Suicide is associated with several risk and protective factors. Suicide, like other human behaviors, has no single determining cause. Instead, suicide occurs in response to multiple biological, psychological, interpersonal, environmental and societal influences that interact with one another, often over time. The social ecological model—encompassing multiple levels of focus from the individual, relationship, community, and societal—is a useful framework for viewing and understanding suicide risk and protective factors identified in the literature. Risk and protective factors for suicide exist at each level. For example, risk factors include:
• Individual level: history of depression and other mental illnesses, hopelessness, substance abuse, certain health conditions, previous suicide attempt, violence victimization and perpetration, and genetic and biological determinants
• Relationship level: high conflict or violent relationships, sense of isolation and lack of social support, family/ loved one’s history of suicide, financial and work stress
• Community level: inadequate community connectedness, barriers to health care (e.g., lack of access to providers and medications)
• Societal level: availability of lethal means of suicide, unsafe media portrayals of suicide, stigma associated with help-seeking and mental illness. It is important to recognize that the vast majority of individuals who are depressed, attempt suicide, or have other risk factors, do not die by suicide.18,19 Furthermore, the relevance of each risk factor can vary by age, race, gender, sexual orientation, residential geography, and socio-cultural and economic status.
Source: https://www.cdc.gov/violenceprevention/pdf/suicidetechnicalpackage.pdf Last accessed 29 June 2022
A close examination of barriers to treatment is warranted by several striking findings: (1) the vast majority (90–95 percent) of people in the United States who complete suicide have a diagnosable mental disorder, yet only about half of them are diagnosed and treated appropriately (Conwell et al., 1996; Fawcett et al., 1991; Harris and Barraclough, 1997; Isometsa et al., 1994b; Robins et al., 1959); (2) many are symptomatic for several years before suicide (Fawcett et al., 1991; Shaffer and Craft, 1999); (3) many have made a past suicide attempt (Harris and Barraclough, 1997); and (4) most who complete suicide make contact with health services in the days to months before their death. Nearly 20 percent make contact with primary care providers in the week before suicide, nearly 40 percent make contact within the month before suicide (Pirkis and Burgess, 1998), and nearly 75 percent see a medical professional within their last year (Miller and Druss, 2001). Among older people, the rates are higher, with about 70 percent making contact within the month before suicide (Barraclough, 1971; Miller, 1976). However, suicide victims are three times more likely to have difficulties accessing health care than people who died from other causes (Miller and Druss, 2001).
Stigma and Discrimination
The stigma of mental illness is one of the foremost barriers deterring people who need treatment from seeking it (US DHHS, 1999). About two-thirds of people with diagnosable mental disorders do not receive treatment (Kessler et al., 1996; Regier et al., 1993; US DHHS, 1999). Stigma toward mental illness is pervasive in the United States and many other nations (Bhugra, 1989; Brockington et al., 1993; Corrigan and Penn, 1998).
The cost of care is among the most frequently cited barriers to mental health treatment. About 60–70 percent of respondents in large, community-based surveys say they are worried about cost (Sturm and Sherbourne, 2001; Sussman et al., 1987). Economic analyses of patterns of use of mental health services clearly indicate that use is sensitive to price: use falls as costs rise, while use increases with better insurance coverage (Manning et al., 1986; Taube et al., 1986). Rises in co-payments of mental health services are associated with lower access (Simon et al., 1996a). The demand for mental health services is more responsive to price than is demand for other types of health services (Taube et al., 1986).
Mental Health System Barriers
The fragmented organization of mental health services has been repeatedly recognized as a serious barrier to obtaining treatment (US DHHS, 1999). The vision, beginning in 1975, of the community support reform movement—an integrated, seamless service system that brings mental health services directly to the community—has not fully materialized. Mental health services continue to be so fragmented that they have been termed the “de facto” service system (Regier et al., 1993). People with mental illness frequently report their frustrations and waiting times as they navigate through a maze of disorganized services (Sturm and Sherbourne, 2001; Sussman et al., 1987). The disorganization is a product of historical reform movements, separate funding streams, varying eligibility rules, and disparate administrative sources—all of which have created artificial boundaries between treatment settings and sectors (Ridgely et al., 1990). Among the hardest hit are people with co-occurring substance abuse and mental health problems, a group at higher risk of suicidality. Co-occurring disorders are the rule rather than the exception in mental health and substance abuse treatment (US DHHS, 1999).
In the past two decades, managed care has grown from relative obscurity to cover almost 72 percent of Americans with health insurance in 1999 (OPEN MINDS, 1999). Driven by the goal of cost-containment, managed care refers to a variety of strategies for organizing, delivering, and/ or paying for health services. Its promise has been to improve access to health care by lowering its cost, reducing inappropriate utilization, relying on clinical practice guidelines to standardize care, promoting organizational linkages, and by emphasizing prevention and primary care. Managed care's emphasis on treatment of mental health problems in primary care is potentially advantageous for certain populations, such as older people and minorities, which are less inclined toward use of specialty mental health care (US DHHS, 1999). Managed care's potential pitfalls are poorer quality of care, denial of needed care, under-treatment, and disruption in the continuity of clinician–patient relationships (IOM, 1997; Mechanic, 1997).
The detection and treatment of depression by primary care physicians is of great relevance to suicidology. Depression evaluation presents the first opportunity for primary care physicians to ask about suicidal ideation, which is one of several symptoms of major depressive disorder (APA, 1994), and a major risk factor for completed suicide (Harris and Barraclough, 1997). Treatment of depression in primary care is associated with reduced rates of completed suicide, according to an uncontrolled ecological study on the Swedish island of Gotland (see discussion in Chapters 7 and 8, Rutz et al., 1989; 1992). The effects of depression treatment in primary care on suicidal behavior are being studied in a controlled clinical trial in the United States. Preliminary results indicate reduced rates of hopelessness, suicidal ideation, and related symptoms of depression in older primary care patients (personal communication, C. Reynolds, G. Alexopoulos, and I. Katz, University of Pittsburgh School of Medicine, 2001).
Substance use disorders are second to mood disorders as the most common risk factor for suicide (Chapter 3). Substance abuse is an especially important risk factor for suicide in young adults (Chapter 3). Furthermore, substance abuse and mood disorders frequently co-occur, with 51 percent of suicide attempters having both (Suominen et al., 1996). Treatment of co-morbid alcoholism and depression with selective serotonin reuptake inhibitors (SSRI) reduces suicidality (Cornelius et al., 2000; Cornelius et al., 2001). Thus, detection and treatment of substance abuse and depression in primary care is important for suicide prevention (Murphy, 2000; PHS, 2001).
Source: Book: Reducing Suicide: A National Imperative. Institute of Medicine (US) Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide; Goldsmith SK, Pellmar TC, Kleinman AM, et al., editors. Washington (DC): National Academies Press (US); 2002.
https://www.ncbi.nlm.nih.gov/books/NBK220944/ Last accessed 6/29/2022