Suicide and suicide risk

TLDR: The global burden of suicide and suicidal behaviours is discussed, and an overview of the current understanding of the mechanisms of suicide is provided, including risk factors for suicidal ideation and the transition from ideation to suicide attempt.

Abstract: Although recent years have seen large decreases in the overall global rate of suicide fatalities, this trend is not reflected everywhere. Suicide and suicidal behaviour continue to present key challenges for public policy and health services, with increasing suicide deaths in some countries such as the USA. The development of suicide risk is complex, involving contributions from biological (including genetics), psychological (such as certain personality traits), clinical (such as comorbid psychiatric illness), social and environmental factors. The involvement of multiple risk factors in conveying risk of suicide means that determining an individual’s risk of suicide is challenging. Improving risk assessment, for example, by using computer testing and genetic screening, is an area of ongoing research. Prevention is key to reduce the number of suicide deaths and prevention efforts include universal, selective and indicated interventions, although these interventions are often delivered in combination. These interventions, combined with psychological (such as cognitive behavioural therapy, caring contacts and safety planning) and pharmacological treatments (for example, clozapine and ketamine) along with coordinated social and public health initiatives, should continue to improve the management of individuals who are suicidal and decrease suicide-associated morbidity. Suicide and suicidal behaviour continue to present key challenges for public policy and health services. This Primer discusses the global burden of suicide and suicidal behaviours, and provides an overview of our current understanding of the mechanisms of suicide, including risk factors for suicidal ideation and the transition from ideation to suicide attempt.

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Fig 1
Nature Reviews | Disease Primers
Manuscript number NRDP-18-086 Suicide and suicide risk 9|9|19
Suicide rate
(per 100,000 population)
0–5
>5–10
>10–15
>15–20
>20–25
>25–30
>30–35
Data not available

Fig 3
Fig 2
Brazil
Egypt
France
Germany
India
Mexico
Republic of Korea
Russia
UK
20 6010 40
Crude suicide rate (per 100,000 population)
0
Canada
China
USA
30 50
2000
2005
2010
2015
2000
2015
6 182 14
Crude suicide rate (per 100,000 population)
0
2005
2010
10 16
Male
Female
124 8
Nature Reviews | Disease Primers
Manuscript number NRDP-18-086 Suicide and suicide risk 9|9|19

Fig 5
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Brain–gut
axis
Stress response:
HPA axis
Cortisol
production
Serotonin dysregulation
in suicidal behaviour
• Neurotrophic pathways
• Glutamatergic and GABA-ergic dysfunction
• Immune function
• Stress-response: Polyamine system
• Lipids
Fig 4
Social context: lack of social cohesion and environmental factors
• Geographical location
• Sociocultural norms
• Disruption to social structure or values
• Economic turmoil
• Social isolation
• Media reporting
• Access to lethal means
• Poor access to mental health services
Proximal factors
Distal factors
Developmental factors
Lasting alterations to gene expression
Early-life adversity Epigenetic changes Genetics Family history
Increased vulnerability to stress
Personality traits
Chronic
substance
misuse
Impulsive
aggression
Negative
affect
Cognitive
deficits
Genetic and
epigenetic
factors
Acute substance abuse
Acts of self-harm with intent to die
Life events Biological, psychological,
genetic and epigenetic factors
DeathThoughts about death
Suicide attempt
(0.3–0.4%)
Suicidal ideation
(2.0–2.1%)
Suicide
(10.6 per 100,000)
Behavioural disinhibition
Depressed and dysregulated mood
Hopelessness and entrapment
Psychopathology
Nature Reviews | Disease Primers
Manuscript number NRDP-18-086 Suicide and suicide risk 9|9|19

Fig 6
Universal interventions
• Restricting access to
means
• Media strategies for
better reporting
• Suicide awareness
campaigns
Selective interventions
• Pharmacological
interventions
• General practitioner
education programmes
• Development of
treatment guidelines
Indicated interventions
• Psychological
interventions
• Social approaches
• Crisis services
and helplines
Assessment of
suicide risk
• Takes place in ED
or primary care
settings
• Computerized
adaptive tests
• Analysis of
electronic
health records
Mental illness
• Affective disorder
(such as MDD or BD)
• Substance use disorder
• Schizophrenia
• Cluster B personality
disorder
Behavioural and
psychological traits
• Anxiety
• Impulsivity
and/or aggression
• Neuroticism
• Hopelessness
↓
Suicide
rates and
burden
of suicidal
behaviour
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Nature Reviews | Disease Primers
Manuscript number NRDP-18-086 Suicide and suicide risk 9|9|19

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