Suicidal acts may be connected to recent events or current conditions in a person’s life. Although such factors may not be the basic motivation for the suicide, they can precipitate it. Common triggering factors include stressful events, mood and thought changes, alcohol and other drug use, mental disorders, and modeling.

Researchers have counted more stressful events in the recent lives of suicide attempters than in the lives of nonattempters (Foster, 2011; Pompili et al., 2011). One stressor that has been consistently linked to suicide is combat stress. Research indicates that combat veterans from various wars are more than twice as likely to commit suicide as nonveterans (Jakupcak & Varra, 2011). At the beginning of this chapter, for example, you read about a young man who committed suicide upon returning to civilian life, after experiencing the enormous stressors of combat in Iraq.

The stressors that help lead to suicide do not need to be as horrific as those tied to combat. Common forms of immediate stress seen in cases of suicide are the loss of a loved one through death, divorce, or rejection (Roskar et al., 2011); loss of a job (Milner el al., 2014; Kuroki, 2010); significant financial loss (Houle & Light, 2014); and stress caused by hurricanes or other natural disasters, even among very young children. A suicide attempt may also be precipitated by a series of recent events that have a combined impact, rather than by a single event, as in the following case:

People may also attempt suicide in response to long-term rather than recent stress. Four such stressors are particularly common—social isolation, serious illness, an abusive environment, and occupational stress.

Social IsolationAs you saw in the cases of Dave, Demaine, and Tya, people from loving families or supportive social systems may commit suicide. However, those without such social supports are particularly vulnerable to suicidal thinking and actions. Researchers have found a heightened risk for suicidal behavior among those who feel little sense of “belongingness,” believe that they have limited or no social support, live alone, and have ongoing conflicts with other people (You et al., 2011).

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Serious IllnessPeople whose illnesses cause them great pain or severe disability may try to commit suicide, believing that death is unavoidable and imminent (Schneider & Shenassa, 2008). They may also believe that the suffering and problems caused by their illnesses are more than they can endure. Studies suggest that as many as one-third of those who die by suicide have been in poor physical health during the months prior to their suicidal acts (MacLean et al., 2011; Conwell et al., 1990). In fact, illness-linked suicides have become more common, and more controversial, in recent years (Levy et al., 2011; Dickens et al., 2008). Although physicians can now keep seriously ill people alive much longer, they often are unable to extend the quality and comfort of the patients’ lives (Werth, 2001).

Abusive or Repressive EnvironmentVictims of an abusive or repressive environment from which they have little or no hope of escape sometimes commit suicide. For example, some prisoners of war, inmates of concentration camps, abused spouses, abused children, and prison inmates try to end their lives (Fazel et al., 2011). Like those who have serious illnesses, these people may feel that they can endure no more suffering and believe that there is no hope for improvement in their condition.

Occupational StressSome jobs create feelings of tension or dissatisfaction that may trigger suicide attempts. Research has found particularly high suicide rates among psychiatrists and psychologists, physicians, nurses, dentists, lawyers, police officers, farmers, and unskilled laborers (Kleespies et al., 2011; Skegg et al., 2010). Such correlations do not necessarily mean that occupational pressures directly cause suicidal actions. Perhaps unskilled workers are responding to financial insecurity rather than job stress when they attempt suicide. Similarly, rather than reacting to the emotional strain of their work, suicidal psychiatrists and psychologists may have long-standing emotional problems that stimulated their career interest in the first place.

Many suicide attempts are preceded by a change in mood (see PsychWatch below). The change may not be severe enough to warrant a diagnosis of a mental disorder, but it does represent a significant shift from the person’s past mood. The most common change is an increase in sadness. Also common are increases in feelings of anxiety, tension, frustration, anger, or shame (Reisch et al., 2010). In fact, Shneidman (2005, 2001) believed that the key to suicide is “psychache,” a feeling of psychological pain that seems intolerable to the person. A study of 88 patients found that those who scored higher on a measure called the Psychological Pain Assessment Scale were indeed more likely than others to commit suicide (Pompili et al., 2008).

Suicide attempts may also be preceded by shifts in patterns of thinking. People may become preoccupied with their problems, lose perspective, and see suicide as the only effective solution to their difficulties (Shneidman, 2005, 2001). They often develop a sense of hopelessness—a pessimistic belief that their present circumstances, problems, or mood will not change. In fact, one study found that people who generally expressed feelings of hopelessness were 11 times more likely to commit suicide over a 13-year follow-up period than people who did not feel hopeless (Kuo et al., 2004). Thus, some clinicians believe that a feeling of hopelessness is the single most likely indicator of suicidal intent, and they take special care to look for signs of hopelessness when they assess the risk of suicide (Rosellini & Bagge, 2014; Sargalska et al., 2011).

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Many people who attempt suicide fall victim to dichotomous thinking, viewing problems and solutions in rigid either/or terms (Shneidman, 2005, 2001, 1993). Indeed, Shneidman said that the “four-letter word” in suicide is “only,” as in “suicide was the only thing I could do” (Maris, 2001). In the following statement a woman who survived her leap from a building describes her dichotomous thinking at the time. She saw death as the only alternative to her pain:

Studies indicate that as many as 70 percent of the people who attempt suicide drink alcohol just before they do so (Crosby et al., 2009; McCloud et al., 2004). Autopsies reveal that about one-quarter of these people are legally intoxicated (Flavin et al., 1990). It may be that the use of alcohol lowers a person’s fears of committing suicide, releases underlying aggressive feelings, or impairs his or her judgment and problem-solving ability. Research shows that the use of other kinds of drugs may have a similar tie to suicide, particularly in teenagers and young adults (Darke et al., 2005). A high level of heroin, for example, was found in the blood of Kurt Cobain at the time of his suicide in 1994 (Colburn, 1996).

Although people who attempt suicide may be troubled or anxious, they do not necessarily have a psychological disorder. Nevertheless, the majority of all suicide attempters do have such a disorder (Singhal et al., 2014; Nock et al., 2013; Fountoulakis & Rihmer, 2011). Research suggests that as many as 70 percent of all suicide attempters had been experiencing severe depression, 20 percent chronic alcoholism, and 10 percent schizophrenia (see Table 9-2). Correspondingly, as many as 25 percent of people with each of these disorders try to kill themselves. People who are both depressed and dependent on alcohol seem particularly prone to suicidal impulses (Nenadić-Šviglin et al., 2011). Certain anxiety disorders, including posttraumatic stress disorder and panic disorder, have also been linked to suicide (Rappaport et al., 2014), but in most cases of suicide these disorders occur in conjunction with major depressive disorder, a substance-related disorder, or schizophrenia (Ishii et al., 2014; Bryan & Corso, 2011). It is also the case that many people with borderline personality disorder, a broad pattern that you will read about in Chapter 16, try to harm themselves or make suicidal gestures as part of their disorder (Amore et al., 2014; Paris, 2011). The issues with which these people are grappling are often quite different from those of other suicidal persons and so will be examined in Chapter 16.

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As you saw in Chapter 7, people with major depressive disorder often have suicidal thoughts. One program in Sweden was able to reduce the community suicide rate by teaching physicians how to recognize and treat depression at an early stage (Rihmer, Rutz, & Pihlgren, 1995). Similarly, a recent review in the United States found that treatments for depression consistently reduce the rate of suicidal thinking, attempts, and completions among patients (Sakinofsky, 2011). Even when depressed people are showing improvements in mood, however, they may remain at high risk for suicide. In fact, among those who are severely depressed, the risk of suicide may actually increase as their mood improves and they have more energy to act on their suicidal wishes. Recall, for example, Jonathan Boucher, the combat veteran whose case opened this chapter. Just before he committed suicide, he had seemed to be calm and enjoying life again, according to family members and friends.

Severe depression also may play a key role in suicide attempts made by those with serious physical illnesses (Werth, 2004). A study of 44 patients with terminal illnesses revealed that fewer than one-quarter of them had thoughts of suicide or wished for an early death and that those who did were all suffering from major depressive disorder (Brown et al., 1986).

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A number of the people who drink alcohol or use drugs just before a suicide attempt actually have a long history of abusing such substances (Ries, 2010). The basis for the link between substance-related disorders and suicide is not clear. Perhaps the tragic lifestyle of many persons with these disorders or their sense of being hopelessly trapped by a substance leads to suicidal thinking. Alternatively, a third factor—psychological pain, for instance, or desperation—may cause both substance abuse and suicidal thinking (Sher et al., 2005). Such people may be caught in a downward spiral: they are driven toward substance use by psychological pain or loss, only to find themselves caught in a pattern of substance abuse that aggravates rather than solves their problems (Maris, 2001).

People with schizophrenia, as you will see in Chapter 14, may hear voices that are not actually present (hallucinations) or hold beliefs that are clearly false and perhaps bizarre (delusions). The popular notion is that when such people kill themselves, they must be responding to an imagined voice commanding them to do so or to a delusion that suicide is a grand and noble gesture. Research indicates, however, that suicides by people with schizophrenia more often reflect feelings of demoralization or fears of further mental deterioration (Meltzer, 2011; Pompili & Lester, 2007). Many young and unemployed people with schizophrenia who have had relapses over several years come to believe that the disorder will forever disrupt their lives. Still others seem to be disheartened by their substandard living conditions. Suicide is the leading cause of premature death among people with schizophrenia.

It is not unusual for people, particularly teenagers, to try to commit suicide after observing or reading about someone else who has done so (Hagihara et al., 2014; Ali, Dwyer, & Rizzo, 2011). Perhaps they have been struggling with major problems and the other person’s suicide seems to reveal a possible solution, or perhaps they have been thinking about suicide and the other person’s suicide seems to give them permission or finally persuades them to act. Either way, one suicidal act apparently serves as a model for another. Suicides by family members and friends, those by celebrities, other highly publicized suicides, and those by coworkers or colleagues are particularly common triggers.

Family Members and FriendsA recent suicide by a family member or friend increases the likelihood that a person will attempt suicide (Ali et al., 2011). Of course, the death of a family member or friend, especially when self-inflicted, is a life-changing event, and suicidal thoughts or attempts may be tied largely to that trauma or sense of loss. Indeed, such losses typically have a lifelong impact on surviving relatives and friends, including a heightened risk of suicide that can continue for years (Roy, 2011). However, even when researchers factor out these issues, they find increases in the risk of suicide among the relatives and friends of people who recently committed suicide (Ali et al., 2011). This additional risk factor is often called the social contagion effect.

CelebritiesResearch suggests that suicides by entertainers, political figures, and other well-known people are regularly followed by unusual increases in the number of suicides across the nation (Queinec et al., 2011). During the week after the suicide of Marilyn Monroe in 1963, for example, the national suicide rate rose 12 percent (Phillips, 1974).

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Other Highly Publicized CasesSuicides with bizarre or unusual aspects often receive intense coverage by the news media. Such highly publicized accounts may lead to similar suicides (Hagihara et al., 2014; Blood et al., 2007; Gould et al., 2007). During the year after a widely publicized, politically motivated suicide by self-burning in England, for example, 82 other people set themselves on fire, with equally fatal results (Ashton & Donnan, 1981). Inquest reports revealed that most of those people had histories of emotional problems and that none of the suicides had the political motivation of the publicized suicide. The imitators seemed to be responding to their own problems in a manner triggered by the suicide they had observed or read about.

Even a media program that is clearly intended to educate and help viewers may have the paradoxical effect of spurring imitators. One study found a dramatic increase in the rate of suicide among West German teenagers after the airing of a television documentary showing the suicide of a teenager who jumped under a train (Schmidtke & Häfner, 1988). The number of railway suicides by male teenagers increased by 175 percent after the program was aired.

Some clinicians argue that more responsible reporting could reduce this frightening impact of highly publicized suicides (Mann & Currier, 2011; Blood et al., 2007). A careful approach to reporting was seen in the media’s coverage of the suicide of Kurt Cobain. MTV’s repeated theme on the evening of the suicide was “Don’t do it!” In fact, thousands of young people called MTV and other radio and television stations in the hours after Cobain’s death, upset, frightened, and in some cases suicidal. Some of the stations responded by posting the phone numbers of suicide prevention centers, presenting interviews with suicide experts, and offering counseling services and advice directly to callers. Perhaps because of such efforts, the usual rate of suicide both in Seattle, where Cobain lived, and elsewhere held steady during the weeks that followed (Colburn, 1996).

Coworkers and ColleaguesThe word-of-mouth publicity that attends suicides in a school, workplace, or small community may trigger suicide attempts. The suicide of a recruit at a U.S. Navy training school, for example, was followed within 2 weeks by another and also by an attempted suicide at the school. To head off what threatened to become a suicide epidemic, the school began a program of staff education on suicide and group therapy sessions for recruits who had been close to the suicide victims (Grigg, 1988). Today, a number of schools, for individuals of all ages, put into action programs of this kind after a student commits suicide (Miller, 2011). Such postsuicide programs are often referred to by clinicians as postvention.