EPIDEMIOLOGY

Suicide Globally

• The World Health Organization reported in 2016 that globally close to 800,000 people die by suicide every year—a rate of 1 death every 40 seconds. Suicide accounts for 1.4% of deaths worldwide, making it the 18th leading cause of death in 2016.
• Suicides are most common in Asia and Eastern Europe. Lithuania has the highest suicide rate per 100,000 population (31.9), followed by Russia (31), Guyana (29.2), and South Korea (26.9).
• The only Western European nation with a particularly high suicide rate is Belgium, with 20.7 per 100,000. However, it is important to take note that Belgium has one of the most liberal laws on doctor-assisted suicide, which may be a factor in its statistics.
• Among the world’s most troubled areas, Afghanistan has a suicide rate of 4.7 per 100,000, Iraq 3, and Syria just 1.9. The lowest suicide rates in the world are concentrated in the Caribbean Islands.
  (WHO, 2019; World Population Review, 2019)

Suicide in the United States

Suicide is the tenth leading cause of death in the United States, and on average, there are 129 suicides per day. In 2017, 47,173 Americans died by suicide and an estimated 1,400,000 suicide attempts were made, with an estimated cost to the country of $69 billion. In 2016, suicide was the second leading cause of death among people ages 10 to 34 years, the fourth leading cause among people ages 35 to 54, and the 10th leading cause of death overall. There were more than twice as many suicides in the United States as there were homicides (19,510).

Although the Healthy People 2020 target is to reduce suicide rates to 10.2 per 100,000 by 2020, suicide rates have steadily increased in recent years. Between 1999 and 2017, there was an alarming 33% increase in suicides, with a 50% increase among girls and women, from 4 to 6 per 100,000, and a 21% increase among boys and men, from 17.7 to 21.4 per 100,000.

By gender: In 2017, men died by suicide 3.5 times more often than women, with white males accounting for 69.67% of suicide deaths. Among females, the suicide rate per 100,000 was highest for those ages 45 to 64 (10.0); and among males, the rate was highest for those ages 65 and older (31.0).

By sexuality: The risk of suicidal behavior is approximately two to three times greater in sexual minorities than heterosexuals: bisexual (16%), homosexual (11%), heterosexual (6%). Lifetime suicide attempts were approximately four times greater in sexual minorities than heterosexuals.

By age: In 2017, the highest suicide rate (20.2 per 100,000) was among adults ages 45 to 54 years. The second highest rate (20.1) occurred in those 85 years or older. Younger groups have had consistently lower rates than middle-aged and older adults. However, the suicide rate for those ages 15 to 24 years increased in 2017 to its highest point since 2000, with a recent increase especially in males and in ages 15 to 19 years.

By race/ethnicity: In 2017, the highest U.S. age-adjusted suicide rate was among whites (15.85), and the second highest rate was among American Indians and Alaska Natives (13.42). Much lower and roughly similar rates were found among black or African Americans (6.61) and Asians and Pacific Islanders (6.59). (Note: The CDC records Hispanic origin separately from the primary racial or ethnic groups of white, black, American Indian, Alaskan Native, and Asian or Pacific Islander, since individuals in all groups may also be Hispanic.)

By education: Fewer years of education have been found to be associated with higher suicide rates. The suicide rate per 100,000 in 2014 was approximately two times higher in men with a high school education (39) than in men with a college degree or more education (17). A similar pattern was seen in women with a high school education (10) and women with a college degree or more (6).

By urbanization level: By 2017, the age-adjusted suicide rate had increased with decreasing urbanization. The suicide rate for the most rural counties (20.0 per 100,000) increased to 1.8 times the rate for the most urban counties (11.1). Factors may include a higher prevalence of gun ownership, lack of access to mental health care, or economic issues.

By methods: In 2017, firearms were the most common method of death by suicide, accounting for a little more than half (50.57%) of all suicide deaths. The next most common methods were suffocation (including hangings) (27.72%) and poisoning (13.89%). Other methods accounted for 7.8 %.

Suicide attempts: Based on the 2017 National Survey of Drug Use and Mental Health, it is estimated that 0.6% of the adults ages 18 or older made at least one suicide attempt, which is approximately 1.4 million adults. Adult females reported a suicide attempt 1.4 times as often as males. (Data on breakdown by gender and race are not available.)

Based on the 2017 Youth Risk Behaviors Survey, 7.4% of youth in grades 9–12 reported that they had made at least one suicide attempt in the past 12 months. Female students attempted suicide almost twice as often as male students (9.3% vs. 5.1%). Black students reported the highest rate of attempts, at 9.8%, with white students at 6.1%. Approximately 2.4% of all students reported making a suicide attempt that required treatment by a physician or nurse. For those requiring treatment, rates were highest for black students (3.4%).

(CDC, 2018a; Winerman, 2019; Hedegaard et al., 2018; Schreiber & Culpepper, 2019; Phillips & Hempstead, 2017; AFSP, 2020; Miron et al., 2019).

More than half of people who died by suicide did not have a known mental health condition. Factors that contribute to suicide among those with and without known mental health conditions include:

• Relationship problem (42%)
• Problematic substance use (28%)
• Job/financial problem (16%)
• Loss of housing (4%)
• Crisis in the past or upcoming two weeks (29%)
• Physical health problem (22%)
• Criminal legal problem (9%)
  (CDC, 2018b)

Suicide among U.S. Veterans and Active-Duty Military

The United States Department of Veterans Affairs reported that in 2017, 6,139 veterans died by suicide.

In 2017, veterans constituted 7.9% of the U.S. adult population but accounted for 13.5% of all deaths by suicide among U.S. adults. Suicide rates per 100,000 population for veterans was 1-1/2 times the rate for nonveteran adults, and firearms were the most common method (70.7% of males and 43.2% of females).

From 2005 to 2017, there was a 43.6% increase in the number of suicide deaths in the general population and a 6.1% increase in the number of suicide deaths in the veteran population. An average of 16 veterans died by suicide each day during that same period, and in 2017 an average of 17 veterans died by suicide each day.

Between 2005 and 2017, the female veteran population increased by over 6%, and in 2017 the rate of suicide among female veterans was more than double the rate among nonveteran women. The 2017 rate of suicide among male veterans was nearly 1-1/2 times higher than the rate among nonveteran males.

In 2017, 58.7% of veterans who died by suicide had a mental disorder diagnosis (highest was bipolar disorder) or substance use disorder (highest was opioid use disorder).

Veterans ages 18 to 34 had the highest suicide rate in 2017, increasing 76% during the period from 2005 to 2017, and veterans ages 55 to 74 had the lowest rate. However, the absolute number of suicides was highest among veterans 55 to 74 years of age, accounting for 38% of all veteran deaths by suicide in 2017.

In 2018 the number of suicides among active-duty personnel was the highest in at least six years and roughly equal to the rates in the general U.S. population. Service members who died by suicide were primarily enlisted persons less than 30 years of age, majority male, and the primary method used was a firearm. The following are the number of suicides and the rate per 100,000 for each branch of the military:

• Army, 139 (29.5)
• Marine Corps, 58 (31.4)
• Navy, 68 (20.7)
• Air Force, 60 (18.5)
• Reserve members, 81 (22.9)
• National Guard, 135 (30.6)
  (U.S. DOD, 2018; Kime, 2019)

Suicide in Washington State

According to the Washington State Department of Health and the CDC, the state ranks 21st in the nation, with a rate of 16.9 suicides per 100,000 population, compared to the national rate of 14.0. (Montana ranked the highest in the nation at 28.9 per 100,000, and New York ranked the lowest at 8.1.)

In 2017, 1,297 Washingtonians died by suicide, compared to 1,123 in 2016. On average, one person dies by suicide every seven hours. More than seven times as many people died by suicide in 2017 than in alcohol-related motor vehicle accidents. Suicide in the state is the:

• 8th leading cause of death
• 2nd leading cause of death for ages 15–34
• 3rd leading cause of death for ages 35–44
• 4th leading cause of death for 45–54
• 8th leading cause of death for 55–64
• 16th leading cause of death for ages 65 and older
  (AFSP, 2020a; Hedegaard et al., 2018)

By gender: Suicide rates are higher for males than for females in all age groups. About 3 males die by suicide for every 1 female. From 2013 to 2017, 5,669 Washington residents died by suicide. Among those, 76.1% were male (4,313 suicides). From 2016 to 2017, suicides in Washington increased 20% in females and 14% in males.

By age: Suicides increased in all age groups, with the greatest percentage increases occurring in youth (10–24 years) and older adults (75 years and older). Youth ages 10 to 24 had a 27% increase in suicide from 2016 to 2017. Males 35 to 64 years of age accounted for 37% of all Washington suicides (2,095 suicides).

By race/ethnicity: In Washington, American Indian/Alaska Natives (AI/AN) have the highest suicide rate, followed by non-Hispanic whites. Whites had the highest number of suicides (4,721). Suicide rates for all races have increased in the last 10 years, with the greatest increases among AI/AN and non-Hispanic whites. Rates of suicide for whites increased 3.4% from 2016 to 2017.

By military service: In 2017, the Department of Veterans Affairs estimated a total of 560,000 veterans in Washington. From 2013 to 2017, 1,182 veterans died by suicide, accounting for 17.6% of all Washington suicides. Counties with the highest number of veteran suicides are King, Pierce, Snohomish, Spokane, and Clark, which also have the highest number of total suicides. Of these, 5.8% of those who died were ages 55 to 74.

By methods: The leading methods of suicide in Washington were firearms (48%), suffocation (27%), and poisoning (17%). The leading methods of suicide in males were firearms (54%) and suffocation (26%), while in females they were poisoning (36%), firearms (28%), and suffocation (26%). Firearms were the most common method across all ages except for youth under 18. Almost 3 out of 4 adults ages 75 years and older who died by suicide used a firearm. Suffocation is the most common method for youth under 18 years old. Suicide by poisoning was more common with middle-aged adults than other age groups.

By county/geography: In Washington, the counties with the highest number of suicides were King, Pierce, Snohomish, Spokane, and Clark, and, as it is nationally, suicide rates were higher outside urban areas. In Washington, the age-adjusted rate in small towns/isolated rural areas was 21.2 per 100,000 people. This was about 24% higher than the state rate. Rates in the various geographical locations were:

• Urban core, 15.4
• Suburban, 15.6
• Large rural town, 17.5
• Small town/isolated rural, 21.2

Self-inflicted hospitalizations: In 2016–2017, there were 7,425 hospitalizations in Washington due to self-inflicted injuries. Females accounted for 63% of hospitalizations, with females ages 15 to 24 accounting for 18% of hospitalizations (1,363). Hospitalizations for self-inflicted injuries have been decreasing in Washington since 2010. However, nationally and in Washington, hospitalizations for females ages 10 to 14 have been increasing. In 2016–2017, there were 373 hospitalizations for females ages 10 to 14 (84.6 per 100,000). Part of the latest increase may be due to improved coding.

(WADOH, 2019).