Clinical Neuroscience Research 1 (2001) 310–323
www.elsevier.com/locate/clires
Epidemiology of completed and attempted suicide:
toward a framework for prevention
Eve K. Mościcki*
National Institute of Mental Health, Room 8209, MSC 9663, 6001 Executive Boulevard, Bethesda, MD 20892-9663, USA
Received 5 June 2001; received in revised form 16 August 2001; accepted 27 August 2001
Abstract
Suicide is an important public health problem. It is a complex, long-term outcome of mental illness, with multiple, interacting antecedents.
This paper reviews descriptive and analytic epidemiologic studies of completed and attempted suicide, discusses the primary sources of
epidemiologic data, and describes the major risk factors for completed and attempted suicide. Risk factors are described within a framework
that distinguishes between distal and proximal, and individual and environmental antecedents. Organization of our knowledge of risk and
protective factors for both completed and attempted suicide provides opportunities to develop and implement life-saving preventive
strategies. q 2001 Elsevier Science B.V. All rights reserved.
Keywords: Suicide; Attempted suicide; Epidemiology; Risk factors; Prevention
1. Introduction
Suicide is a complex and tragic outcome of mental
illness. It is an important public health problem [1], not
only because of the loss of over 30 000 lives per year, but
because the death by suicide of a single individual can have
a devastating effect on the lives of those left behind [2]. Yet
suicide is preventable.
By organizing our knowledge of suicide, we can begin to
focus our prevention efforts. Emile Durkheim, one of the
first to scholars to investigate suicide systematically, examined suicides in France through a sociodemographic lens
toward the end of the 19th century. He demonstrated that
suicide is not a unidimensional occurrence, but differs
among population subgroups [3]. One hundred years later,
at the end of the 20th century, attention has focused on
depression, substance abuse, and suicide as leading causes
of death and disability [4]. The dawn of a new millennium
witnesses our progressively sophisticated knowledge base
of basic, clinical, and epidemiologic research on suicide.
This solid scientific foundation, along with a growing public
recognition and desire for action to save lives [5], has
brought ever-increasing hope that we can, indeed, prevent
suicide.
Suicidality occurs on a continuum of severity that
progresses from less serious and more prevalent behaviors
* Tel.: 11-301-443-3775; fax: 11-301-443-6893.
E-mail address: em15y@nih.gov (E.K. Mościcki).
through increasingly severe, less prevalent, and more lethal
behaviors [6–9]. At one end are behaviors such as casual
ideation without specific plans. These behaviors may
progress in some individuals through persistent, intense
ideation that includes a plan, self-inflicted injury without
intent to die, and, for a very small proportion of persons
at the other end of the continuum, to a suicide attempt
with high lethality, and completion [6,10,11].
The discipline of epidemiology, which studies health and
illness in human populations [12], has contributed some of
the primary tools used by scholars who study suicide from a
public health perspective. Descriptive epidemiologic studies
examine patterns of the occurrence and distribution of
diseases and other health-related outcomes in populations
according to sociodemographic characteristics such as age,
sex, race, or social class, geographic area, and time, thus
providing information on the scope and impact of disease
[13]. The data from such studies complement descriptive
findings from clinical observations, basic research, and
other sources of information, and are used to generate causal
hypotheses. Causal hypotheses are tested in analytic epidemiologic studies, which examine the relationships between
antecedent exposures and health outcomes [12]. A major
contribution of epidemiologic studies of both clinical and
community populations is not only to identify antecedent
exposures as independent risk or protective factors, but also
to quantify the strength of their relative contribution to the
risk of disease or disorder [14]. Understanding the potency
1566-2772/01/$ - see front matter q 2001 Elsevier Science B.V. All rights reserved.
PII: S15 66- 2772(01)0003 2-9
E.K. Mościcki / Clinical Neuroscience Research 1 (2001) 310–323
of risk factors for complex outcomes such as suicide and
suicidal behaviors provides a way to prioritize prevention
efforts and wisely invest limited prevention resources.
The purpose of this paper is to provide a review of
descriptive and analytic epidemiologic studies of completed
and attempted suicides, with the goal of identifying opportunities for prevention.
311
based, in-depth investigation of a consecutive series of
suicides in a defined geographic area. Because they are
anchored in a public health perspective, psychological
autopsy studies can verify causal hypotheses generated
from clinic-based observational studies, provide additional
data on completed suicide that are generalizable to the
population, and can generate further causal hypotheses
that can be tested by basic, clinical, and epidemiologic
research.
2. Completed suicides
2.1. Sources of data
2.2. Incidence and sociodemographic correlates of
completed suicide
The primary source of data on suicide mortality in the
United States is the death certificate. Like most member
nations of the World Health Organization, the U.S. currently
codes deaths using the standardized ninth revision of the
International Classification of Diseases (ICD-9) [15].
National mortality data are compiled on an annual basis,
from standardized death certificate information submitted
by the States to the National Center for Health Statistics,
Centers for Disease Control and Prevention [16,17]. Officially reported mortality data have been regarded as reasonably sound for studies of risk factors and correlates of
completed suicide [18–20]; the current system is not
without flaws, however, and there is general agreement in
the suicide and injury literature that suicide deaths are
misclassified and under-reported. Estimates range from
less than 3% [21] to 24% [22]. The extent of the undercount
appears to vary with the age of death, and misclassification
may be more likely to occur in deaths of children and
adolescents. Reporting practices of vital statistics information vary across States and medicolegal jurisdictions: there
are approximately 2200 separate death investigation jurisdictions in the United States in a variety of organizational
locations [23]. Depending on the local jurisdiction, a death
certificate can be signed by a coroner, who may be an
elected official and typically does not have a medical
degree, or a medical examiner, who is usually appointed
and possesses a medical degree [24]. Even though a
suspected death by suicide requires an investigation, only
approximately 50–55% of all suicide deaths in the U.S. are
autopsied, the majority of them in jurisdictions with medical
examiners [25]. Efforts are under way to improve and
expand surveillance systems and standardize death scene
reporting protocols so that a more accurate picture of the
scope of suicide mortality may become available [5]. The
development of operational criteria for the classification of a
death as a suicide [26], and the ongoing collaborative
public-private effort to construct a standardized framework
for presenting injury mortality data [27] should help to clarify misperceptions about the reliability of officially-reported
suicide data.
The primary source of epidemiologic data on risk factors
for completed suicides is the population-based psychological autopsy study. The study design calls for a population
Suicide is the eighth leading cause of death in the United
States [17]. In 1998, the most recent year for which final
mortality data are available, there were 2 337 256 deaths
from all causes, of which 30 575 were classified as suicide
deaths, representing 1.3% of the total number of deaths [17].
The age-adjusted suicide rate was 10.4/100 000, similar to
death rates from diabetes mellitus (12.9/100 000) and homicide (10.3/100 000). These rates are substantially lower than
the rates for the leading cause of death, diseases of the heart,
at 126.6/100 000. Although suicide rates showed a steady
increase from the mid-1950s to the late 1970s [18], they
reached a plateau in the 1980s and since then have been
slowly declining. The national suicide rate has decreased
12.6% in 10 years, from a high of 11.9/100 000 in 1989 to
10.4/100 000 in 1998. Suicide rates vary widely from state
to state; in 1998 age-adjusted rates ranged from 6.4/100 000
in New Jersey, to 21.2/100 000 in Nevada and 22.1/100 000
in Alaska [17]. Historically, states in the western part of the
U.S. have consistently had the highest suicide rates. The
substantial negative effects of suicide can be seen not only
in terms of human lives, but also in terms of economic
resources. Suicide, with homicide, is the third leading
cause of years of potential life lost (YPLL) in the U.S.
[28], and is also a leading cause of YPLL in Canada [29].
Suicide carries a substantial economic burden [29].
As shown by Durkheim over a century ago, suicide rates
differ by age, gender, race, socioeconomic status, and marital status [3,30]. In the U.S., as in most industrialized
nations, suicide rates increase with age, and are highest
among persons over the age of 75 [17]. However, suicide
is not a leading cause of death among the elderly, who are
far more likely to die from chronic and infectious diseases
than from external causes. In the United States, the 1998
suicide rates for persons 75–84 and 85 years of age and over
were 19.7/100 000 and 21.0/100 000, respectively [17]. In
this age group, suicide rates are considerably lower than the
death rate for diseases of the heart, at 1760.6/100 000, which
is the leading cause of death for all persons 65 years and
over. In contrast, the suicide rate for persons 15-24 was
11.1/100 000. Suicide continues to be the third leading
cause of death in this age group, following unintentional
injuries and homicide [17].
Recent unpublished estimates from the National Center
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Fig. 1. Suicide rates by race/ethnicity, United States, 1998.
for Injury Prevention and Control, Centers for Disease
Control and Prevention, indicate striking differences in
suicide rates between racial and ethnic groups in the U.S.
(A. Crosby, personal communication). As seen in Fig. 1,
American Indians and Alaska Natives have the highest
rates of any racial/ethnic group in the United States, with
a 1998 age-adjusted rate of 15.2/100 000, followed by the
White Non-Latino population, with an age-adjusted rate of
11.8/100 000. Suicide is not a leading cause of death among
the other three major racial/ethnic groups in the U.S., Black
Non-Latino, Asian/Pacific Islander, and Latino. All had
similarly low suicide rates in 1998 of 6.1/100 000, 6.2/
100 000, and 6.0/100 000, respectively.
Fig. 2 shows 1998 rates of suicide in the U.S. by age and
gender for Non-Latino Whites and Blacks. Regardless of
race/ethnicity, men consistently have higher suicide rates
than do women. The ratio of male to female suicide rates
in the U.S. has increased gradually from 3.1 in 1979 to 4.3 in
1998 [17]. In 1998, the overall age-adjusted rate for men
was 17.2/100 000, ranging from rates near 0 in boys ages 5–
9 to 57.8/100 000 in men 85 years and older [31]. The
comparable rates for women were much lower. The overall
age-adjusted rate for women was 4.0/100 000, with a range
near 0 in girls ages 5–9, to 7.0/100 000 in women ages 45–
Fig. 2. Age-adjusted suicide rates per 100 000 population by 5-year age group, race, and gender, United States, 1998.
E.K. Mościcki / Clinical Neuroscience Research 1 (2001) 310–323
54. Gender differences are similar by race: the 1998 ageadjusted rate for black men was 10.5/100 000, compared
with 1.8/100 000 for black women; for white men, the rate
was 18.3/100 000, compared with 4.4/100 000 for white
women [17]. Over 70% of all suicides in the U.S. are
committed by white men (72% in 1998), with the highest
suicide rates occurring among elderly white men (62.7/
100 000 for white men 85 years of age and over in 1998)
[31]. Rates among black men, although consistently lower
than rates for white men, show a different age distribution,
with higher rates among younger men. Recent increases
have been noted in the 15–24 age group. Between 1986
and 1994, rates for black adolescent males 15–19 increased
from 7.1/100 000 to 16.6/100 000, with broad regional
variations [32]. Between 1994 and 1998, rates decreased
to 10.7/100 000. A similar trend is evident among black
males 20–24 years of age, with increases from 15.7/
100 000 in 1986 to 24.8/100 000 in 1994. However,
although rates in this group have also decreased (to 20.1/
100 000), the decline is marginal and the trend continues to
be of concern.
In contrast to changes in suicides rates for black males,
rates for white males in younger age groups have not changed dramatically. The age distribution seen among blacks is
comparable to that found among American Indians and
Alaska Natives, who have the highest rates of any ethnic
group in the United States. The 1994–1996 running average
rate for all American Indians and Alaska Natives was 16.2/
100 000; for men aged 15–24 the rate was 53.51.7/100 000
[33]. Although the overall age-adjusted rate in these groups
has decreased since 1972–1974 [33], the rates continue to be
consistently higher than in other ethnic groups in the U.S.
As with rates among blacks and whites, there are broad
geographic and tribal variations [34,35].
Much higher suicide rates have been found for divorced
and widowed persons than for married persons in all age
groups [36,37]. Rates are highest in persons widowed in the
first half of life. Luoma and Pearson found greatly elevated
rates for young widowers compared with married persons
regardless of race [37]. Rates were highest for young white
and black widowers between 20 and 39 years of age, and for
young widows between 25 and 35 years of age.
2.3. Mechanism of death
Across all age groups, a firearm is the most common
mechanism used by both men and women to commit suicide
in the U.S. Firearms consistently account for approximately
three out of five suicide deaths annually. In 1998, among
men, 62% of all suicides were by means of firearms,
followed by hanging and self-inflicted poisoning. Among
women, 39% of all suicides were by means of firearms,
followed by self-inflicted poisoning and hanging. Of all firearm suicides, nearly 80% are committed by white men. The
dramatic increase in the overall suicide rate seen between
the mid-1950s and the late 1970s can be largely attributed to
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the increase in the firearm suicide rate, especially among
youth [38,39]. Indeed, the ready availability of firearms in
urban areas may be an important factor in the recent
increases noted in suicide rates among young black men
[40]. Use of firearms as a mechanism of suicide increases
with age [41]; between 1980 and 1986, the rate of suicide by
firearms among men and women over 65 increased from 60
to 66% [42]. In 1998, men 85 years and older had the highest
rates, at 47.2/100 000 [17]. Marzuk et al. [43] found differences in suicide rates between geographically close communities that could be attributed to differences in access to
lethal mechanisms. They suggested that tightened restriction of access to two of the most commonly used mechanisms, firearms and prescription medications, could
conceivably result in a reduction of suicide rates.
3. Attempted suicide
3.1. Methodological challenges
Unlike information on suicide mortality, there is no single
primary data source for information on suicide morbidity.
Systematic research on attempted suicide continues to face
two important challenges. First, there is a need for an
agreed-upon, standardized nomenclature that can be used
to reliably and consistently describe attempted suicide
events [7,44]; related to this is the need for clear operational
definitions when collecting data or reporting on clinical
outcomes [7,14,30]. Second, there is a need for a national
system of surveillance for collection of reliable data at the
national level [5]; the development of a national surveillance system hinges on the development of a viable nomenclature. Until the scope of suicide morbidity can be reliably
documented at the national level, clinical, public health, and
policy decisions will continue to be limited.
The need to apply standardized terminology in the study
of suicidal behavior has been widely acknowledged [14,44–
46], and various systems have been proposed (e.g.
[7,45,47]). In the United States, some progress has been
made recently toward a nomenclature based on the system
proposed by O’Carroll et al. [7,48]. These investigators
defined attempted suicide as “a potentially self-injurious
action with a non-fatal outcome for which there is evidence,
either explicit or implicit, that the individual intended to kill
himself/herself. The action may or may not result in injuries” [7]. From an epidemiologic perspective, the definition
is clear and descriptive, and can easily be applied in surveillance and screening activities. Goldston [48] used the
O’Carroll et al. nomenclature as an organizing framework
for his extensive review of instruments currently being used
to assess suicidal behaviors in children and adolescents [48].
An important innovation introduced by the O’Carroll et
al. nomenclature is the effort to address two elements that
need to be taken into consideration in the study of non-fatal
suicidal behavior. These are intent, and injury or medical
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lethality [6,7,48–51]. Intent refers to the individual’s desire
to die and expectation that death will result from action.
Individuals who deliberately injure themselves but do not
intend to die are not suicide attempters [7,52], although they
clearly are in distress and require sensitive care and service.
Lethality refers to the potential for death associated with the
mechanism used to attempt suicide. Even with a strong
intent to die, not all attempters injure themselves severely
enough to need medical attention [52]. Although intent and
lethality are correlated [7,53,54], they are independent indicators of severity, and both need to be considered when
making clinical decisions and predictions of suicidal risk.
3.2. Sources of data
Population-based data on occurrence of attempted
suicides in any age group are infrequently reported
[14,44]. The National Comorbidity Survey (NCS) [8] has
provided researchers with the first nationally representative
data on suicide morbidity. This survey was conducted
between 1990 and 1992 in a representative sample of Americans ages 15–54, and collected information on symptoms
of major mental and addictive disorders, including information on suicide attempts. In addition to the national-level
data provided by the NCS, epidemiologic information on
prevalence of suicide morbidity is available from periodic
psychiatric surveys of representative samples in small, welldefined geographic areas.
The primary source of epidemiologic data on risk factors
for suicide attempts is the population-based epidemiologic
survey and case-control study. A major advantage of this
type of study over studies of samples from clinical and other
service settings is that it provides information on the scope
of suicidal behaviors and risk factors in the general population. Population-based research avoids the biases and lack
of generalizability associated with non-epidemiologic
studies of self-selected clinical populations [55], and
provides findings that are generalizable beyond the study
sample.
3.3. Prevalence and sociodemographic correlates of
attempted suicide
Nearly 80% of suicide completers are men, while the
majority of lifetime attempters are women [56]. Estimates
of lifetime prevalence of attempts in adults range from 1.1 to
4.6 per 100; estimates of 12-month prevalence of attempts
range from 0.3 to 0.8 per 100 [8,11,57–60]. Few studies
measure either lethality or intent. A notable exception is
the NCS, in which respondents were asked about intent of
attempted suicide. Of the 272 attempters in the NCS, nearly
half reported that their attempt was a “cry for help;” 13%
reported that they intended to die but knew the method was
not foolproof; 39.3% reported that they intended to die and
were saved only due to luck [8]. These estimates suggest a
prevalence of serious attempts of approximately 1.8 per 100.
Other studies that have incorporated a measure of lethality
report similar estimates of lethal and/or intentional attempts
among adolescents, ranging from 1.6 to 2.6 per 100
[52,54,61].
There are few well-conducted prospective epidemiologic
studies of psychiatric outcomes that have reported incidence
rates of attempted suicide. Notable among these are rates
estimated from the five-site NIMH Epidemiologic Catchment Area Program (ECA) [62], and studies of youth in
South Carolina and Oregon [9,54]. In the ECA, the landmark psychiatric survey of 18 571 adults, Petronis et al. [62]
found a rate of incident suicide attempts of 22/10 000 in the
year prior to the baseline interview; the rate in the year prior
to the follow-up interview was 19/10 000. There were no
significant gender or age differences. The rates indicate a
ratio of approximately 18 incident attempts to one suicide
death, based on suicide mortality rates from the early 1980s,
when the ECA data were collected.
Andrews and Lewinsohn [54] conducted a detailed study
of psychiatric disorders in a representative cohort
(n ¼ 1710) of older adolescents in five communities in
west central Oregon. The lifetime rate of attempted suicide
at baseline was 7.1%; the rate for females, 10.1%, was
significantly greater than the rate for males, 3.8%. At
follow-up, 1.7% of their sample — 2.2% of females and
1.1% of males — reported having attempted suicide in the
12-month period prior to interview, but the gender differences were not statistically significant. Thirteen (0.7%) of
the attempts reported by 121 adolescents were considered
medically lethal, and six (0.35%) were given the highest
rating on intent to die. Lethality and intent were significantly correlated (0.67). There were no gender differences
in lethality. Medical lethality and intent for the follow-up
period were not reported.
McKeown et al. [9] examined follow-up data from a
representative sample of middle and high school students
in a suburban South Carolina public school district. The rate
of suicide attempts at baseline was 2% [46]. The investigators found 1-year incidence rates of 1.3% in students with no
previous suicidality, similar to the rate reported by Andrews
and Lewinsohn [54]. Consistent with other studies of incident suicidality, they found no significant differences in
gender.
Although lifetime prevalence of attempted suicide is
significantly more frequent among women and girls, regardless of race or ethnicity [54,57,61], gender has not been
found to be significantly associated with incident attempts
[49,54,62]. Although the difference between lifetime and
point prevalence may be partially explained by methodological weaknesses in failing to clearly operationalize
attempted suicide [7], and by the consistent finding that
women are more likely to recall and report past health
events than are men, the reasons are not entirely clear and
merit further study.
Most studies of attempted suicide that included large
enough samples of racial and ethnic minority populations
report lower rates among non-whites than whites [57,61].
E.K. Mościcki / Clinical Neuroscience Research 1 (2001) 310–323
Garrison et al. [61] found a higher frequency of attempts
among white than among black high school girls, but
attempts requiring medical treatment were reported most
frequently among black girls. Mos̀cicki et al. [57] found
that the risk of attempted suicide in the ECA was significantly lower in both black and Hispanic adults than in nonblack/non-Hispanic adults. Medical lethality was not ascertained. Yuen et al. [63] reported a 6-month prevalence rate
of 4.3 per 100 in a large (n ¼ 1779) sample of Native
Hawaiian high school students with diverse socioeconomic,
academic, and geographic characteristics, a population not
previously studied. The estimate is higher than 12-month
rates reported for white adolescents, which are less than
3% [52,54,61]. Medical lethality was not reported, however.
The estimate may include attempts that did not result in
medical injury, or it may indicate a genuinely higher rate
of attempted suicide in this population.
Point and period prevalence rates of attempted suicide
have consistently been found to be higher in younger than
older age groups [49,57,64,65]. The ratio of attempted to
completed suicides in children and adolescents is considerably higher than among older persons [56,64]. In a followup study of the Oregon sample, Lewinsohn, Rohde, and
Seeley [6] reported decreased rates of attempted suicide as
their cohort moved into young adulthood. Adolescent girls
had significantly higher rates of attempted suicide at baseline compared with adolescent boys. However, the suicide
attempt rate for girls dropped significantly after age 18, and
the gender difference disappeared after age 19, even though
rates of major depressive disorder continued to be significantly higher in young adult women than men [66]. Data
from the NCS show that the highest risk for attempted
suicide occurs in the late teens and early 20s [8].
3.4. Mechanism of injury
Little information on mechanisms used in attempted
suicide is available from studies of representative samples.
The most common mechanism reported in all studies of
serious suicide attempters is self-poisoning, accounting for
over 70% of all attempts [49,64,65,67]. Beautrais et al. [49]
reported that carbon monoxide poisoning and cutting or
stabbing ranked behind ingestion in their adult sample.
Andrews and Lewinsohn [54] reported that cutting of wrists
or other parts of the body ranked second. Mechanisms used
by suicide attempters are distinct from the most common
mechanisms used by suicide completers in the U.S.,
although overdose or poisoning is also a frequent mechanism of completed suicide among women.
4. Risk factors for completed and attempted suicide
Suicide is rarely, if ever, the outcome of a single antecedent event. Rather, a constellation of risk and protective
factors, external and internal to the individual, interact with
each other to produce the complex outcome of suicide [30].
315
A risk factor is defined as a characteristic, variable, or
hazard that increases the likelihood of development of an
adverse outcome [68], which is measurable, and which
precedes the outcome [69]. The crucial feature of precedence distinguishes risk factors from other characteristics
such as concomitants or consequences of outcomes, which
are correlates but not risk factors [69].
From an epidemiologic perspective, risk factors can be
organized within a framework that differentiates between
distal and proximal exposures. Distal risk factors represent
the underlying vulnerability — the foundation — for suicidal behavior. Distal risk factors can occur at both the individual and environmental levels. They represent a threshold
above which individual vulnerability to proximal risk
factors increases. Distal risk factors are not specific to
suicide, but can produce multiple adverse physical and
mental health outcomes. Exposure to distal risk factors is
necessary for attempted and completed suicide; however,
distal risk factors alone are not sufficient [70]. Proximal
risk factors are more immediately antecedent to the suicidal
event itself, and can act as precipitants. They are likely to
differ with age, gender, ethnicity, and other sociodemographic factors. In and of themselves, proximal risk factors
are neither necessary nor sufficient for suicide. However, the
interaction of powerful distal risk factors with proximal
circumstances can have a cumulative effect of environmental and individual burden that produces the necessary and
sufficient conditions for suicide.
It is important to note that many individuals may have
one or more risk factors and not be suicidal. Risk, and
protective, factors are not static entities, but rather dynamic
processes that change over time and which, in certain lethal
combinations, can lead to suicide. The co-occurrence of
distal and proximal risk processes in individual, family,
and environmental domains is likely to be associated with
the greatest risk for suicide [6,32,71–76]. The specificity of
risk factors may be less important than their cumulative
burden on a vulnerable individual.
It is useful to distinguish conceptually between distal and
proximal risk when planning prevention programs. Preventive strategies and their potential effectiveness, are likely to
differ depending on the nature of the targeted risk factors.
On one hand, the complex nature of suicide suggests that
complex and elaborate interventions are necessary for
prevention; on the other hand, it implies that preventive
and treatment interventions can be targeted and tested at a
number of points in a theoretical model.
4.1. Psychopathology
Mental disorders, especially mood, personality, and
substance use disorders, underlie the vast majority of
completed and attempted suicides, and provide the primary
context for suicide and suicidal behavior. Findings from
psychological autopsy studies from the United States and
Europe consistently indicate that more than 90% of
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completed suicides among adults are associated with mental
or addictive disorders [22,71,73,74,77–79]. A somewhat
lower proportion of psychiatric diagnoses has been found
in some population-based studies of suicides in young
people [22,80,81]. However, all investigators have found
very high levels of psychiatric symptomatology and significant mental health problems in youth suicides that
approached diagnostic boundaries. These findings may be
more reflective of an imperfect diagnostic system than of
lower rates of psychopathology among young people.
Psychiatric disorders are also the strongest observed risk
factors for attempted suicide in all age groups
[6,8,49,53,54,57,80]. A psychiatric disorder is a necessary
condition for suicide to occur [78,82]. Mental and addictive
disorders alone are not sufficient, however, since the majority of individuals afflicted with these disorders do not die by
suicide.
Mood disorders, frequently co-occurring with other
psychiatric and medical diagnoses, are the most commonly
found diagnoses in psychological autopsy studies of
completed suicides for both men and women, across all
age groups. Recurrent depression may be a more reliable
predictor of suicide than severity of depression. Diagnoses
of substance abuse (especially alcohol) are found with equal
frequency in both men and women who die by suicide [83].
Conduct disorder or antisocial personality have also been
consistently reported in a large proportion of completed
suicides [71,72,74,77,78,80–82,84,85]. The proportion of
suicides in which substance abuse and behavioral disorders
are found is much higher than in older suicides, which are
dominated by depressive disorders [22,72,78,84,86,87]. The
potential role of major depression assumes increasing
importance in suicides among elderly adults [84,87]. Diagnoses of depressive disorders are also more frequently found
among female than among male suicides, even though
females account for a much smaller proportion of completed
suicides [78,83,87].
Schizophrenia and schizoaffective disorder have been
linked with increased risk for both attempted and completed
suicide, although most research has been done in clinical
samples (e.g. [88,89]). Information from population-based
psychological autopsy studies is rare. Currently available
findings suggest that psychotic symptoms are associated
with less than 20% of all suicide deaths [90–92]. Diagnoses
of schizophrenia and other psychotic disorders have been
found more frequently among young adults with estimates
ranging from 6 to 17% [78,84]. Estimates of psychotic
disorders are relatively uncommon among middle and
older adults, with estimates ranging from 0 to 11% [78,84].
The same psychiatric diagnoses, depression, substance
abuse, and aggressive behavior disorders, have also been
found to distinguish suicide attempters from non-attempters
in carefully-controlled studies of both community and clinical populations of adolescents and adults [6,8,49,53,61,62,
93]. Andrews and Lewinsohn [53] found that, among
adolescents with a DSM-III-R [94] diagnosis of affective
disorder, suicide attempters had significantly higher levels
of psychiatric symptoms than did non-attempters even after
symptoms specifically related to suicide were eliminated.
The role of panic disorder continues to draw attention in
the literature. Early reports suggested that panic disorder
was associated with an increased risk for attempted suicide
[95]. More recent work has shown that panic disorder is not
an independent risk factor for completed or attempted
suicide [96–98], but can co-occur with other psychopathology, usually a mood or substance abuse disorder, to increase
suicide risk. Panic attacks, on the other hand, may have an
independent role. Pilowsky et al. found that adolescents
with a lifetime history of panic attacks were more likely
to have expressed suicidal ideation and to have made suicide
attempts than those without a lifetime history of panic
attacks [99].
In general, persons with more than one psychiatric diagnosis are at greatly increased risk for attempted suicide. Cooccurring mental, addictive, and physical disorders have
been found in approximately 70–80% of completed suicides
[71,73–75,78,80,85]. Co-occurrence, of mood and
substance abuse disorders in particular, also greatly
increases the likelihood of attempted suicide [6,8,49,56],
suggesting that suicide morbidity is associated with more
severe forms of mental illness, especially in the presence of
increased proximal risk. Separate studies by Kessler [8],
Beautrais [49] and Mos̀cicki [56], conducted at different
points in time and in widely differing geographic populations, reported an approximately 5-fold increase in risk of
attempted suicide associated with more than one diagnosis.
The nature of the co-occurring diagnosis varies; diagnoses
may be co-occurring mental disorders, mental and substance
use disorders, or mental disorders with physical illness.
Mood and addictive disorders, and mood and personality
disorders appear to be particularly lethal combinations
[49,72,74,78,82,87]. The evidence suggests that co-occurrence may be a necessary condition for suicide to occur, but
further research is warranted.
A history of suicide attempts has consistently been shown
to be one of the strongest risk factors for completed suicide
[74,82,100]. A history of attempts alone has not been found
to be clinically reliable, however, in identifying individuals
at immediate risk for completed suicide [101,102]. Taken in
context with other potent risk factors, especially a current
mental disorder or co-occurring disorders, panic attacks
[99], and hopelessness [6,102,103], it can be of great
value in identifying persons at high risk for suicide [6].
Attempted suicide may be a much stronger predictor of
later suicide for elderly patients than it is for younger
patients [47]. Lower ratios of attempts to completions
have been reported for older than younger persons. Unlike
younger attempters and completers, clinical and sociodemographic factors associated with elderly attempters closely
resemble those associated with elderly completers
[54,104], suggesting that older persons who attempt suicide
should be regarded as being at very high risk for completion.
E.K. Mościcki / Clinical Neuroscience Research 1 (2001) 310–323
317
History of abuse of alcohol or other drugs, with or without
a co-occurring mood disorder, is the most frequently identified form of substance abuse in both completions and
attempts [22,53,61,74,78,80]. Although mood disorder,
especially major depression, is found most frequently in
elderly suicides, alcoholism is the second most common
disorder [78,87]. Multiple substance abuse has been diagnosed in most cases of completed suicide, usually alcohol
abuse coupled with cocaine and/or marijuana [61,72,105].
Cocaine can be a major factor in completed suicides that
occur in geographic areas where it is readily available [106],
as well as independently increasing risk for attempted
suicide [62]. Substance abuse is associated with greater
frequency and repetitiveness of suicide attempts, more
medically lethal attempts, more serious suicidal intent,
and higher levels of suicidal ideation [6,107].
attempts [76]. Family violence and physical and sexual
abuse have been associated with completed and attempted
suicides among young people, and can act as distal or proximal risk factors [75,76,117,119,120].
The effects of family history may be mediated through
shared biological risk or protection in family members, or
through a shared family environment that may protect
against, or may increase, risk for life-threatening outcomes
by potentially altering the underlying biological vulnerability [76,121–123]. Many of the biological and environmental
risk factors associated with family history are themselves
inter-related. For example, biologically vulnerable members
of families in which there are already high rates of mental
disorder and/or substance abuse, or high levels of psychiatric symptoms, are more likely to be living in dysfunctional,
disorganized, violent, and abusive family environments,
thus increasing the risk for inter-generational transmission
of mental and addictive disorders and suicidal behavior.
4.3. Neurochemical risk factors
4.5. Proximal risk factors
Clues to the biological underpinnings of suicidality can
be found in neurochemical studies of completers and
attempters, which have uncovered consistent evidence of
abnormalities and alterations in the serotonin system
[108,109,110–113] (see Sher and Harkavy-Friedman in
this issue for reviews).
An epidemiologic link has been reported between
lowered levels of total plasma cholesterol and increased
risk for suicide [114,115]. This relationship may be
mediated by changes in serotonergic activity, termed the
cholesterol-serotonin hypothesis [116]. Evidence from
animal studies supports this hypothesis, and more research
is needed to clarify the mechanism and identify the clinical
correlates. Neurochemical risk factors are discussed in more
detail elsewhere in this volume.
4.5.1. Stressful life events
Recent, severe, stressful life events, for example, the death
of a spouse, other profound interpersonal loss or rejection,
loss of employment, being jailed, or being diagnosed with a
terminal illness, may act as precipitants of suicidality in
vulnerable individuals. Stressors vary in their perceived
impact by age and gender [83], and it is likely that the number
of recent stressors, rather than their specific nature, may
increase the likelihood of suicide [72,124]. The most
frequently identified stressors in young suicides are interpersonal loss or conflict, a humiliating experience, economic
problems, legal problems, and moving [71,124,125]. Stressors in elderly suicides may be more difficult to identify
[126]. Economic difficulties such as job loss or financial
strain are important stressor in midlife, particularly in men
[83]. Medical illness is the dominant stressor in older adult
suicides [78,87].
4.2. Substance abuse
4.4. Familial risk factors
Suicide completers and attempters are likely to come
from families with a history of suicidal behaviors and/or
of
mood
or
substance
abuse
disorder
[71,75,76,82,117,118]. A disrupted family environment,
characterized by indicators such as separation, divorce,
widowhood, or family conflict, stress, or parental legal troubles, has also been associated with suicide
[36,37,76,117,119]. Absence of the father in the home
environment has been linked with an increase in an adolescent’s risk for attempted suicide [53], as has separation of
adolescent from parents [76]. Parental marital distress does
not appear to be an independent risk factor for adolescent
suicide [76]. Whether family history differentially affects
suicidal behavior by age has not been addressed.
In an extensive review of studies of family history and
risk for suicidal behaviors, Wagner reported finding consistent evidence that negative parenting and physical and
sexual abuse were associated with later adolescent suicide
4.5.2. Intoxication
In addition to being frequently diagnosed as a psychiatric
disorder underlying a large proportion of attempted and
completed suicides, intoxication from substance abuse can
act as a precipitant of suicidal behavior, and has been linked
with impulsive suicides [6,8,22,49,61,62,71,72,78,80,82,
85]. In addition, intoxication at the time of death, most
frequently with alcohol, is a highly significant correlate of
suicide, and has been found in approximately half of youthful
suicides [78,82,105,127].
4.5.3. Hopelessness
An important clinical feature that has been shown to be
strongly related to suicide completion in prospectively
followed patients is hopelessness. In a 10-year follow-up
of inpatients, Beck and his colleagues demonstrated that
hopelessness was the strongest predictor of suicide comple-
318
E.K. Mościcki / Clinical Neuroscience Research 1 (2001) 310–323
tion 5–10 years after admission [103]. This finding was
replicated in a large cohort of outpatients [102]. Fawcett
et al [128] also found that intense hopelessness was the
primary clinical feature that discriminated patients who
died by suicide from the comparison group in the Collaborative Program on the Psychobiology Depression.
4.5.4. Contagion
Exposure to the suicidal behavior of others may lead to
suicidal behavior in a vulnerable individual. Exposures may
include behaviors of family members or peers [76,129,130],
or through the media [131,132]. The potential role played by
the print or broadcast media is somewhat controversial
[131,133], but young people may be at much greater risk
from exposure effects than are adults [133–135]. Studies of
time-space suicide clusters, that is, an unusually high
number of suicide deaths that occur within a small
geographic area and brief time period, suggest that nearly
all clusters occur among adolescents and young adults, with
limited evidence for clusters beyond age 24 [134,135]. Clusters are rare occurrences in the U.S., and vary considerably
by State and year, with estimates ranging between 1 and
13% of all adolescent suicides [134,135].
4.5.5. Firearms
In the U.S., one of the strongest proximal risk factors for
suicide is the presence of a firearm in the home [80,136–
138]. Keeping one or more guns in the home independently
increases the risk of suicide for both genders and across all
age groups, even after underlying distal risk factors, such as
depression and alcohol and other drug abuse, are controlled
for [80,136,138]. In a case-control study of young suicides
compared with demographically similar suicidal and nonsuicidal inpatient controls, Brent and colleagues [136] found
that the risk of completed suicide increased independently if
a firearm was present in the home. In addition, there was no
difference in level of risk with respect to the type of firearm
used, handgun or long gun, or whether the weapon and
ammunition were stored in separate locations [136].
4.5.6. Incarceration
Suicide is the leading cause of death in jails and lockups
[139–141]. Younger detainees may be at higher risk than
older detainees. Jailed individuals are more likely to already
have a higher proportion of distal risk factors for serious
outcomes, including suicide, arrest, and detainment. In addition, with the movement away from inpatient care, many
mentally ill persons, including young people, have ended up
in jails and lockups [142,143].
4.5.7. Medical disorders
Physical illness has been found in approximately onethird to one-half of suicides of persons over 60 years of
age [78,87,126]. However, controlled studies are needed,
since the elderly as a group are more likely than younger
persons to suffer from medical disorders. In an extensive
review of the literature, Harris and Barraclough [144] identified a number of medical disorders that were associated
with an increased risk for suicide, but also with psychiatric
diagnoses. These included HIV/AIDS, Huntington’s
disease, malignant neoplasms, multiple sclerosis, peptic
ulcer, renal disease, spinal cord injuries, and systemic
lupus erythematosus. While positive HIV status was
previously shown to have a greatly elevated suicide risk
[145], recent work has demonstrated that persons who are
most at risk for HIV infection are also at increased risk for
other factors associated with both suicide and HIV infection, including drug abuse [146]. The independent contribution of HIV infection to suicide is now considered by
modest at best. There is no evidence that medical disorders
are independent risk factors for suicide outside the context
of depression and substance abuse [78,86,126,147]. Findings from representative samples clearly demonstrate that
co-occurring psychopathology is likely to be the underlying
factor in elderly suicide. Identification and appropriate treatment of depressive symptoms in physically ill individuals
may therefore be an important step in preventing suicides,
especially among the elderly.
4.5.8. Prescription medications
The role prescription medications can play in suicide and
suicidal behavior, especially among the elderly, needs to be
examined more fully [43]. On one hand, self-poisoning is
the second most frequent mechanism of death in suicides
among women [30,42]. The likelihood of death appears to
be significantly greater from an overdose of the older antidepressant medications, such as desipramine, nortriptyline,
amitriptyline, and imipramine, than from newer antidepressants such as trazodone or fluoxetine [148]. Increased
caution in prescribing practices could contribute to a reduction in suicides from overdoses [43]. On the other hand,
depression may conceivably be a side effect of a poorly
coordinated medication regimen for some elderly persons,
especially if several different physicians prescribe medications incompatible with each other, without taking complete
histories from their elderly patients [149].
4.5.9. Sexual orientation
The hypothesis that gay and lesbian youth account for a
large proportion of suicide deaths, and that sexual orientation is a major risk factor, has not been tested in populationbased studies [150]. Research on this sensitive issue has
been difficult to accomplish for a many reasons, including
the lack of accurate information on the true rate of homosexuality in the population and the reluctance of sexual
minorities to self-identify. To date, only two published
population-based studies have examined sexual orientation
among suicide completers [151]. In the San Diego Suicide
Study, only 13 of 283 consecutive suicides were gay [152].
In the New York Suicide Study, Shaffer et al. [153] identified three of 120 consecutive youth suicides as gay. In
neither study did the investigators find evidence for differ-
E.K. Mościcki / Clinical Neuroscience Research 1 (2001) 310–323
ences in risk factors between the gay and non-gay suicides.
In both studies the dominant finding among both gay and
non-gay suicides was the high rate of mental disorder and
substance abuse [152,153]. Based on this somewhat limited
evidence, sexual orientation does not appear to be an independent risk factor for completed suicide.
Limited evidence from self-selected and clinical samples
suggests that sexual orientation may be associated with
attempted suicide (e.g. [154]). Early work, however, did
not address the key issue of independent contribution of
sexual orientation to suicide risk outside of the major risk
factors [150]. More recent observations do support the
notion that sexual orientation may independently contribute to suicidality. Herrel et al. [155], examined data
from same-sex adult male twins in the population-based
Vietnam Era Twin Registry. They found that same-gender
sexual orientation was significantly associated with
elevated risk for lifetime prevalence of suicidality, even
after adjusting for substance abuse and depressive symptoms. Cochran and Mays [156] examined data from adult
men ages 17–39 who participated in the third National
Health and Nutrition Examination Survey (NHANES-III).
They, too, found a significant, independent effect of samesex sexual orientation on suicidality, including attempted
suicide, after adjusting for history of mood disorders.
While both studies used cross-sectional data, findings
such as these point to important areas that need further
examination.
5. Toward a framework for prevention
The epidemiologic evidence has consistently shown that
suicide has multiple, interacting causes. Suicide is a
complex, long-term outcome that requires complex theoretical models for appropriate study of its antecedents, and
complex intervention strategies that address both distal
and proximal, and individual and environmental risk, as
well as protection. It is clear that we have made a great
deal of progress in understanding the major risk factors
for suicide, and we can now begin to organize our knowledge to enrich our examination of suicide and suicidal behavior, and identify appropriate levels of intervention. This
will allow us to develop and implement effective, lifesaving preventive strategies, and identify and address gaps
through continued research. To this end, the following broad
framework, shown in Table 1, is proposed as a working
model. Table 1 summarizes what is currently known about
risk for suicide and, importantly, also suggests potential
protective factors, which, with notable exceptions (e.g.
[9,34]), have not received adequate attention in the literature.
Risk and protective factors are stratified in this matrix as
either distal or proximal, and individual or environmental,
based on current epidemiologic evidence. Some factors,
especially those in the protection column, are shown with
question marks, and indicate opportunities for further scientific study. Organization of risk and protection along these
or similar dimensions provides a framework within which
specific preventive strategies can be developed for a variety
of settings, tailored to the level – environmental or individual, and distal or proximal – at which risk and protection is
addressed. This type of framework will also help us to better
evaluate preventive efforts and identify areas for continued
research.
The current scientific knowledge base provides opportu-
Table 1
Matrix of risk and protective factors for suicide
Context
Distal Risk
Proximal Risk
Protection
Individual
Mental disorder
Substance use/abuse disorder
Intensely stressful life event
–Argument w/ parents, girlfriend/
boyfriend
–Personal failure/humiliation
Enhancement of coping skills
Early identification of mental/ substance use
disorder?
Appropriate treatment for mental/substance use
disorder?
Appropriate medication management?
Comorbidity
Neurochemical vulnerability
Family history of mental disorder/
suicidality
History of physical/sexual abuse
Previous suicide attempt
Environment
Disruptive/dysfunctional, family
environment
Easy availability of firearms
Stigma against mental illness
Environment with few protective factors
Community violence?
Cultural depression/cultural grief?
–Incarceration
– Perceived loss of independence
– Other life event, loss
Hopelessness
Intoxication
Panic attack?
Stroke?
Contagion, e.g. death of acquaintance
Firearm in home
319
Family cohesion
Social support?
Access to mental health and substance abuse
services?
Responsible firearm storage?
Appropriately trained front-line providers?
320
E.K. Mościcki / Clinical Neuroscience Research 1 (2001) 310–323
nities for both prevention and continued research. The
following areas especially can be addressed:
† Take what action can be taken now as the knowledge
base grows: reduce psychiatric and substance abuse
morbidity through identification and appropriate treatment of mental and substance use disorders; limit access
to the most commonly used mechanisms of death, firearms and prescription medications; standardize and
disseminate a viable nomenclature for suicidal behaviors.
† Develop, test, and disseminate theory-driven, empirically-based preventive interventions in community or
clinical settings, which are tested for safety and efficacy
in randomized, controlled trials, and tested for effectiveness and ‘transportability’ in larger studies; consider the
public health and policy-relevant outcomes of interventions.
† Continue to develop the scientific knowledge base:
increase integrative research on the interaction between
individual and contextual factors; increase research on
individual and contextual factors that may protect against
suicide to provide a balanced picture of risk and protective processes; examine suicide morbidity and mortality
in minority populations to better understand the cultural
context for suicide risk and protection; clarify contributions of panic attacks, physical illnesses, sexual orientation; and develop improved models to predict imminent
suicides.
The best method for preventing suicide is likely to be one
that includes a long-term approach designed to address the
major distal risk factors in an integrated manner, and which
includes the individual and his or her physical and psychosocial environment.
Acknowledgements
The author is very grateful to Virginia Lindahl for her
valuable assistance in the preparation of this manuscript.
Portions of this paper were presented at the October, 2000
workshop on Suicide Screening and Prevention in School
Settings sponsored by the National Institute of Mental
Health and at the March, 2001 workshop on Suicide Etiology and Risk Factors sponsored by the Institute of Medicine/National Academy of Sciences. The author would like
to thank Dr Alex Crosby for information on suicide rates
among racial/ethnic groups, Dr Carl Bell for his suggestion
to add a column on protective factors to the matrix, and the
members of the NIMH Suicide Research Consortium for
their helpful comments on the matrix.
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