The Prevalence of Suicide in the United States

The Prevalence of Suicide in the United States

Abstract

This paper examines the prevalence of suicides in the United States. This paper explores some of the theoretical perspectives that provide insights behind the explanation of suicide. Among the theories presented, one such theory, the Interpersonal-Psychological Theory of Suicideattributes suicideto be an interaction among collective factors. The paper then highlights key data findings, particularly those of gender, age, state, methods used, and race. With 47,173 deaths in the United States from suicide alone, suicide is therefore a serious and far-reaching obstacle. There are many factors that are responsible for the extensiverates of suicide. Specifically, some of the highest contributors to suicide are mental disorders, particularly depression, as well as stressful life events and even prior suicide attempts.This paper also investigates the implications induced by suicide, notably finding that loved ones of those who die by suicide are themselves vulnerable toa greater risk of suicide. With all the adversities and hardships produced by suicide, there are suggestions on how to minimize the rates of suicide and how to provide help for those who are contemplating suicide, specificallypromotingcognitive therapy’s pivotal role in reducing the reattempt rate of suicides.

Introduction

There are a number of challenging public health issues facing the United States in the second turn of the twenty first century. For example, heartdisease is currently the number oneleading cause of death in the United States, accounting for 647,457 deaths in 2017 (Heron 2019:9). Mensah et al. (2007) explain how heart diseases effectnot only all ages ranging from infancy to adulthood, but also impactsall races and sexes as well (p. 38).Although it can affect everyone, this epidemic is so frequently seen in adults that it accounts for aboutone in three U.S. adults havingat least one, if not more, types of cardiovascular disease(Mensah&Brown 2007:39). This is especially prominent for both men and women ages 55-64 since cardiovascular diseases occurs 52% in men and 56.5% in women in this age group (Mensah& Brown 2007:39). The consequences of cardiovascular diseases are highly costly not only to one’s life, but also to one’s financial situations as it is the most expensive disease in the United States (Mensah& Brown 2007:41). Cardiovascular disease alsoresults in more frequent hospital stays as well as more admission to nursing homes (Mensah&Brown 2007:41). Along with this health crisis, strokes are another troubling public health dilemma in the United States that accounts for many deaths. It is the fifth leading cause of death in the United States, resulting in 146,383 deathsin 2017 (Heron 2019:9). As Mensah and Brown (2007) mentions, “heart disease and stroke were responsible for more deaths in 2003 than all of the remaining causes among the fifteen leading causes of death combined” (p.40).The consequences of stroke are detrimental to one’s functionality as reported that, “in 2008…stroke was a leading cause of long-term severe disability” (“Prevalence of Stroke,” 2012:379). Further, strokes had major implications for costs with estimates that $18.8 billion was spent on care for survivors (Prevalence of Stroke – United States, 2006-2010 2012:379). A final source of death in the United States is diabetes. Diabetes is the seventh leading cause of death in the United states contributing to 83,564 deaths in 2017(Heron 2019:9). According to Caspersen (2012) diabetes affects 10.9 million U.S. adults who are 65 years old or older and 79 million people are on the verge of diabetes and have prediabetes(p.1482). The consequences for diabetes include a risk for developing cardiovascular diseases which, as previously mentioned, is the number one cause of death (Caspersen 2012: 1483). Caspersen (2012) reports that,“40.1% of US diabetic patients aged 65 to 74 years had CVD, 26.8% had coronary heart disease, and 9.1% had suffered a stroke,” (p.1483). As seen, therefore, all three of these issues, heart diseases, strokes, and diabetes are interconnected and overall very prevalent causes of death, but there is one more challenging public health issue facing the United States in the second decade of the twenty first century: Suicide. Suicide is currently the 10^th leading cause of death in the United States, accounting for 47,173 deaths in 2017 (Heron 2019:9). Suicide is a necessary topic to address because it is a troubling dilemma that is excessively growing in the United Stateswith a 33% increase from 1999 to 2017 (Hedegaard, Curtin, & Warner, 2018:1)Although suicide is very prominent, it is a problem that consistently is stigmatized, with inadequate dialogue, and is even shielded from public discussion. These rising numbers covey the essential urgency for this problem to be addressed and furthermore, answered to bring about a change and to decrease these rates.

This paper examines the prevalence of suicides in the United States. The paper begins by presenting theoretical perspectives on this topic. Next, the paper presents data and characteristics of suicide in the United States. Then the paper proposesfactors that have been associated withsuicide. Afterward, the paper discusses the major implications instigated by suicides in the United States. Finally, the paper presents some suggestions for managing and reducing overall suicide rates.

Theoretical Perspectives

Researchers have presented numerous theoretical perspectives to help account and explain suicide. One perspective, the Interpersonal-Psychological Theory of Suicide helps in describing the factors that may contribute to one’s suicide.The interpersonal-psychological theory of suicide maintains one is more likely to commit a suicide when they have a perceived burdensomeness, thwarted belongingness, and an acquired capability to execute suicide (Van Orden et al.,2010:575).Van Orden et al., (2010)established that, “the foundation of the interpersonal theory…is the assumption that people die by suicide becausethey can and because they want to” (p.581).Perceived burdensomeness and thwarted belongingness are what gives rise tosuicidal desires (Van Orden et al., 2010:581). Perceived burdensomeness is the belief that one is a burden on those who they affiliate with (p.583). According to Van Orden et al., (2010), this perception has been especially linked to the feeling of being a burden to one’s own family members (p.583). This feeling as though they are a trouble or worry to their familyhas been further linked to fatal suicidal behaviors (Van Orden et al., p.583). As stated by Van Orden et al., (2010), this concept of perceived burdensomeness, “comprises two dimensions of interpersonal functioning – beliefs that the self is so flawed as to be a liability on others and affectively laden cognitions of self-hatred” (p.583). This shows how perceived burdensomeness represents how one’s own thinking of the self is generalized and distorted to believe that others think of them in the same negative way they think of themselves. Along with perceived burdensomeness, the concept of thwarted belongingness, which is the feeling of being socially alienated from others, further initiates one’s suicidal desires (Van Orden et al., 2010:581). According to Van Orden et al., (2010), “social isolation is one of the strongest and most reliable predictors of suicidal ideation, attempts, and lethal suicidal behavior across the lifespan” (p.581). This theory dicatesthat those who feel isolated, without a sense of belonging, or feeling as though they arenot an integral part of their social networksacquire a desire for death (Van Orden et al., 2010:581). On top of these ways that a desire for death is developed, this theory also proposes that one must acquire the capability in order to commit the deadly act ofsuicide (Van Orden et al., 2010:585). In this theory, the desire for suicide is not enough for one to actually commit the act (Van Orden et al., 2010:585). This capabilityfor suicide becomes developed by both fears associated with death becoming reduced as well as a heightened pain tolerance due to repeated experiences of pain (Van Orden et al., 2010:585). This is one theory that explain the course of suicide through the development of one’s desires for suicide as well as an acquired capability to commit suicide. It promotes the idea of how suicide is multifaceted, with numerous components accountable for one’s suicide.

Durkheim’s theory of suicide is a sociological approach that explains suicide in terms of one’s belongingness to various social groups. He proposes four distinct types of suicides, which are,egoism, anomie, altruistic, and fatalism (Travis 1990:225). These types can further be split into two groups, with egoistic and altruistic falling under the category of social integration and anomic and fatalistic in the category of social regulation (Gunn 2014:213-214). Within the social integration category, it is all about one’s connectedness to their social groups as well as having strong and reliable social ties which grounds the individual (Travis 1990:226). When one feels so strongly apart of their social group, this manifests the type of altruistic suicide because this high notion of affiliation is what drives suicidal behavior (Gunn 2014:214). People commit suicide as a sacrifice for the overall well-being of their social groups, such as suicides seen in the military because they are so ingrained in the fabric of their social structure that they are willing to die for it (Gunn 2014:214). On the flip side, when one has minimal affiliations to social networks, this underpins egoistic suicide (Gunn 2014:213). People who commit egoistic suicides are not integrated in society and adhere to their own standards and norms than the ones created by their society (Travis 1990:226). Excessive individualism is what motivates people who commit egoistic suicides, therefore making people who are isolated or alienated more likely to commit suicide (Travis 1990:226). The social regulation realm is about how, “society has control over the emotions and motivations of the individual members” (Gunn 2014:214).  Anomic suicides are carried through by people with little social regulation, therefore social structures are failing to give them the support and meaning to their life (Gunn 2014:214).  Fatalistic suicide is when one has such high social regulation that they feel overwhelming control by their society and therefore suicide is the ultimate escape from that restriction (Gunn 2014:214). Durkheim’s theory of suicide reflects the notion of how rigid, extreme ends of the spectrum of involvement in one’s society leads to suicidal behaviors. Gunn (2014) describes how, “societies with a moderate degree of social integration have the lowest incidence of suicide” (p.213). This shows how the extreme nature of either belonging excessively to social institutions or insufficiently is what propels and fosters the development of suicidal behavior.

Data and Characteristics of Suicides in the United States

Suicide is a prevalent and widespread problem that currently is affecting millions of people of various ages and backgrounds in the United States. In 2017, “there was more than twice as many suicides (47,173) in the United States as there were homicides (19,510)” (“Suicide” 2019).  There are about 129 suicides each day in the United States (“Suicide Statistics” 2019). 10.6 million U.S. adults 18 or older had suicidal thoughts in 2017 and approximately1.4 million U.S. adults attempted suicide (Bose et al., 2018:43-44). Althoughin 2017 females attempted suicide 1.4 times more than males, males were 3.54 times more likely to die from suicide than women (“Suicide Statistics” 2019). Currently, suicide is the second leading cause of death among people aged 10 to 34 (“Suicide” 2019). As seen, suicide is a significant issue hovering over many individuals throughout the United States.

Figure 1 presents the trends of the rate of suicide for the total population of the United States as well as rates specifically for females and males over a 16-year period from 2001 to 2017.Overall, suicide rates for males have steadily increased from 2006to 2017. In every year, the rate of male suicides hasbeen the highest compared to the rates of the total population and to the rates of females. The year 2017 had the highest rates of suicide for the total population, with a rate of 14.0 per 100,000. Both male and female rates of suicide were its highest in 2017, with a rate of 22.4 per 100,000 and a rate of 6.1 per 100,000 respectively. In 2017, the rate of male suicides was over three times higher than the rate of female suicides. The female rate of suicides has always remained significantly lower compared to the rate of the total population. (“Suicide” 2019).

Figure 1. Trends of Male and Female Suicides Over Time per 100,000

(Source: Extracted from “Suicide,”2019. National Institute of Mental Health)

Figure 2 presents the gender and age differences among suicide in 2017. For males, ages 75 and over had the highest rate of suicide, with a rate of 39.7 per 100,000. Males who are between the ages of 45 and 64 had the second highest rate of suicide, with a rate of 30.1 per 100,000. Overall, men account for the highest amount of deaths by suicide in every single age group category. As the ages advance, the difference between male and female suicide rates continues to widen and disperse further. Female’s rates of suicide were its highest in the age group 45-64, with a rate of 9.7 per 100,000.The pattern of male suicide rates increased with each age category, except forages 65-74 where the rate dropped by 3.9 compared to the 45-64 age group rate. Female’s rate of suicide increased from ages 10 to 64 butdecreased starting at age 65. Both male and female rates of suicide were at its lowest in the 10-14 age category with a rate of 1.7 per 100,000 for female suicides and 3.3 per 100,000 for male suicides (p.2-3).

Figure 2: Suicide Rates by Gender and Age 2017

(Source: Compiled from Hedegaard, Curtin, and Warner 2018:2-3)

Figure 3 represents the rates of suicide in each state from 2017. As seen, the highest rates of suicide are seen most inthe Western region and part of the Midwestregion of the United States, with the exceptionsof Maine, with a rate of 20.5 per 100,000 and West Virginia with a rate of 21.6 per 100,000. The state with the highest rate of suicide is Montana with a rate of 29.6 per 100,000. Wyoming and Alaska have the second and third highest rates of suicide with rates of 27.1 per 100,000 and 27.0 per 100,000 respectively. The state with the lowest rate of suicide is New York with a rate of 8.5 per 100,000.New Jersey has the second lowest rate of suicide at 8.8 per 100,000 and Massachusetts has the third lowest rate of suicide with a rate of 9.9 per 100,000. The eastern region of the United States accounts for most of the lower rates of suicide. California, being a state in the western region, is an outlier with its suicide rate being relatively low for the west with a rate of 10.9 per 100,000 (p.53).

Figure 3: Rates of Suicide per 100,000 by State in 2017

(Source: Compiled fromKochanek et al., 2019:53)

Table 1 presents the methods used in suicide deaths broken down by gender in 2017. For females, the most common method used in suicide was poisoning, which was used 31.4% of the time. For males the most common method used in suicide was firearm, with them used in 31.2% of suicides. For suffocation, females and males used this method roughly about the same, with females using it 27.9% and males using it 27.7% of the time. 9% of males used the method of poisoning, making that the least used method for suicides among males. Females used firearms 31.2% of the time, which is 24.8% lower usage compared to males. The use of firearms though is the second most common method of suicide for females (“Suicide” 2019).

Table 1.Percentage of Suicide Deaths by Methods in the United States (2017)

(Source: Extracted from “Suicide,” 2019. National Institute of Mental Health)

Table 2 presents the number and rate of deaths by suicide broken down by race, ethnicity, age, and sex. Non-Hispanic American Indian or Alaska Native had the highest rate of suicides out of all the races, with a rate of 11.0 per 100,000 for females and a rate of 33.8 per 100,000 for males. Non-Hispanic whites had the second highest overall rate for females and males, with a female rate of 7.9 per 100,000 and a male rate of 28.2 per 100,000. The Non-Hispanic American Indian or Alaska Native category had its highest rates of suicide among males aged 25-44, whereas the Non-Hispanic white category had its highest rates of suicide among males aged 75 and over. Hispanics had the lowest rate of suicide for both females and males, with the female rate of 2.6 per 100,000 and the male rate of 11.2 per 100,000. In every single one of the race categories, the female rate of suicide was significantly lower compared to the male rate of suicide (p.5-6).

Table 2: Number of deaths and rates of death by sex, race, ethnicity, and age

Female Male

(Source: Compiled from Curtin & Hedegaard 2019:5-6)

Factors Responsible for Suicides in the United States

            A troubling factor that increasesthe risk of suicide in the United States isalcohol usage both in chronic usage as well as at the immediate time of one’s death. Kaplan et al. (2013) mentions that, “individuals with alcohol dependence who come to clinical attention are at approximately ninefold higher risk to die by suicide compared with the general population” (p.38).40% of those who are in treatment for alcohol-related disorders report at least one previous attempt of suicide(Pompili 2010:1397). Alcohol can be a motivator at the precise time of one’s suicide as well with reports that 37% of those who died by suicide used alcohol right before their death and that 40% of those who attempted suicide used alcohol right before their attempt (Kaplan 2013:38). In the report by Jack et al., (2018) they found that 66.3% of people who committed suicide had a blood alcohol concentration greater than 0.08 g/dL (p.7).Alcohol’s immediate ramifications can help account for the reasons why many suicides, in particularly impulsive suicide attempts, are made (Pompili 2010:1404). Alcoholcan cause one to lose their inhibitions, along with their fears associated with death and hurting oneself (Pompili 2010:1404).At the same time, alcohol alsopromotes aggressive behaviors (Pompili 2010: 1405).The major force that can be behind losing one’s inhibitions and the exaggerated aggressive behavior can be the result of alcohol’s ability to change one’s own internal thoughts. This major consequence of alcohol can heighten one’s depressive and hopelessness thoughts, which can lead to the drive to pursue and push suicidal behaviors (Pompili 2010: 1404).A hopelessness thought is where one feels as though their current circumstances will never change or get better, therefore, with alcohol pressing these kinds of feelings and providing the activity level to promote suicide, it can lead to a deadly consequence. In one study of acute intoxication by Kaplan et al.,(2013),it found that men were more likely to have alcohol in their systems, with24% of men and 17% of women intoxicated when they died by suicide (p.40). Alcohol could therefore be a determining factor for the gender difference of completed suicides since men were found to use alcohol more readily at the time of their death (Kaplan et al., 2013:40).This could be likely due therefore to the pervading and instant repercussions that alcohol has in regard to one’s own thoughts and actions.Moreover, the study also found that American Indians and Alaska Natives were most likely to be intoxicated out of any other racial group at the time of their death(Kaplan et al., 2013:40). As previously mentioned, American Indians are the highest racial group category to die by suicide in the United States (Curtin & Hedegaard 2019:5-6), therefore alcohol usage can account for why their rates are the most prevalent and high. Overall, both long-term uses of alcohol as well as the immediate usage of alcohol at the time of one’s death can both prompt and contribute to suicidal tendencies and behaviors.

Mental disorders are a problematic and frequent factor responsible for many suicides. According to studies, 90% of those who commit suicide have a diagnosable mental disorder (Nock et al., 2010:868).About 60% of people who commit suicide have a diagnosis of major depressive disorder (Wang 2015:203).Nock et al., (2010) found that as suicide intent increases, the more likely one is to have a mental disorder, with 66% of those who have thoughts of killing themselves having a DSM-IV disorder, 77.5% who create a suicide plan having a disorder, and 79.6% who attempt suicide having a mental disorder (p.870). They also found that those who make a planfor their suicide attempt are more likely to have a mental disorder than those who spontaneously attempt suicide without a plan (Nock et al., 2010:870). Jack et al., (2018) found in their report that 50.1% of those who died by suicide had a current diagnosis of a mental disorder and 27.4% were in treatment at the time of their suicide (p.7). Specifically, they found that 45.1% of males were diagnosed with a mental health disorder and 23.2% were getting treatment at the time of their suicide (p.8). Comparatively, they found that females had higher percentages of both being diagnosed with a mental health disorder (66.2%) and being in treatment (41.1%) (Jack et al., 2018:8).This gender difference among being diagnosed with a mental disorder and being in treatment also explainsthe major gender difference in suicide. Since men are less likely to receive a diagnosis for a disorder and therefore not get the treatment for it, it increases their risk for committing suicide.In the report byJack et al., (2018), they also found that the highest mental disorders associated with suicide were,“depression/dysthymia (75.3%), anxiety disorder (16.8%), and bipolar disorder (15.2%)” (p.7). Overall, mental disorders are a major contributor to difficulties faced by those who commit suicide.

Stressful life events are another additional component to the risk of committing suicide.There are various forms of stressful life events that cause one to commit suicide. Jack et al., (2018) found that 29.4% of those who committed suicide had some sort of crisis within the two weeks of their suicide (p.7). Wang et al., (2012) describes how stressful life events are linked with suicidal behavior in those who are younger and often simultaneously occurs with mental disorders (p.102). Wang et al., (2015) found that two major life stressors, financial troubles and interpersonal problems with family members are specifically linked with future suicide attempts in individuals with major depressive disorder (p. 212). Although stressful life events may coincide with mental disorders, stressful life events werefound though to increase the risk of suicide attempts independently of mental disorders, which shows that these events on their own can contribute as a trigger to suicide (Wang et al., 2015:212). Wang’s et al., (2012) study on the relationship between stressful life events and suicide attempts found that there are some stressful life situations that are more closely tied to suicide than others (p.106). Wang et al., (2012) found that specifically assaultive violence, such as sexual assault, domestic abuse, and being muggedand financial stresses such as being unemployed, laid off, or bankrupt were the highest kind of stressors associated with suicide attempts (p.105-106). Wang et al., (2012) calculated the PAF value for the stressful life events which, “represents the percentage of suicide attempts in the population in the past year that may be attributed to the occurrence of the SLE” (p.104). The PAF value for financial stress was 20.9% and the PAF value for assaultive violence was 2.6% (Wang et al., 2012:106). Wang et al., (2012) compared these PAF values to Bolton and Robinson’s PAF values for mental disorders on suicide attempts and found that the PAF value for financial stress was higher than any of the PAF values for mental disorder on suicide attempts, except for major depressive disorder (p. 106). They also found that assaultive violence had higher PAF values than many mental disorders such as anxiety disorders, psychotic disorders, and personality disorders (p. 106-107). This shows howsome stressful life events have such a significant, pressing, and great effect on suicide that can be even more of a concern than mental disorders. Wang et al., (2012) also found that other stressful life events such as shocking or traumatic effects, such as a death in the family or life-threatening accidents are also prominently relatedto one attempting suicide (p.105). Other events such as property lost and damage, legal problems, and learned traumas, such as relatives being mugged or assaulted, are also closely linked to suicide attempts (Wang et al., 2012:105). Not only are stressful life events themselves closely associated with suicide attempts, but also the amount of how many of these events one encountersis interconnected with suicide attempts. Wang et al., (2012) found that exposure to multiple stressful life events, especially three of more, is sharply correlated to suicide attempts (p. 107). Stressful life events can trigger suicidal behaviors and further the number of these kinds of events in one’s life can also have damaging effects.

Having a physical illness can pose aserious risk for one to commit suicide.In a report by Jack et al., (2018) they found that 22.4% of males and 21.9% of females had a physical health problem at the time that they committed suicide (p.23). People suffering from chronic physical illnesses such as asthma and terminal illnesses have been associated with suicidal behavior (Goodwin et al., 2003:1784). In Goodwin’s et al., study of physical illness and suicidal behaviorin the adult population (2003), each physical illness that was reported by the participants were linked to an increase in the chance that one will attempt suicide (p.1785). They found that some physical illnesses had a greater likelihoodthat one will attempt suicide than others, particularly,“AIDs was associated with over a 100-fold increase…hernia with over a ten-fold increase, and ulcer with over a three-fold increase” (Goodwin et al., 2003:1785). Other physical illnesses such as “stomach problems, autoimmune disease, kidney problems, heart attack, hypertension, arthritis, and lung disease were associated with over a two-fold increase in the odds of suicide attempt” (Goodwin et al., 2003:1785). Goodwin et al., (2003) found that after controlling for mental disorders, AIDs, ulcer, and lung disease still maintained as strong predictors for suicide attempts (p.1785).Physical illnesses can therefore have an amplified effect among the adult population in committing suicide.

Another major contributor to suicide would be the ownership of firearms in one’s household as well as higher prevalence of firearms in one’s state. As seenpreviously from Table 1, firearms account for the highest methods used for suicide among men with it being used 56.0% of the time (“Suicide” 2019). Females also had high percentages of using firearms as a method of suicide, with it being used 31.2% of the time (“Suicide” 2019). Siegel and Rothman (2016) reported that, “the number of annual firearm suicides is almost twice as high as the number of firearm homicides” (p.1316). There has been a strong association between increased suicide rates andfirearm ownership in one’s home not only the for thefirearm owner themselves but even for other household members (Siegel & Rothman 2016:1316). This establishment means that any person living with a firearm present in their house can be at an increased risk of committing suicide(Siegel& Rothman 2016:1316).Miller et al., (2013) found in their study that, “higher rates of firearm ownership are strongly associated with higher rates of overall suicide and firearm suicide” (p. 948).Their finding means that owning a firearm not only has a strong link to an increase in the frequency of firearms used as a method in suicide, but also is correlated to an increase in the total number of suicides more generally (Miller et al., 2013:951).In a study by Siegel and Rothman (2016) they found that over a 33-year period, the percentage of firearm ownership was greatest among the states Wyoming (72.8%), Montana (68.4%), Idaho (61.6%), and Alaska (56.0%) (p.1319). As previously seen in Figure 3, these four states have some of the highest rates of suicide in the country (Kochanek et al., 2019:53). Siegel and Rothman found that among these states that had the highest gun ownership percentages, they also had consistently high rates of both male and female firearm suicide rates (p.1319). In the study done by Siegel and Rothman (2016) they found that consistently across all 50 states, regardless of the percentage of firearm ownership, females used firearms less than males (p.1318-1319). There was still a “strong relationship between higher levels of firearm ownership in a state and higher firearm suicide rates for both genders” (Siegel& Rothman 2016:1320).This means that although females used firearms at a lower rate comparatively to males, higher firearm ownership in a state was still seen to have an association to thehigher prevalence of female’s rate of firearms used in suicides (Siegel & Rothman 2016:1320). For example, in Wyoming, the rate of male use of firearms in suicide was 26.1, whereas female rates using firearms in suicide were 3.9 (Siegel and Rothman 2016:1319). Similarly, Montana, which is the state with the highest rates of suicide and second highest rates of firearm ownership, had a male rate of 23.5 for the use of firearms in suicide and a female rate of 3.2 for using firearms in suicide (Siegel &Rothman 2016:1319). Furthermore, Siegeland Rothman (2016) found that there is a significant relationship between states that have a high firearm ownership and the overall rates of male suicides, but the same relationship was not found for overall female rates of suicide(p.1320).Therefore, ownership of firearms may help to account for the gender difference in suicide more generally and also explain the differences among methods used in suicide specifically.The presence of firearmsalone can readily affect and increase the risk that one will commit suicide. Ownership of firearms at a state-level as well as in individual’s households is a principal factor in suicide.

One of the top factors that increases the risk of suicide is a prior suicide attempt. Suicide attempts are not only associated with further attempts, but they are also strongly associated with a completed suicide (DeJong et al., 2010:2). DeJong et al., (2010) reported that about one third of people who committed suicide had attempted suicide other times before (p.2). In a study done by Bostwick et al., (2016) they found that out of 81 people who died by suicide, there were 33 people who survived their initial attempt, but later died by suicide (p.1096). Further, out of these 33 people, 80.0% of males and 87.5% of females committed suicide within a year of their initial attempt (Bostwick et al., 2016:1097). They also found that the likelihood of one dying from a subsequent suicide after a prior suicide attempt increased with age and that specifically males had a higher likelihood of committing suicide after a prior attempt (Bostwick et al., 2016:1097). Bostwick et al., (2016) found that 11.9% of males ages 45 to 64 who survived their suicide attempt later died by suicide and that 23.5% of males aged 65 and older later died by suicide after their initial attempt(p.1096.). Bostwick et al., (2016) found the opposite to be true for females aged 65 and older with none of them dying by a later suicide after their prior attempt(p.1096).Therefore, with the linkage between prior suicide attempts and suicide completions being so persistent among older people as well as males, it may help explain the exacerbated and magnified age and gender differences.

Implications of this Phenomenon

Suicide not only has implications on the person who committed it, but also greatly effects the stability, mental health, and lives ofloved ones and friends.People who lose their loved one by suicide face major obstacles that uniquely differ from those caused by other sources of death (Young et al., 2012:179). In the United States, roughly about 85% of people will know someone that committed suicide (Young et al.,2012:178). It has been found that, “for each suicide completed, at least 6 loved ones are directly affected by the death” (Young et al., 2012:178). Usually, people who are the closest to the person who committed suicide are the ones that are affected the worst (Young et al., 2012:178).The implications on those who are closely tied to the person who committed suicide consists of emotions that are consistently found with people who lose their loved ones by other causes of death such as grief, sadness, and shock (Young et al., 2012:179). On top of these emotions though, the loved ones of those who commit suicide also can develop unique emotions to their loved one’s death such as, “overwhelming guilt, confusion, rejection,shame, and anger” (Young et al., 2012:179). As a result, with these differences in emotions, it may prolong their recovery and healing (Young et al, 2012:179). Part of the delay to their healing can also be from the stigma associated with suicide, which makes those who lose loved ones by suicide less likely or hesitant to talk about it as well as express their emotions appropriately (Young et al., 2012:180-181). This ultimately results in leaving them feeling isolated, both in regards by other people and even from the person who has committed suicide as well since many feel abandoned by them (Young et al., 2012:180-181).People who experience suicide by a loved one are prone to develop PTSD symptoms due to those who either discover the dead body or even some who present during the suicide (Young et al., 2012:181).People who lose their loved ones are also prone to depression with one study finding that, “bereaved participants reported twice the rate of recurrent and current depression compared with other bereaved individuals” (Young et al., 2012:182). Therefore, people who lose a loved oneby suicide face the consequences ofexperiencing a complex set of effects and enduring unprecedented hardships that greatly differ from the experiences and emotions caused by other forms of death.

People who lose a loved one by suicide also face anotherimmense consequence of becoming at risk for suicide themselves. The suicide bereaved themselves are put at a greater risk for suicidal thoughts and behaviors (Young et al., 2012:181). Young et al., (2012) mentions a finding from Crosby and Sacks who discovered that,

People who had known someone who died by suicide in the last year were 1.6 times more likely to have suicidal thoughts, 2.9 times more likely to have a plan for suicide, and 3.7 times more likely to have made a suicide attempt themselves (p.181).

These findings are astonishing because it shows the rippling effects of how consequences of one’s suicide can so greatly affect others to commit suicide.This attempt of suicide could be due from the overwhelming emotions they are experiencing or even viewing the suicide of their loved one as a model of escape from suffering (Young et al., 2012:181).American Indians, accounting for the highest rate of suicides among all ethnic groups in the United States (Curtin & Hedegaard 2019:5-6), are particularly prone to this effect of attempting suicide after someone they know has. In a study done by Grossman et al., (1991) they found that among American Indian adolescents 18% had someone in their family either attempt suicide or commit suicide, 18% had a friend who had a suicide attempt, and 9% had a friend that committed suicide (p.872). Grossman et al., (1991) also found that 15% of these adolescents themselves had previously attempted suicideand 58% had tried to do so multiple times (p.872). Further, they were able to find that both a friend’s suicide attempt and a suicide attempt or committed suicide from a relative was correlated with an adolescent’s suicide attempt but found a stronger correlation among a friend’s suicide attempt than a relative’s (Grossman et al., 1991:872). The fact that suicide has these kinds of effects is significant in that it shows how suicide effects more than just merely the individual and stems farther to impact those in one’s surroundings.

Suicide, both directly and indirectly has a costly burden inthe United States. In the study done by Shepard et al., (2016), they analyzed the cost of both fatal injuries, like suicide, as well as nonfatal injuries, such as suicide attempt (p. 353). Within both categories of injuries, they looked at the direct economic costs, such the medical costs related to the injuries, as well as indirect economic costs, such as how suicide impacts productivity losses or lost time (Shepard et al., 2016:353).In order to derive these costs, they adjusted for underreporting suicide deaths to get to the closest and most accurate cost possible (Shepard et al., 2016:354). Shepard et al. (2016), reported that, “fatal and nonfatal suicide-related injuries in 2013 was about $58.4 billion” (p.355). Male suicides and suicide attempts accounted for 82.2% of this cost, with $48.1 billion from them alone (Shepard et al., 2016:355). Women’s contribution to this cost although very significant, was much lower than the male cost, accounting for 17.8% of the overall cost, with 10.4 billion dollars from them.Indirect costs accounted for a majority ofthe total cost($56.8 billion), overall making up 97.1% of that cost (Shepard et al., 2016:355). When the adjustment for underreporting was applied, Shepard et al., (2016) found a 59.8% increase in the total cost for both fatal and nonfatal injuries, with the estimation of suicide cost to be $$93.5 billion (p.356).  This study is significant to the overall implications of suicide based on two important dimensions. First, it shows the significant financial burden that suicide entails. Secondly, it proves how the consequence of underreporting suicide in general undermines the true cost of suicide. Even though suicide places a hefty cost already, it is still not an accurate reflection of what the real cost is most likely to be. Consequently, suicide incurs pricey and lingering difficulties to financial troubles in the United States.

Suggestions

            A form of prevention to help reduce suicidal thoughts and behaviors in people can be psychotherapy, especially cognitive therapy. As mentioned previously, “attempted suicide is one of the strongest risk factors for completed suicide” (Brown et al., 2005:563). The study by Brown et al., (2005) had people who had attempted suicide either randomly assignedinto cognitive therapy for ten sessions, or usual care following the attempt (p.564). In cognitive therapy the main focus was on, “identification of proximal thoughts, images and core beliefs that were activated prior to the suicide attempt” (Brown et al., 2005:564). After these kinds of thoughts were examined, the participants were given cognitive strategies that helped them to challenge these thoughts and help them to cope and recognize stressors such as hopelessness, impulsiveness, and social isolation that trigger their suicidal behaviors (Brown et al., 2005:564).The results from the Brown et al., (2005) study found that about 41.6% of participants in the usual care group attempted suicide at least once more, whereas about 24.1% of participants in the cognitive therapy group had at least one later suicide attempt (p.567). They also found that those in cognitive therapy group were 50% less likely to have another suicide attempt than those in the usual care group (Brown et al., 2005:567). Not only was cognitive therapy found to reduce the likelihood of later suicide attempts, but it also changed people’s perceptions and beliefs with those in the cognitive therapy group having significantly lower depressive and hopelessness thoughts at 6 months compared to those in the usual care group (Brown et al., 2005:568). This shows how cognitive therapy can be an important tool utilized for suicide interventions that has the capacity for change in suicide rates.

With physical illness and mental disorders constituting a large portion of suicides, primary care interventions can be a form of help in reducing suicides. Since physical illnesses are so prominent in those who commit suicide, it has been found that “about half of people who die by suicide visit their PCP [primary care provider] within one month of doing so and about 20% visit their PCP within just one week of taking their life” (Dueweke& Bridges 2018:290). Dueweke and Bridges (2018) review of interventions geared toward primary care settingsregarding suicide risk found that “educating practitioners, screening for suicide risk and/or mood disturbance, managing depression symptoms, and assessing and managing suicide risk” were all were major elements of these interventions (p.290-291). First, educating practitioners entailed, “instruction in assessment, clinical management, and documentation of suicide risk” as well as training methods such as utilizing handouts, discussions, and even role playing (Dueweke& Bridges 2018:291). Moreover, Dueweke and Bridges (2018) found for instance that one form of practitioner education they analyzed from the SPRC Toolkit enabled, “an improved sense of preparedness, knowledge of risk factors and warning signs for suicide, and perceived competence regarding assessment and management of at-risk patients” (p.296). Although these improvements raised primary care providers awareness and expanded their knowledge, they found that educating practitioners alone as an intervention did not reduce overall suicide rates (Dueweke& Bridges 2018:296).In regard toscreening for suicide risk and depression, which is the second factor they found, they discovered that the overall effectiveness of implementing thiscomponent to primary care settings was only beneficial when referral for treatment was available and issued as well (Dueweke& Bridges 2018:296). This is significant because since most people are seeing a primary care providerbefore their suicides instead of a mental health specialist, the addition of screening would play a pivotal role in the identification of risk and furthermore, with that information from the screening, primary care providers canrecommendtheir patients to mental health specialists for further treatments (Dueweke& Bridges 2018:296). The third aspect, managing depressive symptoms, was found to on its own be effective at reducing suicide (Dueweke& Bridges 2018:296). Overall, since depression is the disorder with the highest correlation to suicide, they reported a study done by Bruce and colleagues that found that antidepressant medications or psychotherapy for depression reduced rates of suicidal ideation at a faster rate (Dueweke& Bridges 2018:296). In that study, they found that over the 4 month period of treatment, those in these forms of intervention for depression had a reduced rate of suicide ideation by 12.9%, whereas in the usual care group rates only dropped by 3.0% (Dueweke& Bridges 2018:296-297). Dueweke and Bridges (2018) also reported that collaborative management of depression where mental health specialists worked jointly with primary care providers was successful for lowering rates of suicidal ideation (p.297). In the final factor of assessing and managing suicide risk, Dueweke and Bridges (2018) found that particularly single-session crisis response planning intervention has been found to be effective in lowering suicide rates, with one study finding a 76% decrease in suicide attempts (p.298). This plan helps one to utilize their resources such as having people list who they can contact for help such as family members (Dueweke& Bridges 2018:298). It also helps them to recognize thoughts, or behaviors that may be prompting their suicidal afflictions as well providing insights to developing better coping mechanisms (Dueweke& Bridges 2018:298). Dueweke and Bridges (2018) feels that this form of intervention can be applicable and beneficial to primary care settings (p.298). Thus, implementing these various additions to the primary care setting can be crucial for spotting, treating, and lowering suicides.

Conclusion

In conclusion, this paper examined the prevalence of suicide in the United States. This paper begun by discussing public health issues that results in deaths such as heart disease, stroke, and diabetes.Despite these sources of death, more importantly, suicide is an imperative topic that needs to be addressed since it isan escalating and prevailing cause of death in the United States. In order to better understand suicide, this paper dove into theoretical perspectives that explained suicide. One such perspective, Durkheim’s theory of suicidedescribed suicide in terms of one’s relationship to their various social ties.Next, the paper described key data regarding suicide in terms of many variables such as gender, age, state, method, and race. Generally,it was found that males had the overall highest rate of suicide in terms of gender and American Indian and Alaskan Natives had the highest suicide rates among all the races. After, the paper explored factors that contributed to these various suicide rates. Specifically, having a physical illness, alcohol, and firearm ownership played critical roles in countless suicides. The implications of suicide were then analyzed, finding that theloved ones of those who died by suicide experience extra challenges to grieving death such as developing mental disorders as well as facing unique emotions. Another major implication, the financial burden of suicide in the United States, was examined and found to pay a hefty price. Finally, the paper suggests recommendations in order to reduce and prevent suicide. Establishing interventions in primary care settings is seen as an effective way to help avoid and further lessen the overall rates of suicides. Suicide is a powerful and pervasivechallenge currently in the United States that needs to be eliminated.