lists were screened and
authors of included studies were contacted to identify additional
studies. The search in November 2013 was updated. Studies tested
an intervention for the primary prevention of suicide using a RCT,
controlled before-and-after, controlled interrupted time series, or
interrupted time series study design. Interventions targeted students
within the post-secondary setting (i.e. college, university, academy,
vocational, or any other post-secondary educational institution)
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without known mental illness, previous suicide attempt or self-harm,

or suicidal ideation. Outcomes included suicides, suicide attempts,
suicidal ideation, changes in suicide-related knowledge, attitudes and
behavior, and availability of means of suicide. Eight studies met
inclusion criteria. They were heterogeneous in terms of participants,
study designs, and interventions. Five of eight studies had high risk of
bias. In three RCTs (312 participants), classroom-based didactic and
experiential programs increased short-term knowledge of suicide
(SMD 1.51, 95% CI 0.57-2.45, moderate quality evidence) and
knowledge of suicide prevention (SMD 0.72, 95% CI 0.36-1.07,
moderate quality evidence). The effect on suicide prevention self-
efficacy in one RCT (152 participants) was uncertain (SMD 0.20, 95%
CI -0.13-0.54, low quality evidence). One controlled before-and-after
analyzed the effects of an institutional policy that restricted student
access to laboratory cyanide and mandated professional assessment
for suicidal students. The incidence of student suicide decreased
significantly at one university with the policy relative to 11 control
universities, 2.00 vs. 8.68 per 100,000 (p<0.05). Four controlled
before-and-after studies explored effects of training 'gatekeepers' to
recognize and respond to warning signs of emotional crises and
suicide risk in students they encountered. The magnitude of effect
sizes varied between studies. Gatekeeper training enhanced short-
term suicide knowledge in students, peer advisors residing in student
accommodation, and faculty and staff, and suicide prevention self-
efficacy among peer advisors. There was no evidence of an effect on
participants' suicide-related attitudes or behaviors. One controlled
before-and-after study found no evidence of effects of gatekeeper
training of peer advisors on suicide-related knowledge, self-efficacy,
or gatekeeper behaviors measured four to six months after
intervention. In conclusion, insufficient evidence supported
widespread implementation of any programs or policies for primary
suicide prevention in post-secondary educational settings. As all
evaluated interventions combined primary and secondary prevention
components, the independent effects of primary preventive
interventions were not determined. Classroom instruction and
gatekeeper training increased short-term suicide-related knowledge.
No studies that tested the effects of classroom instruction on suicidal
behavior or long-term outcomes were found. Limited evidence
suggested minimal longer-term effects of gatekeeper training on
suicide-related knowledge, while no evidence was found evaluating
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its effect on suicidal behavior. A policy-based suicide intervention

reduced student suicide, but findings have not been replicated. These
findings are limited by the overall low quality of the evidence and the
lack of studies from middle- and low-income countries (6).
Suicidal behavior and self-harm are common in adolescents and
are associated with elevated psychopathology, risk of suicide, and
demand for clinical services. Despite recent advances in the
understanding and treatment of self-harm and links between self-
harm and suicide and risk of suicide attempt, progress in reducing
suicide death rates has been elusive, with no substantive reduction in
suicide death rates over the past 60 years. Extending prior reviews of
the literature on treatments for suicidal behavior and repetitive self-
harm in youth, this article provides a meta-analysis of RCTs reporting
efficacy of specific pharmacological, social, or psychological
therapeutic interventions in reducing both suicidal and nonsuicidal
self-harm in adolescents. Data sources were identified by searching
the Cochrane, Medline, PsychINFO, EMBASE, and PubMed databases
as of May 2014. RCTs comparing specific therapeutic interventions vs.
treatment as usual or placebo in adolescents (through age 18 years)
with self-harm were included. Nineteen RCTs including 2,176 youth
were analyzed. Therapeutic interventions included psychological and
social interventions and no pharmacological interventions. The
proportion of the adolescents who self-harmed over the follow-up
period was lower in the intervention groups (28%) than in controls
(33%) (Test for overall effect z=2.31; p=0.02). Therapeutic
interventions with the largest effect sizes were DBT, CBT, and MBT.
There were no independent replications of efficacy of any
therapeutic interventions. The pooled risk difference between
therapeutic interventions and treatment as usual for suicide
attempts and nonsuicidal self-harm considered separately was
statistically insignificant. In conclusion, therapeutic interventions to
prevent self-harm appear to be effective. Independent replication of
the results achieved by DBT, MBT, and CBT is a research priority (7).
Suicide is a major public health problem in the WHO European
Region accounting for over 150,000 deaths per year. Suicidal crisis:
acute intervention should start immediately in order to keep the
patient alive. An underlying psychiatric disorder is present in up to
90% of people who completed suicide. Comorbidity with depression,
anxiety, substance abuse and personality disorders is high. In order to
achieve successful prevention of suicidality, adequate diagnostic
 147
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procedures and appropriate treatment for the underlying disorder

are essential. Existing evidence supports the efficacy of
pharmacological treatment and CBT in preventing suicidal behavior.
Some other psychological treatments are promising, but the
supporting evidence is currently insufficient. Studies show that
antidepressant treatment decreases the risk for suicidality among
depressed patients. However, the risk of suicidal behavior in
depressed patients treated with antidepressants exists during the
first 10-14 days of treatment, which requires careful monitoring.
Short-term supplementary medication with anxiolytics and hypnotics
in the case of anxiety and insomnia is recommended. Treatment with
antidepressants of children and adolescents should be given under
supervision of a specialist. Long-term treatment with lithium is
effective in preventing both suicide and attempted suicide in patients
with unipolar and bipolar depression. Treatment with clozapine is
effective in reducing suicidal behavior in patients with schizophrenia.
Other atypical antipsychotics are promising but more evidence is
required. Multidisciplinary treatment teams including psychiatrist
and other professionals such as psychologist, social worker, and
occupational therapist are always preferable, as integration of
pharmacological, psychological and social rehabilitation is
recommended especially for patients with chronic suicidality. The
suicidal person independently of age should always be motivated to
involve family in the treatment. Psychosocial treatment and support
is recommended, as the majority of suicidal patients have problems
with relationships, work, school and lack functioning social networks.
A secure home, public and hospital environment, without access to
suicidal means is a necessary strategy in suicide prevention. Each
treatment option, prescription of medication and discharge of the
patient from hospital should be evaluated against the involved risks.
Training of GPs is effective in the prevention of suicide. It improves
treatment of depression and anxiety, quality of the provided care and
attitudes towards suicide. Continuous training, including discussions
about ethical and legal issues, is necessary for psychiatrists and other
mental health professionals (8).
This pilot RCT examined the effect of an online intervention for
college students at risk for suicide, eBridge, which included
personalized feedback and optional online counseling delivered in
accordance with motivational interviewing principles. Primary
outcomes were readiness to seek information or talk with family and
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L. Ben-Nun Suicide

friends about mental health treatment, readiness to seek mental

health treatment, and actual treatment linkage. Participants were 76
college students (45 women, 31 men; mean age 22.9 years, SD 5.0
years) at a large public university who screened positive for suicide
risk, defined by at least two of the following: suicidal thoughts,
history of suicide attempt, depression, and alcohol abuse.
Racial/ethnic self-identifications were primarily Caucasian (n=54) and
Asian (n=21). Students were randomized to eBridge or the control
condition (personalized feedback only, offered in plain report
format). Outcomes were measured at 2-month follow-up. Despite
relatively modest engagement in online counseling (29% of students
posted ≥1 message), students assigned to eBridge reported
significantly higher readiness for help-seeking scores, especially
readiness to talk to family, talk to friends, and see a mental health
professional. Students assigned to eBridge reported lower stigma
levels and were more likely to link to mental health treatment.
Offering students personalized feedback and the option of online
counseling, using motivational interviewing principles, has a positive
impact on students' readiness to consider and engage in mental
health treatment (9).
Although injury is the leading cause of death for Americans aged
40 and under, curricula in U.S. Schools of Public Health rarely include
training on injury prevention or control. Domestically and
internationally, when the topic of injury is addressed, the focus is
often on unintentional injuries. Yet intentional injuries from violence
and self-harm (apart from acts of war and terrorism) and the acute
and chronic health problems associated with them take a large and
often hidden toll on individuals, families, and communities
worldwide. Adequate education on the prevention of violence and
suicide by teenagers remains missing from public health and medical
training. Public health and medical practitioners are confronted by
violence-related injury but are provided little formal education on
youth violence or suicide, effective responses, or prevention.
Adolescents' involvement in violence remains a serious public health
problem. Involvement in aggression and self-harm by adolescents
leaves them at immediate risk of injury and often has ongoing and
negative effects on future development, involvement in community
and family life, and risk of morbidity and mortality for self and others.
Public health practitioners are at the nexus of health care and service
provision at local, state, federal, and multinational levels, and are
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L. Ben-Nun Suicide

well suited to provide training and technical assistance on youth

violence prevention across disciplines and settings (10).
Suicide in later life is a major public health concern in the U.S.,
where more than 6,000 older adults take their own lives every year.
Suicide prevention in this age group is made challenging by the high
lethality of older adults' suicidal behavior; few survive their first
attempt to harm themselves. Factors in each of five domains place
older adults at increased risk for suicide-psychiatric illness,
personality traits and coping styles, medical illness, life stressors and
social disconnectedness, and functional impairment. Little research
has examined the effectiveness of interventions to reduce the toll of
suicide in older adulthood. The study of strategies to decrease suicide
deaths in later life should emphasize four areas. First approaches to
early detection of older people at risk through improved
understanding of multi-dimensional determinants and their
interactions. Second is research on the impact of general health
promotion that optimizes well-being and independent functioning for
older adults on suicide outcomes. Third concerns the study of
approaches to the provision of mental health care that is evidence-
based, accessible, affordable, acceptable, and integrated with other
aspects of care. The fourth area of high priority for research is
approaches to improvement of social connectedness and its impact
on suicide in older adults (11).
Suicidal ideation and attempted suicide are a huge problem in
South Africa, especially in the rural areas. Previous research has
emphasized the importance of the ability of school professionals to
identify young people who are at risk of committing suicide. The
objectives of this study were to assess the knowledge of teachers
with regard to identifying the warning signs of suicidal behavior,
assessing the type of information they give to students in the class
after a suicide of one of their class mates, and assessing their views
and training needs on the prevention of suicidal behavior in students.
Five focus group discussions were conducted with 50 high school
teachers in Limpopo Province, South Africa. All focus group
discussions were audiotaped, transcribed verbatim, and then
analyzed using an inductive approach. The results demonstrate that
teachers lack knowledge of the warning signs of suicidal behavior
among students. They also report that they do not know how to
support students in the event of attempted or completed suicide of
another student. The school curriculum is perceived as lacking
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information on suicide and suicidal behavior. In conclusion, teachers

in Limpopo Province need to be trained to identify students at risk,
and to respond to situations by referring individuals at risk to
appropriate mental health professionals. School-based suicide
prevention programs that are based on theory and evidence should
be developed. These programs should include teacher training to
help teachers to identify symptoms of psychosocial problems that
might lead to suicide, develop their skills in handling such problems,
and help students to cope with their emotions after a suicide incident
in the class or at school (12).
The current research evaluates the effectiveness and relative
merits of three screening measures (the BDI-II, the BHS, and the
Psychache Scale) in evaluating preexisting suicide risk factors for a
sample of 7,522 undergraduate students. All measures demonstrated
significant diagnostic accuracy for indicating suicide ideation,
previous single and multiple suicide attempts, and a recent suicide
attempt, which are all serious risk factors for subsequent death by
suicide in university students. However, the Psychache Scale
displayed superior performance in accurately identifying suicide risk
compared with both the BDI-II and the BHS. Identifying students
most at risk for suicide requires diagnostically efficient measures,
thus preliminary cut-scores for identifying at-risk students are
provided (13).

Assessment: suicide is difficult to prevent because the prevalence

of risk factors is high among the general population. Prevention
strategies are effective in suicide prevention including means of
restriction, responsible media coverage, and general public
education, as well identification methods such as screening,
gatekeeper training, and primary care physician education.
Restricted access to lethal means is associated with decline in
suicide with that specific method, and in many cases with overall
suicide mortality. There is a beneficial effect on suicide rates of
restrictions in access to barbiturates, dextropropoxyphen, domestic
gas and car exhaust with high content of carbon monoxide.
Resilience factors against suicide include traditional practices and
subsistence activities, meaningful community involvement and an
active lifestyle.
In order to achieve successful prevention of suicidality, adequate
diagnostic procedures and appropriate treatment for the underlying
 151
L. Ben-Nun Suicide

disorder are essential. Existing evidence supports the efficacy of

pharmacological treatment and CBT in preventing suicidal behavior.
Some other psychological treatments are promising, but the
supporting evidence is currently insufficient. Studies show that
antidepressant treatment decreases the risk for suicidality among
depressed patients.
Community suicide prevention programs should include more
than one strategy and, where appropriate, should be strongly linked
with the community's mental health resources. With adequate
planning, coordination, and resources, the public health approach
can help reduce the emotional and economic costs imposed on
society by suicide and suicidal behavior.

References
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suicide? Curr Psychiatry Rep. 2012;14(6):624-33.
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perspective. Suicide Life Threat Behav. 1995;25(1):82-91.
3. Hawton K, Fagg J, Simkin S, et al. Methods used for suicide by farmers in
England and Wales. The contribution of availability and its relevance to prevention.
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11. Conwell Y. Suicide later in life: challenges and priorities for prevention. Am J
Prev Med. 2014;47(3 Suppl 2):S244-50.
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12. Shilubane HN, Bos AE, Ruiter RA, et al. High school suicide in South Africa:
teachers' knowledge, views and training needs. BMC Public Health. 2015 Mar
14;15:245.
13. Troister T, D'Agata MT, Holden RR. Suicide Risk Screening: Comparing the
Beck Depression Inventory-II, Beck Hopelessness Scale, and Psychache Scale in
Undergraduates. Psychol Assess. 2015 Apr 27. [Epub ahead of print]

SUMMARY
Suicide (Latin suicidium, from sui caedere, "to kill oneself") is the
act of intentionally causing one's own death. Suicide is often carried
out because of despair, the cause of which is frequently attributed to
a mental disorder such as depression, bipolar disorder,
schizophrenia, BPD, alcoholism, or drug abuse.
Suicidal behavior is a significant public health problem. Suicide
alone represents the 10th leading cause of death worldwide. Suicide
is a complex phenomenon and may be the result of an interaction of
biological, psychological and socioeconomic factors.
In Ancient Greek, most of the information found in mythology, but
the suicide in a mythological tale, although in terms of motivation
and mental situation of heroes may be in imitation of similar
incidents of real life, in fact is linked with the principles of the ancient
Greek religion. Important factor was to avoid captivity and the
consequent overcrowding of indignity, especially for politicians and
military leaders. The methods of suicide fitted their epoch, but bear
resemblance to those of the modern time. Poisoning was common to
both men and women but equally popular in both sexes was also the
hanging. It was not unusual to fall from a high in order to reach the
death, while stabbing a sword in the body for self killing was
widespread in men and soldiers.
Was suicidal behavior prevalent in biblical times? Who committed
suicide in biblical times? What were reasons for this behavior? Was it
justifiable? Was the suicide preventable? This research aims to
answer these questions. All biblical texts were examined and
characters who committed suicide were studied closely.
Samson, son of Manoah, was born with special strength in his hair
that had not been cut since his birth. Samson fell in love with Delilah.
In spite of Samson’s love, this woman betrayed him, disclosing his
secret to Philistines. As he slept on Delilah’s knee, she shaved his
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head and his powerful strength left him. Now the Philistines
captured him, and his eyes were put out. However, gradually his hair
grew again. When Philistines were gathered, Samson “ …bowed
himself with all his-might; and the house fell upon the lords, and upon
all the people” (Judges 16:30). Samson, who had been chained to the
middle pillars of a temple, pushed them apart, and caused the
collapse of the building. So Samson died together with the death of
thousands people inside.
Can Samson’s suicide be regarded as heroic? The use of his
special strength to kill so many of his enemies does indeed indicate a
heroic victory over his enemies. He wanted vengeance, so his
behavior came because of his humiliation and suffering, and of the
fact that he refused to live as a prisoner in the hands of the cursed
Philistines.
Samson was driven to seek vengeance by Delilah’s betrayal, his
capture by Philistines, loss of vision, humiliation, and loss of social
status. His vengeance, cumulating in suicide, was the best answer to
his capturers, the cursed Philistines. Samson’s death, together with
thousands of Philistines, shows that his enemies failed to defeat this
powerful man and sent a special message to all his enemies. He
never accepted his defeat, and died like a hero struggling alone
against countless enemies.
King Saul, the first King of Israel, ruled the country more than
3000 years ago. Saul’s life ended when he lost the battle against the
Philistines on Mount Gilboa. “Then Saul said to his armor bearer,
“draw your sword and pierce me through with it, lest these
uncircumcised come and pierce me through and abuse me. But his
armor bearer would not, for he was greatly afraid” (I Samuel 31:4). So
Saul committed suicide “...Saul took a sword, and fell upon it (31:4).
“And when his armorbearer saw that Saul was dead, he fell likewise
upon his sword, and died with him” (31:5).
King Saul was a great warrior, fighting with the Philistines all his
life. Unfortunately, he lost his last battle with the Philistines, his three
sons were killed, and there were no pathways to escape from the
mount of Gilboa. Did Saul, a manic-depressive patient, develop such
severe depression that led it to his suicide? He faced a tragic reality,
with no incentive to survive, since the Philistines would torture and
kill him, the great King. Therefore, it seems likely that manic–
depressive disorder was not a factor in this case.
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Double suicide is an agreement between two people or more to

kill themselves. Double suicides are quite rare and are seen in old,
married couples. Can this event be defined as a double suicide in King
Saul's case? The decision to commit suicide was shared by two
individuals - King Saul and his armor-bear and was independently
accepted by both men. Thus, this suicide can be defined as double
suicide.
Seppuku, (Sape-puu-kuu) the Japanese formal language term for
ritual suicide [Hara-kiri (Har-rah-kee-ree)] was an integral aspect of
feudal Japan. Hara-kiri, which literally means "stomach cutting" is a
particularly painful method of self-destruction when a victim falls on
the sword and in this way ends his life.
We see that King Saul's suicide resembles the characteristics of
Japanese Hara-kiri suicide. Instead of submitting the dishonor of
capture by enemy, he fell on his sword, thereby demonstrating
strength of character, courage, and a high strong code of ethics. The
threat of disgrace, prosecution, hopelessness, impulsivity, the death
of his sons, and access to a weapon - a sword - are identifiable factors
linked to King Saul's suicide.
Ahithophel was a senior adviser to King David. When Absalom
rebelled against his father David, Ahithophel came to Absalom’s side
and advised Absalom to pursue David and kill him. In this way, the
people would be on Absalom side, but his advice was rejected.
Absalom chose the opposite way, by preparing his army to fight. As a
result of this “Now when Ahithophel saw that his advice was not
followed, he saddled a donkey, and arose and went home, to his city.
Then he put his household in order, and hanged himself, and died;
and he was buried in his father’s tomb” (II Samuel 17:23).
Ahithophel came to Absalom’s side and advised Absalom to
pursue David and kill him. In the end, Absalom was killed. For
Ahithophel this was a real tragedy. When his advice was not
accepted, he understood that this fight was lost, and David would
surely execute him. These adverse life events lead to intimate
relationship break-up with David, a poor handling of emotions, social
exclusion and hopelessness. There was no other way to solve the
forthcoming hostility and avoid David’s vengeance. Ahithophel was
so depressed that he decided to end his life.
King Elah, who ruled over Israel in Tirzah for two years, was the
son of King Baasha. (I Kings 16:8). “His servant Zimri, captain of half
his chariots, conspired against him, as he (King Elah) was in Tirzah,
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drinking himself drunk …” (16:9). “And Zimri went and smote him, and
killed him…. And reigned in his stead” (16:10). Therefore, Zimri
became King and reigned seven days over Tirzah. Zimri was very
wicked man. He assassinated King Elah, and subsequently the
members of King Baasha’s household. So all the people were against
Zimri, and the army besieged the city. Having no choice Zimri
committed suicide: he “went into the citadel of the king’s house and
burned the king’s house down upon himself with fire, and died” (I
Kings 16:15-20).
We see that Zimri committed suicide by setting the house on fire.
At the critical moment, Zimri was depressed and so despaired that his
life had no meaning Zimri reigned only for a few days over Tirzah,
before committing suicide by setting fire to his house. The Bible
provides no details about Zimri's family, quarrel with a family
member, a relative, and/or a friend. He knew he would be
overthrown and could not cope with the idea of defeat. Thus,
psychosocial factors played a decisive role to commit suicide. There
was only one escape from the disgrace of defeated by his enemies to
end his life in the way that he chose.
Abimelech a son of Jerubbaal, went to Ophrah and killed his 70
half-brothers, the sons of Jerubbal from different wives (Judges 9:5).
Later, Abimelech was anointed King, and he “…had reigned three
years over Israel” (9:22). However, the men of Shechem betrayed
Abimelech so a war developed between the people of Shechem and
Abimelech. During this war Abimelech captured the city of Thebez
(Judges 9:50,51), and from the tower of this city one woman “cast a
piece of a millstone upon Abimelech’s head, and crushed his skull”
(9:53). Seeing approaching death, Abimelech asked his armor-bearer
to kill him with a sword. Here Abimelech committed assisted suicide,
rather than having it said that he died at the hands of a woman.
Abimelech was a brave warrior; he fought with his enemies during
most of his life, but in the end was defeated by a simple stone cast by
a woman. His pride would not allow him to die at this woman’s hand
and there was no possibility of being rescued and healed.
Military suicide is a prevalent human behavior. Abimelech was a
brave warrior; he fought with his enemies during most of his life, but
in the end was defeated by a simple stone cast by a woman. His
pride would not allow him to die at this woman’s hand and there was
no possibility of being rescued and healed. The prognosis for
traumatic skull injury accompanied by fracture is very grave with no
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chance of survival, so he chose assisted suicide. In this way, his death

would appear as the death of a warrior, not kneeling before an
unknown simple woman. Abimelech died like a hero completing
suicide in military circumstances.
There is strong aggregation of suicidal behaviors in some
families. A family history of suicidal behavior is associated with
suicidal behavior in the proband, even after adjusting for presence
of psychiatric disorders in the proband and family, indicating
transmission of attempt that is distinct from family transmission of
psychiatric disorder. Familial transmission of suicide and major
depression, while partially overlapping, are distinct. Cluster B traits
and impulsive-aggressive behavior represent intermediate
phenotypes of suicide. Risk for suicidal behavior in families of
probands with mood disorders is related to early onset of mood
disorders, aggressive/impulsive traits, and reported childhood
abuse in probands. Molecular genetic studies indicate familial
heritability and common occurrence in twins.
Familial factors were not present in the biblical characters
studied. There was no history of family discord, or history of twins,
whether monozygotic or dizygotic, or mention of family member who
committed suicide.
All the biblical characters who committed suicide were men, all
fought with their enemies. All suffered from damaged ego, all felt
hopeless about finding another solution to their problems, all wanted
to escape from this world, and none of them wanted to suffer in
captivity, losing their social status, pride and dignity.
Adverse life events have been associated with increased risk of
suicide. In all biblical characters studied in this research, adverse
negative life events such as war, and adverse social events such as
disrupted interpersonal relationships were associated with suicidal
behavior.
In contemporary times, attempted and completed suicide
constitutes a major public health problem worldwide, with
widespread rates observed in different countries.
Suicide incidence and gender asymmetry increases with age.
Hanging is the most frequent method. Lower rates of
psychopathology are evident among child suicides compared to
adolescents. Previous suicide attempts are an important risk factor.
Children are less likely to consume alcohol prior to suicide. Parent-
child conflicts are the most common precipitant.
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Boys use more violent means to commit suicide in comparison to

girls. For children with suicide attempt, adjustment disorders and
depression are the two main diagnoses for hospitalization. Suicidal
behavior in children under 11 years of age is closer to a behavior of a
person who has committed suicide than an adolescent attempting
suicide. The children with attempted suicide come often from
broken families and have a difficult relationship with their parents.
Suicide acceptability is in small part a possible reason why suicides
tend to cluster in adolescents.
Suicide rates in young people have increased during the past three
decades, particularly among young males. Risk factors for youth
suicide are mental disorders, in particular, affective disorders,
substance use disorders and antisocial behaviors. Suicidal
participants exhibit higher rates of depressive symptoms, sleep
problems, expressive suppression, rumination, and impulsivity.
Perception of poor health is associated with a significantly
increased likelihood of suicidal ideation and suicide attempt among
adults in the community.
The overall prevalence of people reporting ever having made a
suicide attempt is 3.4% and the 1-year prevalence is 0.5%. Suicidal
ideation is more prevalent among young people than among older
people, whereas ever-attempted suicide shows no age gradient.
Suicidal thoughts and behaviors are predictive of subsequent fatal
suicidal acts.
Suicide is a major public health concern for older adults, who have
higher rates of completed suicide than any other age group in most
countries of the world. Late-life suicide is a persistent threat and a
reality from which no one emerges unscathed. Family members and
significant others feel guilty and inconsequential. The assisted living
community that fosters independence and self-determination can be,
simultaneously, an environment in which the warning signs of
suicidal ideation and self-destruction can be missed.
Suicide is a major cause of death among individuals with ED,
especially AN. Females with ED have a higher rate of suicide
compared to females without ED.
Veterans have a current suicide plan and preparations to carry out
their plan. Warning signs include sleep disturbances, intense anxiety,
intense agitation, hopelessness, and desperation. Any suicide
variables (e.g., ideation, attempts, or completed) are concerning.
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Applicable dialogue can recognize changing thoughts, judgment, and

behavior patterns.
Stroke is a dramatic event and is associated with disability,
mortality, and social costs. Stroke may occur at any age; however,
most strokes occur in individuals aged 65 years and older. Stroke is a
significant risk factor for both suicide and suicidal ideation, especially
among younger adult depressed patients. Clinical and socioeconomic
factors increase the risk of poststroke suicide attempts.
Patients with malignancy are at increased risk for suicide.
Physicians' suicide rates are higher than those of the general
population. The suicide rate of male physicians is slightly higher than
that of the general population, while of their female colleagues is
clearly higher. This tendency is pronounced in female psychiatrists,
anesthetists, and nurses.
Some road traffic crashes are disguised suicide attempts, with
substantial proportion of motor vehicle crash deaths recognized as
"hidden" suicides. Driver suicides represent a small proportion of all
suicides. These drivers consume alcohol immediately prior to the
crash and experience a number of life events, including relationship
conflict, legal or criminal issues, and financial problems.
Self-harm among prisoners is high, and suicide rates are
increasing. While released prisoners are at high suicide risk and have
a slightly different pattern of psychiatric risk factors for suicide
compared with the general population. Factors significantly
associated with post-release suicide include released from a local
prison, a history of alcohol misuse or self-harm, a psychiatric
diagnosis, and requiring Community Mental Health Services follow-
up after release.
Suicide of soldiers has its own specifics, because not only it
represents the tragedy for the individuals and their family, but also
has great psychological effect on social environment and military unit
in which it occurs. Psychological complex of basic inferiority, low
educational level, family problems, and poor integration into military
unit are the leading determinants of suicide.
Military personnel are highly vulnerable to multiple
psychopathologies due to a lack of social support system,
traumatizing life events and deprived sense of control. Serious
psychopathologies such as PTSDs, GAD, and depression may increase
the risk of suicide. The commonest motives for suicide are decreased
capacity of adaptation to military service, actual psychic disturbance,
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emotional interruption, fear of environment judgment, and family

problems. Suicide risk factors in soldiers are primary in their
immature personality organization, its relation with family and
military environment factors which, in coexistence with actual life
accidents.
The number of traumatic events is associated with increased risk
of suicide attempts. Soldiers who are multiple attempters report a
greater number of chronic stressors. Chronic stressors are associated
with more severe and longer-lasting suicidal crises. Among suicide
decedents, the most common risk factor is having a failed intimate
relationship in the 90 days prior to suicide. Among those who
attempted suicide, the most common risk factor is a major
psychiatric diagnosis. Early military separation (<4 years) and
discharge that is not honorable are suicide risk factors.
Depression and alcohol abuse are major factors associated with
military suicides. Emotional disorders and alcohol misuse, when
combined with the hardships of war, contribute to a steady rate of
suicides during the Civil War.
Was suicide associated with a military situation in characters
studied in this research? In the cases of Samson, King Saul, and
Abimelech, factors include the humiliating defeat in the battle,
refusal to surrender to their enemies, the impossibility of escaping,
hopelessness, and despair.
Depression is the most common psychiatric disorder in people
who died by suicide. Suicidal behavior is related to male gender,
longer (>13 months) duration of depression, anhedonia, feeling
worthless, comorbid anxiety, previous suicidal ideation, and use of
professional care. Impulsive-aggressive personality disorders and
alcohol abuse/dependence are predictors of suicide in MDD, and
impulsive and aggressive behaviors seem to underlie these risk
factors.
Bipolar disorder is strongly associated with suicide ideation and
suicide attempts. Severity of depressive episode and hopelessness
are factors for suicidal ideation, and hopelessness, comorbid
personality disorder, and previous suicide attempt are independent
risk factors for suicide attempts.
The medical record of characters studied in this research shows
no signs of some type of depression such as MDD, brief depressive
episodes, or very brief depressive episodes. No signs of comorbidity
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of MDD with PTSD are recorded. Thus, the defeat in military cannot
be related to the development of depression.
Among characters studied in this research, only King Saul suffered
from bipolar I disorder. Can bipolar disorder be linked to suicide in
King Saul's case? Although King Saul suffered from bipolar disorder I,
this mental disorder cannot be related to his suicidal behavior. His
suicide was associated with a situation when the battle on Mount
Gilboa was lost and there was no chance of escape. King Saul, having
a strong character, died likes a hero.
Can impulsivity be associated with suicide in the cases of Samson,
King Saul, Ahithopel, King Zimri, and Abimelech? Was the impulsivity
associated with defeat in battle? Can the King Saul's impulsivity be
linked to severe behavioral complications of bipolar disorder?
It is likely that the relationship between impulsivity and
hopelessness in the face of defeat led to suicide of these individuals.
It is likely that the relationship between impulsivity and hopelessness
in the face of defeat led to suicide in King Saul, a member of a high
socioeconomic class.
Any anxiety disorder is associated with suicidal ideation and
suicide attempts. Comorbid anxiety disorders amplify the risk of
suicide attempts in persons with mood disorders, and suicide risk
among depressed patients.
The medical record of the characters studied in this research
indicates no GAD. Their situation was hopeless and desperate due to
specific circumstances. Suicide in these cases was not associated with
GAD.
OCD is associated with a high risk for suicidal behavior. Depression
and hopelessness are the major correlates of suicidal behavior. Being
unmarried, presenting higher basal scores in the HAM-D, current or
previous history of affective disorders and symmetry/ordering
obsessions were independently associated with suicidal behaviors.
The medical record of the characters studied in this research
shows no signs of OCD. Thus, this cause of suicide can be dropped.
Recurrent suicidal threats, gestures or behavior or self-mutilation
are common in patients suffering from BPD. Self-mutilating suicide
attempters are at greater risk for suicide for several reasons: they
experience more feeling of depression and hopelessness, are more
aggressive and display more affective instability; they underestimate
the lethality of their suicidal behavior and are troubled by suicidal
thoughts for longer and more frequent times.
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Self-mutilation is a risk factor of suicide in BPD. Suicide threats are

often related to emotions connected with interpersonal
relationships.
The medical record of the characters studied in this research
shows no signs of BPD. Thus, this cause of suicide can be removed.
MDD has a short-term effect on suicide risk, while poor social
adjustment may increase risk throughout each follow-up interval.
Schizophrenia and schizoaffective disorder are particularly at risk
for suicide. Elevated levels of impulsive-aggressive personality traits
are found among schizophrenic and schizoaffective suicide
completers. Risk factors with a strong association with later suicide
included being young, male, and with a high level of education.
Illness-related risk factors are important predictors, with number of
prior suicide attempts, depressive symptoms, active hallucinations
and delusions, and the presence of insight all having a strong
evidential basis. A family history of suicide, and comorbid substance
misuse are associated with later suicide.
The medical record of the characters studied in this research
shows no signs of schizophrenia or schizoaffective disorder. Thus,
these diseases can be excluded.
The incidence of suicide in psychiatric hospital is high, higher than
that observed in the general population. Many risk factors for suicide
are identified in this context. The accessibility to one or more means
of suicide (water, rail, high floor, knives, and possibility of hanging) is
a recognized factor in psychiatric institutions. In the psychiatric
environment, hospitalization period determines the risk of suicide: it
is highest during the 1st week of hospitalization and within two
weeks after leaving.
Factors related to suicide include the treatment environment,
failure to assess patient behavioral characteristics, and staff reliance
on no-suicide contracts.
Suicide risk peaks in periods immediately after admission and
discharge. The risk is particularly high in persons with affective
disorders and in persons with short hospital treatment.
The number of visits to the emergency department is an
independent risk factor for suicide. The suicide risk screen can
identify adolescents at elevated risk for suicide who presented to the
emergency department with unrelated medical concerns and a
subgroup of adolescents who may be at highly elevated risk for
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suicide due to the combination of depression, alcohol abuse,

suicidality, and impulsivity.
In different countries, there are variations in the methods of
suicide. These variations can be related to the culture of each
country, and its understanding of life and death, the social
acceptability of suicide, access to a lethal weapon, and acceptance of
death as an inevitable part of life. Differing methods of suicide
include hanging, strangulation, or suffocation, gassing, jumping from
a height, gunshot, using a firearm or explosive, or drowning, cutting,
poisoning, helium, cannabis, suicide on subways or railways, and
pesticide use. Other methods include suicide bombing, complex
suicide, double suicide, seppuku (Hara-kiri), massive suicide, and
"Kamikaze" attacks.
In southeast Iran emergency department, housewives, self-
employed individuals and those with a low or medium income
dominate the suicide cases. The most common method of suicide is
burning followed by drug ingestion.
Samson, who was chained to the middle pillars of a temple,
pushed them apart, and caused the collapse of the building. Samson
died together with the thousands people inside. Ahithophel hanged
himself; King Zimri committed suicide by setting fire to his house;
Abimelech committed assisted suicide asking his armor-bearer to kill
him with a sword; King Saul and his armor-bearer performed suicide
a double suicide. King Saul's suicide resembles the characteristics of
Japanese Hara-kiri (literally means "stomach cutting", a painful
method of self-destruction when victim falls on the sword and in this
way ends his life.
The risk of suicide includes mental disorders, alcohol or substance
abuse/dependence, drug misuse, cultural, family and socio economic
problems, genetics, pesticide poisoning, air pollution, different
antidepressant treatments, history of suicide attempt, deliberate
self-poisoning, concomitant chronic physical or mental illness, sexual
problems, adverse life events, and staying in lodging homes.
In general population, male gender, longer (>13 months) duration
of depression, anhedonia, feeling worthless, comorbid anxiety,
previous suicidal ideation and use of professional care are
significantly related to suicidality.
In older people, male sex, lower education and lower income,
depressed mood are associated with an increased risk of suicide.
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There is an association between excessive video game and

Internet use and risk for teen depression and suicidality. Individuals
use the Internet to search for suicide-related information and to
discuss suicide-related problems with one another. Internet use may
exert both positive and negative effects on young people at risk of
self-harm or suicide.
Protective factors moderate the impact of stress on depression
and suicidal behavior. Protection is important in the presence of
chronic conditions, such as depressive disorders, reducing the
likelihood of further episodes.
In young-old adults (65-74 years old), protection factors include
satisfaction with life, consideration that suicide cannot resolve
problems, fear of humiliating one's children, religious beliefs, never
thought about suicide, and living in harmony with nature.
Religiosity has a direct independent protective effect against self-
injurious thoughts and behaviors in Jewish adolescents.
Judaism endorses the last interpretation of the relationship
between free will and destruction of life. It forbids suicide, based on
theological considerations, regarding such an act as one of the
gravest of sins. The Bible considers human life to be a divine gift but
suicide per se in neither condemned nor approved. Those suffering
from suicidal thoughts are treated with respect and support is
offered. According to Jewish tradition the shortening of life through
suicide, assisted suicide, or euthanasia is forbidden. There is no
condemnation of the suicide of any of the biblical character
discussed.
Suicide is difficult to prevent because the prevalence of risk
factors is high among the general population. Prevention strategies
are effective in suicide prevention including means of restriction,
responsible media coverage, and general public education, as well
identification methods such as screening, gatekeeper training, and
primary care physician education.
Restricted access to lethal means is associated with decline in
suicide with that specific method, and in with overall suicide
mortality. There is a beneficial effect on suicide rates of restrictions in
access to barbiturates, dextropropoxyphen, domestic gas and car
exhaust with high content of carbon monoxide.
Resilience factors against suicide include traditional practices and
subsistence activities, meaningful community involvement and an
active lifestyle.
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In order to achieve successful prevention of suicidality, adequate

diagnostic procedures and appropriate treatment for the underlying
disorder are essential. Existing evidence supports the efficacy of
pharmacological treatment and CBT in preventing suicidal behavior.
Some other psychological treatments are promising, but the
supporting evidence is currently insufficient. Antidepressant
treatment decreases the risk for suicidality among depressed
patients.
Community suicide prevention programs should include more
than one strategy and, where appropriate, should be strongly linked
with the community's mental health resources. With adequate
planning, coordination, and resources, the public health approach
can help reduce the emotional and economic costs imposed on
society by suicide and suicidal behavior.
Suicidal behavior has accompanied humans since the dawn of our
history. All the characters studied - Samson, King Saul, Ahithopel, and
Zimri - chose suicide as the only honorable and reasonable option.
Nothing has change in the world. Desperate and hopeless people
continue to commit suicide. The gift of life has no meaning in their
mind. Prevention and intervention strategies are not always
successful.
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THE AUTHOR'S LIST OF PUBLICATION

BOOKS
Written and Edited by Professor Liubov Ben-Nun.
Printed and Published: B.N. Publication House. Israel.
Distributed Worldwide. Not for Sale.

1. The Diseases That Affected King David. ( In Hebrew). 2003.

2. Medicine in the Bible. Research from the Viewpoint of Contemporary
Medicine. 2004.
3. Family Medicine. The Roots. Research in Biblical Times from the Viewpoint of
Contemporary Medicine. 2005.
4. The Diseases of the Kings of Israel. 2006.
5. Psychiatry in Biblical Times. The Roots. 2007.
6. Infectious Diseases that Afflicted People of Jericho. 2008.
7. Disease that Afflicted the People of the Ancient Philistine Cities. 2009.
8. Obstetrics and Gynecology from Biblical to Contemporary times. 2009.
9. The Family Life Cycle and the Medical record of King David the Great. 2009.
10. Moses. The Medical Record and the Family Life Cycle of the Great Leader of
the Jewish People. 2010.
11. The Epidemics in the Desert in Biblical Times. 2010.
12. Family System Dynamics of Biblical Jacob. 2011.
13. A Disease that Afflicted Ancient Egypt. 2011.
14. A Disease that Afflicted the Newborn Son of King David. 2011.
15. Cardiovascular Diseases from Biblical to Contemporary Times. 2011.
16. A Fatal Condition Related to Male Circumcision. 2011.
17. Male Circumcision from Ancient to Contemporary Times. 2011.
18. Pediatrics from Biblical to Contemporary Times. 2011.
19. How did Biblical King Saul Die? 2012.
20. Falls Described in the Bible from a Contemporary Perspective. 2012.
21. Organ Donation and Transplantation in the Bible from a Contemporary
Perspective. 2012.
22. Traumatic Brain Injuries in the Bible from the Viewpoint of Contemporary
Medicine. 2012.
23. Abdominal and Thoracic Traumatic injuries in the Bible from the Viewpoint of
Contemporary Medicine. 2012.
24. Evaluation of Biblical Samson's Hair Characteristics from the Viewpoint of
Contemporary Medicine. 2013.
25. Heat-related Illness in the Bible. "..the sun beat down upon his head of
Jonah, so that he fainted.." (Jonah 4:8). Research in Biblical Times from the
Viewpoint of Contemporary Medicine. 2013.
26. A Milk Composition that Caused Sleep in the Biblical Character. Research in
Biblical Times from the Viewpoint of Contemporary Medicine. 2013.
27. Music Therapy in the Bible. Research in Biblical Times from the Viewpoint of
Contemporary Medicine. 2013.
28. Approach to a Patient with Severe Bone Pain. From Biblical to Contemporary
Times. Vol 1, Vol 2, Vol 3. 2013.
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29. Relationships between Siblings in One Ancient Family. 2013.

30. Significance of Water from Biblical to Contemporary Times. 2013.
31. Quail Disease in the Desert in Biblical Times. 2013.
32. A Disease that Afflicted Judah's Sons. 2013.
33. A Disease that Afflicted Elimelech's Family. 2013.
34. Water for Medical Treatment According to the Bible from the Perspective of
Contemporary Medicine. 2013.
35. Attitude towards Cannibalism in the Bible from a Contemporary Perspective.
2014.
36. Hair Loss that Afflicted the Prophet Elisha. 2014.
37. Ocular Trauma in the Bible from the Viewpoint of Contemporary Medicine.
2014.
38. The Medical Record of Amnon the King David's Son. 2014.
39. How did Absalom the son of King David Die? 2014.
40. Hand Paralysis as Described in the Bible from the Viewpoint of Contemporary
Medicine. 2014.
41. Tearing Clothes in the Bible. 2014.
42. Euthanasia as Described in the Bible. 2014
43. Verbal Communication Skills. 2014.
44. Non-verbal Communication Skills. 2014.
45. Communication Skills in the Blind. 2014.
46. Communication Skills in the Disabled. 2014.
47. Lice-borne Diseases. 2014.
48. Surrogate Motherhood. Hagar and Sarah. 2014.
49. Conjoined Twins. 2014.
50. The Family life Cycle/the Medical Record of King David the Great. Third ed. 2-
Volume Set. 2015.
51. Pain in childbearing "… in pain you shall bring forth children" (Genesis 3:16).
2015.
52. Psychosocial Aspects of Infertility "Give me children or else I die" (Genesis
30:1). 2015.
53. Treatment of Infertility. 2015.
54. Twin Pregnancy. 2015
55. Awareness of Ovulation. 2015.
56. Dehydration and Hunger. 2015.
57. Aspects of Life Span. 2015.

ARTICLES
1. Ben-Noun L. Comparison of physician-led and dietician-led weight reducing
programs. Harefuah. 1988;114:488-90.
2. Ben-Noun L. A family presentation. The family physician. 1988;16:10-3.
3. Ben-Noun L. Poorly controlled diabetes in the elderly. Practitioner.
1989;233:14-6.
4. Ben-Noun L. Mitral valve prolapse syndrome, panic disorder and
agoraphobia. Practitioner. 1989;233;379-80.
5. Ben-Noun L. Mental disorders in severe dysfunctional and in well-functioning
families (Pilot study). Harefuah. 1989;116: 457-60.
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6. Ben-Noun L. Severity of asthma: parent’s assessment versus the physician’s.

Practitioner. 1989;233:1052.
7. Ben-Noun L. Benzodiazepine withdrawal syndrome. The family physician
1989;17:244-6.
8. Ben-Noun L. Benzodiazepines-side effects, adverse reactions and hazards.The
family physician. 1990;18:191-3.
9. Ben-Noun L. Characteristics of smoking and differentiation in smoking habits.
Harefuah. 1990;119:189-2.
10. Ben-Noun L. Use of stethoscope by mothers of asthmatic children ages 1-5.
Harefuah 1990; 119:362-4.
11. Ben-Noun L. Clerambault syndrome in an elderly woman. Harefuah.
1991;120:131-2.
12. Ben-Noun L. Management of benzodiazepine withdrawal. The family
physician. 1991;19:278-82.
13. Ben-Noun L. Developmental language disorder in children of severely
dysfunctional families. Harefuah. 1991;121:219-22.
14. Ben-Noun L. Enuresis in children 5-18 years old in severe dysfunctional
families Harefuah. 1993;124:71-5.
15. Ben-Noun L. Evaluation of visits to an emergency department in rural
population. Harefuah. 1993;125:456-61.
16. Ben-Noun L, Shvartzman P. Shigellosis in primary care practice. Harefuah.
1994; 27:381-3.
17. Ben-Noun L. Chronic diseases in immigrants from Russia (CIS) at a primary
care clinic and their sociodemographic characteristics. Harefuah. 1994; 127:441-5.
18. Ben-Noun L. Sweet’s syndrome associated with erythema nodosum. Aust
Fam Physician. 1995;24:1867- 69.
19. Ben-Noun L. Use of medication for hypertension and coronary heart disease
by Russian immigrants. Harefuah. 1995;129: 392-4.
20. Ben-Noun L. Pattern of visits to a primary care clinic by recent Russian
immigrants. Harefuah. 1996;130:308-10.
21. Ben-Noun L. Characteristics of patients refusing professional psychiatric
treatment in a primary care clinic. Isr J Psychiatry Relat Sci. 1996;33:167-74.
22. Ben-Noun L. Use of aspirin for fever by Russian immigrant children. Harefuah.
1996;130:820-1.
23. Ben-Noun L. Acute asthma attack associated with sustained-release
verapamil. Ann Pharmacoth. 1997;31:593-5.
24. Ben-Noun L. Awareness of ovulation and sex determination in Biblical times.
Harefuah. 1997;132:726-7.
25. Ben-Noun L. Characteristics of asthma among Israeli adults. IMAJ.
1997;33:339-43.
26. Ben-Noun L. From biblical stories- multiple pregnancy and fetal sex
determination in biblical times. Harefuah. 1998;134:52-3.
27. Ben-Noun L. Generalized anxiety disorder in dysfunctional families. J Behav
Ther Exp Psychiatry. 1998;29:115-22.
28. Ben-Noun L. Drug-related asthma. J Pharmacy Technology. 1998;14:116-24.
29. Ben-Noun L. Is there a relationship between smoking and asthma in adults ?
J Int Med Res. 1999;27:15-21.
30. Ben-Noun L. Coronary artery bypass-long term psychological and social
outcomes. J Anxiety Disorders. 1999;13:505-12.
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31. Ben-Noun L. The capability to resist smoking relapse. Public Health Rev.
1998;26:331-42.
32. Ben-Noun L. Speech disorder in Biblical times - Moses: “a heavy mouth and a
heavy tongue.” Harefuah 1999; 136:908-10.
33. Ben-Noun L. Pattern of primary care clinic visits of adult asthmatics. Public
Health Rev. 1999;27:321-28.
34. Ben-Noun A, Biderman A, Shvartzman P. Patients’ smoking status in
practice - the physician’s view. IMAJ. 2000;2:351-4.
35. Ben-Noun L. Interferon Therapy in liver cirrhosis type C. J Pharm Technol.
2000; 16: 81-8.
36. Ben-Noun L. Drug-induced respiratory disorders: incidence, prevention and
management. Drug Safety. ADIS International Journal. 2000;23(2):143-64.
37. Ben-Noun L. What was the disease of the legs that afflicted King Asa ?
Gerontology. (Switzerland) 2001;47:96-9.
38. Ben-Noun L. Characteristics of comorbidity in adult asthma. Public Health
Rev. 2001;29:49-61.
39. Ben-Noun L, Sohar E, Laor A. Neck circumference as a simple screening
measure for identifying overweight and obesity patients. Obesity Research.
2001;9:470-7.
40. Ben-Noun L. What diseases of the eyes affected biblical men? Gerontology.
2002;48:52-5.
41. Ben-Noun L. Drinking wine to inebriation in biblical times.
Israel J Psychiatry. 2002;39:61-4.
42. Ben-Noun L. What was the disease of the bones that affected King David ? J
Gerontol Med Sci. 2002;57:152-54.
43. Ben-Noun L. Was the biblical King David affected by hypothermia ? J
Gerontol Med Sci. 2002;57:364-7.
44. Ben-Noun L. Characterization of Anthrax: Its precise description and Biblical
name - Shehin. Harefuah. 2002 May;141 Spec No:4-6, 124.
45. Ben-Noun L. What is the Biblical attitude towards personal hygiene during
vaginal bleeding ? Eur J Obstet Gynecol Reprod Biol. 2003;106:99-101.
46. Ben-Noun L. Figs - the earliest known ancient drug for cutaneous anthrax.
Ann Pharmacother. 2003;37:297-300.
47. Ben-Noun L. Laor A. Relationship of neck circumference to cardiovascular
risk factors. Obesity Research. 2003;11(2):226-231.
48. Ben-Noun L. Family dynamics in biblical times: Joseph as a family
Psychotherapist. Hist Psychiatry. 2003;14:219-28.
49. Ben-Noun L. What was the Mental Disease that Afflicted King Saul ? Clin Case
Studies (CCS) USA. 2003;2:4-7.
50. El-On J, Ben-Noun L, Galitza Z, Ohana N. Case report: clinical and
serological evaluation of echinococcosis of the spine. Trans R Soc Trop Med Hyg.
London. 2003;97(5):567-9.
51. Ben-Noun L, Laor A. Relationship between changes in neck circumference
and changes in blood pressure. Am J Hypertens. 2004;17:409-14.
52. Ben-Noun L. The disease that caused weight loss in King David the Great. J
Gerontol Med Sci. 2004;59:143-5.
53. Ben-Noun L. Mental disorder that afflicted King David the Great. Hist
Psychiatry. 2004;54(4):467-76.
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54. Ben-Noun L. Colorectal carcinoma that afflicted King Jehoram Minerva Med.
2004;95(6):557-61.
55. Ben-Noun L, El-On J. The biblical leprosy. Minerva Med. Venereol. Italy.
2005;140(6):733-7.
56. Ben-Noun L, Laor A. Relationship between changes in neck circumference
and cardiovascular risk factors. Exp Clin Cardiol. 2006;11:14-20.
57. Ben-Nun L. Breast-feeding. The Roots. Minerva Pediatr. 2006;58(6):551-6.
58. Ben-Nun L. Was Cain affected by some mental disorder? JCCM. 2007;2:24-9.
59. Ben-Nun L. What are medicinal properties of pomegranates? JCCM.
2007;2:530-8.
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PICTURES

Blinded Samson. Lovis Corinth. 1912.

Death of Samson. Gustave Dore.

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The suicide of Saul. Pieter Bruegel the Elder.

The Battle of Gilboa. Jean Fouquet.

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Abimelech dies. Julius Schnorr.

The Death of Abimelech. Gustave Doré.

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