2
Magnitude of the Problem

Suicide is a global problem, a leading cause of death in the world claiming about 30,000 lives in the United States each year, almost 1 million annually world-wide. In the United States, the suicide rate was 10.7 per 100,000 in 1999. It greatly exceeded the rate of homicide (6.2 per 100,000) in 1999, as it has for the last 100 years (Figure 2-1) (Bureau of Justice Statistics, 2001; Bureau of the Census, 1976; Hoyert et al., 2001; Minino and Smith, 2001; NCHS, 2001; NCIPC, 2000). Suicide is the third leading cause of death in youth 15–24 years old. White males over 85 have the highest rate of suicide, about 65 per 100,000. Suicide rates are also elevated in some ethnic groups. For example, suicide is about 1.5 times more prevalent than average among Native Americans. While whites continue to have higher suicide rates than blacks, the gap seems to be narrowing in young males.

Suicides in males outnumber those in females in almost all nations, including the United States. While males are more likely to complete suicide, females are more likely to attempt suicide. Nationally and internationally there is geographic heterogeneity, suggesting that social and cultural differences have a significant impact on suicide rates (see also Chapter 6). In the United States in 1998, firearms accounted for the majority of suicides both in general (57.0%) and among youth 15–24 (61%) (NCIPC, 2000). Suffocation (18.7%; 25%), poisoning (16.6%, 7%), and falls (2.0% both) follow in usage. This differs in other nations; for example, self-poisoning, especially with insecticides, is the most common method in both Pakistan (Khan and Reza, 2000) and rural China (Yip, 2001).



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Reducing Suicide: A National Imperative 2 Magnitude of the Problem Suicide is a global problem, a leading cause of death in the world claiming about 30,000 lives in the United States each year, almost 1 million annually world-wide. In the United States, the suicide rate was 10.7 per 100,000 in 1999. It greatly exceeded the rate of homicide (6.2 per 100,000) in 1999, as it has for the last 100 years (Figure 2-1) (Bureau of Justice Statistics, 2001; Bureau of the Census, 1976; Hoyert et al., 2001; Minino and Smith, 2001; NCHS, 2001; NCIPC, 2000). Suicide is the third leading cause of death in youth 15–24 years old. White males over 85 have the highest rate of suicide, about 65 per 100,000. Suicide rates are also elevated in some ethnic groups. For example, suicide is about 1.5 times more prevalent than average among Native Americans. While whites continue to have higher suicide rates than blacks, the gap seems to be narrowing in young males. Suicides in males outnumber those in females in almost all nations, including the United States. While males are more likely to complete suicide, females are more likely to attempt suicide. Nationally and internationally there is geographic heterogeneity, suggesting that social and cultural differences have a significant impact on suicide rates (see also Chapter 6). In the United States in 1998, firearms accounted for the majority of suicides both in general (57.0%) and among youth 15–24 (61%) (NCIPC, 2000). Suffocation (18.7%; 25%), poisoning (16.6%, 7%), and falls (2.0% both) follow in usage. This differs in other nations; for example, self-poisoning, especially with insecticides, is the most common method in both Pakistan (Khan and Reza, 2000) and rural China (Yip, 2001).

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Reducing Suicide: A National Imperative FIGURE 2-1 Rates of Suicide and Homicide in the United States: 1900–2000. Based on data from the Bureau of Justice Statistics (2001), Bureau of the Census (1976), Hoyert et al. (2001), Minino and Smith (2001), and NCHS (2001). Inconsistencies in reporting before 1933 may account for some of the early fluctuations in rates. This chapter reviews the characteristics of some of the populations at risk, describes the geographical differences, and briefly explores the limitations of the epidemiological data. The chapter closes with an analysis of the economic cost to society that suicide presents. GEOGRAPHIC TRENDS Suicide rates are generally higher in northern European nations than in southern European nations (see Table 2-1). For example, Hungary’s suicide rate was over 33 per 100,000 as of 1999 (WHO, 2001a). In comparison, Greece has had low suicide rates, only 3.8 per 100,000 as of 1998 (WHO, 2001a). Suicide rates have been high in recent years in many, but not all, of the former Soviet states. For example, suicide rates are over 35 per 100,000 in the Russian Federation and Lithuania, but are less than 5 per 100,000 in Armenia, Azerbaijan, and Georgia (WHO, 2001a).

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Reducing Suicide: A National Imperative TABLE 2-1 National Suicide Rates per 100,000 for Selected Countries. Most Recent Data from the World Health Organization (WHO, 2001a) Country Total Male Female Year Armenia 1.8 2.7 0.9 1999 Austria 19.2 28.7 10.3 1999 Azerbaijan 0.7 1.1 0.2 1999 Belarus 34.0 61.1 10.0 1999 Brazil 4.1 6.6 1.8 1995 Canada 12.3 19.6 5.1 1997 China 14.1 13.4 14.8 1998 Rural Areas 23.3 21.9 24.8 1998 Urban Areas 6.8 6.8 6.8 1998 Finland 23.8 38.3 10.1 1998 Georgia 4.3 6.6 2.1 1992 Greece 3.8 6.1 1.7 1998 Hungary 33.1 53.1 14.8 1999 India 10.7 12.2 9.1 1998 Italy 8.2 12.7 3.9 1997 Japan 18.8 26.0 11.9 1997 Kuwait 2.2 2.7 1.6 1999 Lithuania 41.9 73.8 13.6 1999 Mexico 3.1 5.4 1.0 1995 Norway 12.1 17.8 6.6 1997 Philippines 2.1 2.5 1.7 1993 Poland 14.3 24.1 4.6 1996 Republic of Korea 13.0 17.8 8.0 1997 Russian Federation 35.5 62.6 11.6 1998 Singapore 11.7 13.9 9.5 1998 Sri Lanka 31.0 44.6 16.8 1991a Sweden 14.2 20.0 8.5 1996 Tajikistan 3.5 5.1 1.8 1995 Thailand 4.0 5.6 2.4 1994 Ukraine 29.1 51.2 10.0 1999 United Kingdom of Great Britain & Northern Ireland 7.4 11.7 3.3 1998 United States 10.7 17.6 4.1 1999 aThe more recent total suicide rate for 1996 was 21.6, but rates by sex were not available. Overall, suicide rates are lower in other Asian nations compared to China, including Singapore (11.7 per 100,000), Japan (18.8 per 100,000), and Thailand, which reports a very low rate of 4.0 per 100,000 (Table 2-1, WHO, 2001a). The suicide rate for China has decreased dramatically in recent years, dropping from 23 per 100,000 in 1999 to 17 per 100,000 in 2000 (WHO, 2001b).

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Reducing Suicide: A National Imperative Studies from across the world find higher rates of suicide in rural versus urban areas (Plotnikov, 2001; Yip, 2001; Yip et al., 2000). In China, for example, the rate is two to five times greater in rural regions (Ji et al., 2001; Jianlin, 2000; Phillips et al., 1999; Yip, 2001). Higher rates in rural regions have also been documented for young males in Australia (Wilkinson and Gunnell, 2000) and in the Ukraine (Kryzhanovskaya and Pilyagina, 1999). Even among adolescents in Greece, where the suicide rate is relatively low, urban areas report significantly lower rates than rural areas (Beratis, 1991). In China (Yip et al., 2000), unlike Australia for example (Morrell et al., 1999), the usual pattern of more suicides among men than women is reversed in rural areas due to the very high female suicide rate, especially among young women (Ji et al., 2001; Yip, 2001; Yip et al., 2000). Like the United States (see below), suicide rates are higher in rural areas in China. In 1998, women in rural China completed suicide at a rate of over 30 per 100,000 for ages 25–34 and 45–64, with increasing rates at older ages (WHO, 2001a). The male rate surpasses that for women starting at age 55, with over 129 per 100,000 dying by suicide over the age of 75 in rural China (WHO, 2001a). In comparison, the overall rate for females and males in urban China is 6.8 per 100,000 in 1998, with the highest rate for males over 75 at about 32 per 100,000 (WHO, 2001a). Suicide rates vary greatly across the United States, with higher rates generally in the western states. New Jersey is the lowest with 6.4/100,000 in 1998. Nevada and Alaska are the highest with rates in excess of 21/ 100,000 (Murphy, 2000). Mapping the rates by county (see Appendix A and Figure 2-2) illustrates that those counties with the highest rates are predominantly in the western states with lowest population density. Counties with the lowest rates (7.5 suicides per 100,000) appear to be clustered in the central United States. Finally, counties classified with intermediate rates are largely in the eastern portion of the United States. Population density has been suggested as a factor in these differences (Saunderson and Langford, 1996). Examining the suicide rates by urbanization in the United States reveals that the rates are higher in less populated area compared to densely populated cities (Figure 2-3). For the most part this difference is a reflection of the decrease in firearm suicides with urbanization (Figure 2-4). This relationship of suicide by firearms and population density is even more dramatic when suicide among elderly persons is explored. Among the elderly, suicide by firearms decreases dramatically with increased urbanization (Figure 2-5), but non-firearm suicides are more common in urban areas. When controlling for education, employment status, and divorce rate, Birckmayer and Hemenway (2001) also found that living in urban areas was associated with increases in U.S. suicide rates for non-firearm suicides among adults.

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Reducing Suicide: A National Imperative FIGURE 2-2 Annual Suicide Rates per 100,000 (1996–1998). The Poisson Mixture Model applied to county-level data. FIGURE 2-3 Suicide Rates by Urbanization: United States, 1996–1998. Source: NCHS (2001). Provided by LA Fingerhut.

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Reducing Suicide: A National Imperative FIGURE 2-4 Suicide Rates by Urbanization and Use of Firearms Among Persons 15–64 Years: United States, 1996–1998. Source: NCHS (2001). Provided by LA Fingerhut. Limited access to mental health services and to emergency care have been implicated in the increased rates seen in some rural areas. Rural residents suffer higher overall mortality rates from accidents and injuries of all intents because of isolation from care facilities (IOM, 1999). Mental health services are poor in many rural areas (e.g., Howland, 1995) and travel distance to mental health treatment impedes use by rural residents (Fortney et al., 1999, see also Chapter 9). The reported suicide rates are confounded by the effects of race, sex, and age. A statistical analysis described in Appendix A illustrates an approach to adjust rates for these variables. That analysis reveals that even after accounting for these important demographic variables, considerable spatial variability remains. Again, the highest adjusted rates are typically found in the less densely populated areas of the western United States. The analysis also reveals that there are spatial anomolies; in the western United States and Alaska, where suicide rates are typically high, there are a few counties that have calculated estimates that are consistent with the national average. Similarly, in the central United States, where

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Reducing Suicide: A National Imperative FIGURE 2-5 Suicide Rates by Urbanization and Use of Firearms Among Persons 65 Years and Older: United States, 1996–1998. Source: NCHS (2001). Provided by LA Fingerhut. there is a high concentration of counties with the lowest suicide rates, there are a few counties that exhibit the highest suicide rates. What are the protective factors that have produced these spatial anomalies? Are these spatial anomalies simply due to reporting bias or some other unmeasured characteristic that has produced the outliers? Examining these spatial anomalies in greater detail is certainly a fruitful area for further research. POPULATIONS AT RISK Gender Differences In western nations such as Greece, Mexico, and the United States, male suicides outnumber female suicides 3- to 5-fold (WHO, 2001a). The gender gap is narrower in Asian nations, where the difference tends to be less than 2-fold. China is singular in this regard, with more female than male suicides, although this gap has narrowed in recent years (WHO, 2001a). Risk factors for suicide differ significantly by gender. Although

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Reducing Suicide: A National Imperative women are twice as likely as men to experience episodes of major depression in the United States, they are 25 percent less likely than men to complete suicide (Murphy, 1998). There are several factors that may explain this. Men who are depressed have a higher prevalence of comorbid alcohol and substance abuse than women. Also, men’s depression in later life is more likely to go unrecognized and untreated than women’s depression (Rihmer et al., 1995). Murphy (1998) suggests that men may regard a need for help as a weakness and consequently avoid help seeking; while women may place a higher value on interdependence and consider how their actions will affect others to a greater degree than do men. A comparison of male and female suicide victims provides additional clues as to the gender differences for completed suicide (Brent et al., 1999). First, females are more likely to engage in suicidal behavior using potentially reversible methods, such as overdose. Second, females are less likely to use alcohol during a suicide completion. Third, alcohol intoxication in the context of a suicide increases the likelihood of use of a gun for completion of suicide in males, but not females. Youth Although suicide rates for all age groups have been relatively stable since the 1950s, the reported rate among adolescents has increased markedly. Between 1970 and 1990, the rates for youth aged 15 through 19 nearly doubled; the rate tripled since the mid 1950s. Since 1990, the overall suicide rate for this age group has stabilized at approximately 11 deaths per 100,000. One national school-based study of youth found high one-year prevalence rates for suicide attempts (7.7 percent), ideation (20.5 percent), and making a plan (15.7 percent) (Kann et al., 1998). The increase in the suicide rate is thought to be attributable to an increase in alcohol and substance abuse and increased availability of firearms over this period of time (Brent et al., 1987). Being unemployed or out of school was associated with completed suicide in a large case-control study completed in New York (Gould et al., 1996; Shaffer et al., 1996). In other countries that experienced a dramatic increase in suicide in the past 10 years, such as New Zealand and in the province of Quebec, social change, including diminishing opportunities for employment, is thought to be a primary factor (Beautrais, 2000). Suicide victims under the age of 30 are more likely to have problems with substance abuse, impulsive aggressive personality disorders, and precipitants such as interpersonal and legal problems (Rich et al., 1986b) than those over 30. Co-occurrences of mental illness, substance abuse, conduct disorder, or all three are significant risk factors for suicide, but

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Reducing Suicide: A National Imperative especially in adolescent males (Brent et al., 1999; Shaffer et al., 1996). In general, suicidal behavior is a more impulsive act in younger people. Younger people are less likely to complete a suicide than older people. Even within the adolescent age range, younger adolescents who complete suicide show lower suicidal intent than older ones (Brent et al., 1999; Groholt et al., 1998). Furthermore, youth are more likely to be influenced by media presentations of suicide and to die in cluster suicides1 (although even so, only about 5% of youth suicides occur in clusters; Gould and Shaffer, 1986; Gould et al., 1990; Phillips and Carstensen, 1986). Guns are the most common mechanism of suicide among youths. In a case-control study of suicide, the availability of guns in the home conveyed the largest risk in adolescents and young adults (Kellermann et al., 1992). A comparison of the suicide rates in Seattle and Vancouver (see also Chapter 8) showed that when gun control was absent (in the United States) youth (15–24) suicide was significantly greater, with 10-fold more suicide by firearms (Sloan et al., 1990). Moreover, guns in the home, particularly loaded guns, pose up to a 30-fold increased risk for suicide, especially among individuals without major mental disorder (Brent et al., 1993; Kellermann et al., 1992). The rate of psychopathology among younger adolescent suicide victims is much lower than among older adolescents, so that the availability of guns becomes the paramount risk factor for younger, impulsive individuals (Brent et al., 1999; Shaffer et al., 1996). Elderly In almost all industrialized countries, men 75 years of age and older have the highest suicide rate among all age groups (Pearson et al., 1997). Of the countries that provide suicide data, Hungary has the highest suicide rates for both elderly men and women: in 1991–1992, the suicide rate for men 75 years and older was as high as 177.5/100,000 (Sartorius, 1996). The lowest rates for both elderly men and women were in Northern Ireland and England/Wales, with rates for men of 20/100,000 and 18/ 100,000, respectively (Schweizer et al., 1988). In 1990 the United States had a suicide rate of 24.9/100,000 for men aged 75–84. In 1998 the rate had risen to 42.0/100,000. Although older individuals comprise approximately 10% of the U.S. population, they account for 20% of the completed suicides (Hoyert et al., 2001; Hoyert et al., 1999). Men account for about four out of five completed suicides among those older than 65. This is partly explained by the fact that men are more 1   The term cluster suicides refers to higher-than-expected numbers of suicides occurring in a small geographic area within a limited time period.

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Reducing Suicide: A National Imperative likely to use more lethal methods. Seventy-six percent of men and 33% of women who completed suicide used firearms, while 3% of men and 33% of women who completed suicide used overdose on medications in the United States (NCHS, 1992). Risk factors that predispose to suicide differ across the life span. Widowhood (Smith et al., 1988), serious medical illness, and social isolation (Draper, 1994) are more likely to be salient vulnerability factors among older as opposed to younger adults. Whereas affective illness is a vulnerability factor across all age groups (Asgard, 1990; Rich et al., 1986b), the limited findings for dual diagnosis tend to be weak or negative in later life but consistently positive among young people (Asgard, 1990; Barraclough et al., 1974; Rich et al., 1986b). It is important to note that risk factors often co-occur, such as social isolation and depression, or social isolation and drug abuse, or depression and drug abuse. Considerations specific to suicide in the elderly include: (1) the greater likelihood that the elderly will die in or following a suicide attempt; (2) the greater prevalence of indirect self-destructive behaviors such as poor-adherence to treatment regimens in the elderly; and (3) co-morbid conditions that increase suicide risk, including bereavement, depression, and terminal illness. There is greater likelihood of death in or following a suicide attempt in the elderly. While in younger age groups suicide attempts are more often impulsive and communicative acts, in later life most attempts can be considered “failed suicides.” Older individuals make fewer suicide attempts per completed suicide. The highest suicide attempt to completion rate is in younger women (200:1), compared with 4:1 in the elderly. Suicide attempts in the elderly are more likely to lead to completed suicide than in any other age group: 6% of individuals aged 55 and older died by suicide within a year of a suicide attempt compared to 2% of younger attempters (Gardner et al., 1964). The reasons for this low attempt to completion ratio are complex. The elderly are more medically fragile and frequently live alone, which increases the probability of a fatal outcome. Suicides in older people are often with high intent, long-planned and frequently involve highly lethal methods. The elderly are often less rescuable because of these aspects of their suicidal behavior. Furthermore, suicide methods selected by the elderly are less likely to be affected by short-term modeling effects, such as suicide epidemics. Although most people who kill themselves give direct or indirect warnings, older people are less likely to directly communicate their intent to die. As the elderly are often preoccupied with death and dying, their environment is more likely to miss the indirect warning that they give, such as “nothing is in front of me anymore.” However, contrary to common belief, lack of hope and depression are not part of normal aging, not even in the terminally ill elderly.

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Reducing Suicide: A National Imperative Indirect self-destructive behavior in the elderly are particularly notable. In addition to overt suicide attempts, there are subtle behaviors especially in the elderly, with conscious or unconscious intent to die, such as refusal to eat or drink, noncompliance with treatment, or extreme self-neglect. Farberow (1980) used the term “sub-intentional suicide” to refer to indirect self-destructive behaviors which often lead to premature death, and are common in certain settings such as nursing homes (where more immediate means to complete suicide are limited), and among people whose religion forbids suicide. Osgood et al. (1991) found that the rate of completed suicide among elderly nursing home residents was 15.8/100,000 as compared to 19.2/100,000 for elderly living in the community. By contrast they estimated the rate of indirect self-destructive behavior leading to death to be 79.9/100,000 among nursing home residents, and the rate of such behavior not resulting in death to be 227/ 100,000. Kastenbaum and Mishara (1971) found that 44% of men and 22% of women who were hospitalized for chronic medical illnesses exhibited indirect self-destructive behavior during a 1-week period. Bereavement is an important risk factor in the elderly. The effect of spousal loss on suicidality appears to be the most pronounced in elderly men. In the United States, the highest suicide rate is among bereaved elderly white men: 84/100,000 (NCHS, 1992). Rates of suicidal ideation are also elevated in elderly with complicated or traumatic grief, which differs from bereavement-related depression and includes PTSD-like symptoms (Szanto et al., 1997). Although chronic physical illness has been associated with an increased suicide risk in depressed patients (Duggan et al., 1991), depression and not physical illness differentiated elderly suicide completers from non-completers (Conwell et al., 2000). A 1-year follow-up study of psychiatric register cases observed that depressed patients aged 55 years or older had more than twice the rate of suicide (475/100,000) than younger depressed patients (207/100,000) (Gardner et al., 1964). In the 60–90 year old age group, the rates of suicide attempts associated with untreated mood disorders increase with each subsequent decade (Bostwick and Pankratz, 2000). Psychological autopsy studies have found depression to be the most common psychiatric diagnosis in elderly suicide victims, while alcoholism is the most common diagnosis in younger adults (Conwell and Brent, 1996; Dorpat and Ripley, 1960). Conwell and Brent (1996) reported that 76 percent of elderly suicide victims had diagnosable psychopathology, including 54 percent with major depression and 11 percent with minor depression. Seventy percent or more of elderly suicide victims were seen by their primary care physician within one month from their death (Barraclough et al., 1971; Conwell, 1994; Miller, 1976). Terminal illness needs to be

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Reducing Suicide: A National Imperative however, has been increasing. While the rates in African American adolescents has increased through the 1990s, the rates appear to have leveled off. The differences in suicide rates among ethnic groups in the United States, among immigrant populations, and among countries throughout the world point to the influence of social and cultural factors. Risk factors vary in their importance for different groups. Youth suicide is more highly associated with impulsiveness than for other age groups. On the other hand, older persons are at greater risk for completing suicide because of the seriousness of the intent and social isolation. Studies of the differences in the risk of suicide among populations can enhance our understanding of the impact of risk and protective factors. This is best accomplished by collection of specific data from well defined and characterized populations whose community level social descriptions are well known, which would allow the integration of population-based approaches with studies of individual characteristics. Suicide rates vary across geographic region. Rates are lower in more densely populated areas around the world. When rates within the United States are analyzed county by county, striking variations in some adjacent counties are revealed. This approach bridges traditional sociological and anthropological studies that use ecological data and case controlled approaches that examine individual risk factors for suicide. Future studies could identify social factors that differ between two communities that are adjacent, or otherwise similar, but have dramatically different suicide rates. This approach could provide more precise assessments of the roles of social factors in suicide including public health issues such as access to and the quality of health care. Costs to Society: The annual cost of lost productivity due to suicide deaths was calculated to be $11.8 billion (in 1998 dollars). This does not include medical care costs, or costs incurred by loss of productivity of either those suffering from suicidality or the close family and friends of a suicide victim. REFERENCES Agerbo E, Mortensen PB, Eriksson T, Qin P, Westergaard-Nielsen N. 2001. Risk of suicide in relation to income level in people admitted to hospital with mental illness: Nested case-control study. British Medical Journal, 322(7282): 334-335. Anderson RN. 2001. United States Life Tables, 1998. National Vital Statistics Report, 48(18): 1-40.

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Reducing Suicide: A National Imperative Anno BJ. 1985. Patterns of suicide in the Texas Department of Corrections, 1980-1985. Journal of Prison and Jail Health, 2: 82-93. Anno BJ. 1991. Prison Health Care: Guidelines for the Management of an Adequate Delivery System. Washington, DC: U.S. Department of Justice, Department of Corrections. Asgard U. 1990. A psychiatric study of suicide among urban Swedish women. Acta Psychiatrica Scandinavica, 82(2): 115-124. Bagley C, Tremblay P. 1997. Suicide behaviors in homosexual and bisexual males. Crisis, 18(1): 24-34. Barraclough B, Bunch J, Nelson B, Sainsbury P. 1974. A hundred cases of suicide: Clinical aspects. British Journal of Psychiatry, 125: 355-373. Barraclough BM, Nelson B, Bunch J, Sainsbury P. 1971. Suicide and barbiturate prescribing. Journal of the Royal College of General Practitioners, 21(112): 645-653. Beautrais AL. 2000. Risk factors for suicide and attempted suicide among young people. Australian and New Zealand Journal of Psychiatry, 34(3): 420-436. Beauvais F. 1998. American Indians and alcohol. Alcohol Health and Research World, 22(4): 253-259. Bechtold DW. 1994. Indian adolescent suicide: Clinical and developmental considerations. American Indian and Alaska Native Mental Health Research Monograph Series, 4: 71-80. Bedeian AG. 1982. Suicide and occupation: A review. Journal of Vocational Behavior, 21(2): 206-223. Bell CC. 1986. Impaired black health professionals: Vulnerabilities and treatment approaches. Journal of the National Medical Association, 78(10): 925-930. Bell CC, Clark DC. 1998. Adolescent suicide. Pediatric Clinics of North America, 45(2): 365-380. Beratis S. 1991. Suicide among adolescents in Greece. British Journal of Psychiatry, 159: 515-519. Birckmayer J, Hemenway D. 2001. Suicide and firearm prevalence: Are youth disproportionately affected? Suicide and Life-Threatening Behavior, 31(3): 303-310. Bland RC, Newman SC, Dyck RJ, Orn H. 1990. Prevalence of psychiatric disorders and suicide attempts in a prison population. Canadian Journal of Psychiatry, 35(5): 407-413. Bostwick JM, Pankratz VS. 2000. Affective disorders and suicide risk: A reexamination. American Journal of Psychiatry, 157(12): 1925-1932. Boxer PA, Burnett C, Swanson N. 1995. Suicide and occupation: A review of the literature. Journal of Occupational and Environmental Medicine, 37(4): 442-452. Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L. 1999. Age- and sex-related risk factors for adolescent suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 38(12): 1497-1505. Brent DA, Perper JA, Allman CJ. 1987. Alcohol, firearms, and suicide among youth: Temporal trends in Allegheny County, Pennsylvania, 1960 to 1983. Journal of the American Medical Association, 257(24): 3369-3372. Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. 1993. Firearms and adolescent suicide. A community case-control study. American Journal of Diseases of Children, 147(10): 1066-1071. Brooke D, Taylor C, Gunn J, Maden A. 1996. Point prevalence of mental disorder in unconvicted male prisoners in England and Wales . British Medical Journal, 313(7071): 1524-1527. Bureau of Justice Statistics, U.S. Department of Justice. 2001. Homicide Victimization, 1950– 1999. [Online]. Available: http://www.ojp.usdoj.gov/bjs/ [accessed October 12, 2001]. Bureau of Labor Statistics, U.S. Department of Labor and Bureau of the Census, U.S. Department of Commerce. 1998. Current Population Survey, Annual Demographic Supplement.

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Reducing Suicide: A National Imperative Psychosis can create a particularly terrible kind of pain that leads to suicidal behavior. Robert Bayley, who suffered for years from schizophrenia, recounted his struggles with extremely frightening hallucinations: The reality for myself is almost constant pain and torment. The voices and visions, which are so commonly experienced, intrude and so disturb my everyday life. The voices are predominantly destructive, either rambling in alien tongues or screaming orders to carry out violent acts. They also persecute me by way of unwavering commentary and ridicule to deceive, derange, and force me into a world of crippling paranoia. Their commands are abrasive and all-encompassing and have resulted in periods of suicidal behavior and self-mutilation. I have run in front of speeding cars and severed arteries while feeling this compulsion to destroy my own life. As their tenacity gains momentum, there is often no element of choice, which leaves me feeling both tortured and drained. —ROBERT BAYLEY “First person account: Schizophrenia”