Myths About Suicide and the Truth

There are many misconceptions and myths concerning suicide. In this article Dr. Michael Pare addresses some of these. The evidence presented in this article is Level 4, that is evidence based on the opinion of respected authorities in the field familiar with the current literature.

Myth #1
Suicide is not a major problem in Canada.
This is false.

The Truth is: Over the past fifteen years there has been an average of over 3,500 recorded suicide deaths each year. That is about ten people a day - everyday. The actual number of suicides is likely significantly higher (estimated at 2-3 times higher) since it is well known that many "so called" accidental deaths are actually suicides. One of the best web pages concerning suicide is the Canadian Suicide Information and Education Centre.

Myth #2
People who talk about suicide rarely actually commit suicide.
This is false.

The truth is: People who commit suicide often give a clue or warning of their intentions. The majority of people who attempt suicide say or do something to express their intention before they act. Do not overlook even subtle threats or statements like, "I wish I wasn't around" or "Life hardly seems worth it". Always treat even subtle threats seriously. It is estimated that the majority of people who go on to commit suicide have attended their family physician in the 2-3 months preceding their suicide. This fact points to an important opportunity for family physicians to uncover and potentially stop the suicidal process. If clinicians recognize the signs given by those contemplating suicide and are aware of other factors that lead an individual to want to take their own life suicide rates may decrease.

Myth #3
The suicidal person wants to die and there is nothing anyone - including the physician - can do: they will eventually do it.
This is false.

The truth is: Suicidal persons usually feel ambivalent about dying. People usually don't want to die - they want instead to end their horrible emotional suffering. You can help by identifying the potentially suicidal person and talking to them about it.

• Be direct. Talk openly and matter-of-factly about suicide.
• Be willing to listen. Allow expressions of feelings. Accept the feelings.
• Be non-judgmental. Don't debate whether suicide is right or wrong, or their feelings are good or bad.
• Don't lecture on the value of life. They will not believe you anyway - they "know" life is worthless. You can - on the other hand - reassure them that when they are not depressed they will enjoy life again.
• Get involved. Become available. Show interest and support.
• Don't be sworn to secrecy. You may need to involve others. You may have to involuntarily commit the patient.
• Offer hope that alternatives are available - but do not offer glib reassurance.
• Take action. If possible get family and friends involved. Have them remove means, such as guns or stockpiled pills.
• Get help from persons or agencies specializing in crisis intervention and suicide prevention.

Myth #4
A suicide attempt means that the attempter will always have thoughts of suicide.
This is false.

The truth is: Often a suicide attempt is made during a particularly stressful period. If the remainder of that period can be well managed, then the attempter can go on with a healthy and productive life. Everybody has at least theoretically thought about ending their own life (you would have to be very unimaginative not to at least dispassionately consider it). Yet many people (estimated as many as one third of the general population) at some time in their lives has thought seriously about committing suicide. Most decide to live, because they eventually come to realize that the crisis is temporary and death is very permanent. On other hand, some people having a severe crisis sometimes perceive their dilemma as inescapable and feel an utter loss of hope in the future. These are some of the feelings and things they experience:

• "I can't stop the horrible pain."
• "I can't see any way out of this shit."
• "I can't sleep, eat or work."
• "I can't get out of this terrible depression."
• "I can't make this absolute sadness go away."
• "I can't see a future without unbearable pain."
• "I can't see myself as worthwhile. I'm a total failure."

An excellent web page for the depressed suicidal patient is: "If you are thinking about suicide: read this first."

Myth #5
If you ask a person directly, "Do you feel like killing yourself?" this will lead to a suicide attempt.
This is false.

The truth is: Asking a person directly about suicidal intent will often relieve the anxiety surrounding the feeling and act as a deterrent to the suicidal behavior. You don't create self-destructive feelings in another person simply by talking about suicide. Talking about suicidal feelings may lead to a discussion of upsetting or painful thoughts that were already there but hidden beneath the surface. Openly addressing the subject shows a willingness to help and is the first step towards positive intervention. Yet there are a series of questions which approach this sensitive topic more gently than simply asking: "Are you thinking of killing yourself?" Questions concerning suicide:

• Have you ever thought that life wasn't worth the effort?
• Have you ever had thoughts of hurting yourself or anyone else in the past?
• Have you ever thought of ending your life?
• Have you ever attempted to end your life?
• Are you currently thinking about this?
• Are you planning to do it?
• What method would you use if you attempted to kill yourself?
• Could you resist?
• What stops you from killing yourself?
• Have you ever thought of killing someone else?
• Would you call me if you were more suicidal?
• Would you promise to go immediately to the emergency department, if you felt truly suicidal?

Myth #6
Suicide is more common among the rich.
This is false.

The truth is: Suicide affects the rich, the poor and the middle class equally. Nevertheless there are a number of epidemiological factors that act as risk factors. These factors do not predict suicide rather they are part of a suicide assessment because of their demonstrated statistical correlation with suicide.

• Family history of suicide.
• Males > females.
• History of previous attempts.
• Native Canadian.
• Psychiatric diagnosis: mood disorder, schizophrenia, alcoholism, etc.
• Single: especially separated, widowed, or divorced.
• Lack of social supports.
• Concurrent medical illness(es).
• Unemployment.
• Decline in socioeconomic status.
• Psychological turmoil.

Myth #7
There are clear cut methods of predicting suicide risk that all doctors should become aware of.
This is false.

The truth is: Many experts have concluded that after reviewing the literature of prediction and prevention that there is no proven scientific bases for specific prediction. The quality of evidence is at level 4 (evidence based on the opinion of respected authorities or expert committees as indicated in published consensus conferences or guidelines - see especially The Surgeon General Call To Action to Prevent Suicide 1999).

• Psychiatric disorders: Suicidal persons often suffer from psychiatric disorders such as major depressive disorder, schizophrenia, bipolar disorder, personality disorders or alcoholism. Completed suicides are strongly associated with excessive drinking. Depression is the single factor most contributory to suicide. Unfortunately some studies have suggested that primary care physicians miss the diagnosis of depression 50 % of the time. Yet most depressed patients tell their doctors that they are feeling suicidal by statements such as:
  • "I've lost a hold on my life."
  • "I'm trapped with no way to escape."
  • "My suffering is almost indescribable."
  • "I wish I would die - it seems to me the only way out of my intolerable misery."
• Hopelessness is the most serious warning sign that a person is considering suicide.
• Gender and age: Males are more likely to complete suicide. Suicide is also highest in older adults.
• Living circumstances: People who live alone, are unemployed, and have suffered a recent loss are at highest risk.
• There are a number of other risk factors (mentioned elsewhere in this report). Yet it is simplistic to evaluate the risk of suicide based on the risk factors alone while ignoring protective factors. The actually risk is a balance between risk factors and protective factors. Coping factors include personal resilience, family support, meaningful personal pursuits, helpful human contact - including supportive psychotherapy with the primary care physician.

Myth #8
Improvement following a suicidal crisis means that the suicidal risk is over.
This is false.

The truth is: When a suicidal person begins to feel better, he or she will still be confronted with problems and responsibilities. This can be very difficult and can lead to a return of suicidal thoughts. It may take months to feel consistently better and in control.

Myth #9
Anyone who tries to kill himself or herself must be crazy.
This is false.

The truth is: Most people have reasons for their suicidal feelings. Most suicidal people are not psychotic or insane. Most people have thought of suicide from time to time. Most suicides and suicide attempts are made by intelligent, temporarily despairing individuals who are expecting too much of themselves (and/or others), especially in the midst of a crisis. They may be upset, grief-stricken, depressed or despairing, but are not necessarily suffering from mental illness. Yet many are - in fact - suffering from an emotional illness. The following five DSM-IV disorders are correlated with suicide and suicidal behavior: More than 90 percent of completed suicides carry a diagnosis of alcoholism, depression, schizophrenia, or some combination of these three:

1. Mood Disorders (15 percent lifetime risk of suicide): A misleading reduction of anxious or depressed affect can occur in some patients who have resolved their ambivalence by deciding to commit suicide. A patient who has made the decision to die may appear at peace and not show signs of an inner struggle. Concern is warranted especially when the patient appears emotionally removed, shows constricted affect, or is known to have given away belongings. The likelihood of suicide is increased when the patient exhibits: panic attacks; psychic anxiety; anhedonia; alcohol abuse. The possibility of suicide is also increased when the patient exhibits: increased hopelessness; suicidal ideation; or a history of suicide attempts.
    
   • Panic Disorder (7-15 percent lifetime risk of suicide): Suicide rate may be similar to that of mood disorders. Greater likelihood is correlated with more severe illness or comorbidity. Suicide does not necessarily occur during a panic attack. Demoralization or significant loss increase the likelihood of suicide. Agitation may increase the likelihood of translating impulses into action.
      
   • Schizophrenia (10 percent lifetime risk of suicide): Suicide is relatively uncommon during psychotic episodes. The relationship between command hallucinations and actual suicide is not clearly causal. Suicide potential is increased by: good (surprisingly) premorbid functioning; early phase of illness; hopelessness or depression; recognition of deterioration; e.g., during a post-psychotic depressed phase.
      
2. Alcoholism (3 percent lifetime risk of suicide): Abusers of alcohol/drugs comprise 15-25 percent of suicides. Yet alcohol use is associated with nearly 50 percent of all suicides. Increased suicide potential in an alcoholic patient correlates with: active substance abuse; adolescence; second or third decades of illness; comorbid psychiatric illness; recent or anticipated interpersonal loss. Substance abuse can represent self treatment to blunt the anxiety or mood disturbance associated with a masked, comorbid psychiatric disorder.
    
3. Borderline Personality Disorder (7 percent lifetime risk of suicide): Much higher risk associated with comorbidity, especially with mood disorder and substance abuse. Borderline personality disorder is associated with increased risk of: impulsivity; hopelessness/despair; antisocial features (with dishonesty); interpersonal aloofness ("malignant narcissism"); self-mutilating tendencies; psychosis with bizarre suicide attempts.

Myth #10
The problem with suicide is that people thinking of it usually keep their feelings to themselves and there are no clear warning signs.
This is false.

The truth is: Even the most severely depressed person has ambivalent feelings about suicide. Most suicidal people do not want death; they want the pain to stop. The impulse to end it all Ð however overpowering - does not last forever. Be aware of the warning signs: there is no typical suicide victim. It happens to young and old, rich and poor. Fortunately there are some common warning signs which, when acted upon, can save lives. Here are some signs to look for:

• Talks about committing suicide and/or is preoccupied with death and dying.
• Experiences drastic changes in behavior and is uninterested in their personal appearance.
• Withdraws from friends and/or social activities.
• Seems depressed and loses interest in hobbies, work, school, etc.
• Prepares for death by making out a will and final arrangements.
• Gives away prized possessions.
• Has attempted suicide before.
• Takes unnecessary risks.
• Has experienced a loss through death, divorce, or break up.
• Loss of self-esteem.
• Lack of support system to deal with problems.
• Is having trouble with the law.

Being aware of these myths and misconceptions can help prevent a tragedy, so be vigilant.

- Michael Paré

1. American Association of Suicidology
    
2. The Samaritans of the Monadnock Region
    
3. Risk Management Foundation of the Harvard Medical Institutions
    
4. Canadian Association for Suicide Prevention
    
5. Suicide Information and Education Center (SIEC)
    
6. The Surgeons General call to action to prevent suicide 1999
    
7. If you are thinking about suicide: read this first.

You can search for abstracts of the above references by following this link: PubMed

Last updated April, 2000