• US: Call or text 988 (Suicide & Crisis Lifeline), available 24/7
• UK: Call 116 123 (Samaritans)
• International: You can find a helpline for your country at findahelpline.com or the International Association for Suicide Prevention
• If you're in immediate danger, please call your local emergency number (911, 999, 112, etc.) or go to the nearest emergency room

• Personally struggling with thoughts of suicide or self-harm
• Worried about someone else (a friend, family member, patient)
• Looking for clinical/educational information (e.g. risk assessment, warning signs, how to help someone)

Suicide — Psychiatry Exam Notes

1. Definitions (key terminology)

2. Epidemiology (WHO/Kaplan & Sadock data)

• Globally, suicide causes >700,000 deaths/year, about 1.5% of all deaths worldwide — more than breast cancer, war, and homicide combined.
• Global age-standardized rate (2019): ~9 per 100,000. Highest regional rates: Europe (12.08), South-East Asia (11.19), Africa (10.28); lowest in Eastern Mediterranean (6.01).
• Males die by suicide more than twice as often as females (13.25 vs 5.74 per 100,000 globally) — the classic exam point: women attempt more, men complete more (men use more lethal methods).
• Suicide is the 4th leading cause of death in ages 15-29 globally.
• Methods: hanging is most common worldwide (especially in Europe, Africa, Asia); firearms dominate in the US (55% of US suicides in 2021); self-poisoning and jumping are more common among females.
• Rates rise with age, peaking in those ≥70 years in most regions (exception: young South-East Asian females).

3. Risk Factors (classic exam list)

• Major depressive disorder — highest attributable risk
• Bipolar disorder (especially mixed/depressive episodes)
• Schizophrenia (often early in illness course, command hallucinations)
• Substance use disorders (alcohol especially — disinhibition + impulsivity)
• Borderline and antisocial personality disorder
• Anorexia nervosa

• Prior suicide attempt — single strongest predictor of completed suicide
• Hopelessness (stronger predictor than depression severity alone)
• Family history of suicide
• Access to lethal means (firearms, medications)
• Recent psychiatric hospitalization/discharge (highest risk in first week post-discharge)
• Chronic pain/terminal illness
• Impulsivity/aggression traits
• Social isolation, recent loss (bereavement, divorce, job loss)
• History of childhood abuse/trauma

4. Clinical Risk Assessment

1. Direct questioning — ask explicitly about ideation, intent, and plan (asking does NOT increase risk — this is a heavily tested myth).
2. Assess plan specificity and lethality — method, access to means, timeline.
3. SAD PERSONS scale (mnemonic often tested):
   • Sex (male)
   • Age (<19 or >45)
   • Depression
   • Previous attempt
   • Ethanol abuse
   • Rational thinking loss (psychosis)
   • Social supports lacking
   • Organized plan
   • No spouse
   • Sickness (chronic illness)
4. Columbia Suicide Severity Rating Scale (C-SSRS) — widely used in clinical/research settings to grade ideation and behavior severity.
5. Evaluate protective factors and reasons for living.

5. Management

• Immediate safety: determine need for hospitalization (voluntary vs involuntary/civil commitment if imminent risk), means restriction (remove firearms/medications), 1:1 observation if inpatient.
• Treat underlying psychiatric disorder: antidepressants for MDD (note: black-box warning for increased suicidality in <25 y/o early in SSRI treatment — a common exam point), mood stabilizers/lithium (lithium has specific evidence for reducing suicide risk in bipolar disorder), antipsychotics (clozapine has specific FDA indication for reducing suicide risk in schizophrenia).
• Psychotherapy: Dialectical Behavior Therapy (DBT) — strongest evidence for reducing suicidal/self-harm behavior, especially in borderline personality disorder. CBT for suicide prevention is also evidence-based.
• Safety planning intervention, crisis line involvement, follow-up scheduling (highest-risk period is immediately post-discharge from inpatient care — close follow-up is essential).
• ECT may be considered in severe depression with acute high suicide risk requiring rapid response.

Recent evidence note

Suicide Epidemiology — Elaborated (Psychiatry Exam Notes)

1. Global Burden

• >700,000 deaths/year worldwide from suicide — roughly 1.5% of all deaths globally, exceeding deaths from breast cancer, war, and homicide combined.
• Global age-standardized rate (2019): ~9.39 per 100,000 (males 13.25, females 5.74).
• True rates are almost certainly underestimated — only 60 of 194 WHO Member States have good-quality mortality registration, and suicides are frequently misclassified as accidental deaths, homicides, or "undetermined cause."
• Suicide accounts for 57% of all violent deaths in men and 71% in women globally; in high-income countries this rises to 85% of violent deaths in both sexes.
• 4th leading cause of death among 15-29 year-olds worldwide (after road injury, TB, interpersonal violence) — >150,000 deaths/year in this age band.

2. Regional Variation (WHO Regions, 2019, per 100,000)

3. Age and Sex Interaction (crude rates per 100,000, by age band)

• Rates rise progressively with age in nearly every region, peaking sharply in the 70+ group — e.g., Africa: males go from 0.85 (age 5-14) to 72.21 (70+); Americas: males rise from 0.79 to 28.10 (70+).
• The exception is South-East Asian females, whose suicide rate peaks in young adulthood rather than old age — a distinctive, testable regional anomaly (linked to early marriage, domestic conflict, and limited autonomy in some South-East Asian settings).
• Adolescent/young adult suicide (15-24) is disproportionately significant as a cause-of-death ranking (4th leading cause in 15-29 y/o) even though the absolute rate is lower than in the elderly — because competing causes of death (cancer, cardiovascular disease) are rare in youth.

4. Income-Level Paradox

• 77% of all suicides occur in low- and middle-income countries (reflecting population distribution), but the highest age-standardized rate is in high-income countries (10.9 per 100,000).
• Male suicide rates are highest in both high-income (16.4) and low-income (15.2) countries — a bimodal pattern.
• Female suicide rate is highest in lower-middle-income countries (7.11).
• Explanatory factors cited: differences in coping/help-seeking behavior between sexes, alcohol consumption patterns, and differential access to lethal means across economic settings.

5. United States Data (CDC, 2021)

• 48,152 total deaths by suicide in the US in 2021 (38,330 males, 9,822 females) — roughly a 4:1 male-to-female ratio in completed suicides, contrasted with the well-known reverse ratio for attempts (females attempt ~3x more often than males but with lower lethality methods).
• National age-adjusted rate: 14.1 per 100,000 — notably higher than the global average, consistent with the high-income country pattern above.
• State-level variation is dramatic:
  • Highest age-adjusted rates: Wyoming (32.3), Montana (32.0), Alaska (30.8), New Mexico (25.0), South Dakota (23.1) — largely rural, mountain-west states with high firearm ownership and geographic/social isolation.
  • Lowest rates: District of Columbia (6.2), New Jersey (7.1), New York (7.9), Massachusetts (8.0) — dense urban, higher-resource states.
• This rural-urban gradient is a recurring, testable theme: rural areas combine higher firearm access, greater social isolation, and reduced access to mental health services.

6. Method Epidemiology (important for both psychiatry and forensic medicine exams)

• Among males globally, hanging is followed by firearms (9.7%) then self-poisoning (8.6%).
• Among females, self-poisoning (24.7%) and jumping from height (14.5%) are more common — reflecting typically lower-lethality method preference, part of the explanation for the attempt/completion sex paradox.
• Method availability directly drives population-level suicide rates — this is the epidemiological basis for "means restriction" as a suicide-prevention strategy (e.g., firearm storage laws, pesticide regulation in agrarian countries, bridge barriers).

7. Socio-Demographic Risk Modifiers

• Unmarried, divorced, or widowed status; unemployment; immigrant status; minority sexual orientation — all increase risk.
• Elevated-risk occupational/institutional groups: military/veterans, prisoners, indigenous populations.
• Durkheim's classical sociological framework (still exam-relevant): religion, marriage, and parental responsibility act as protective/integrative social forces that suppress suicidal impulses; anomie (breakdown of social norms) increases risk.

Quick Exam Takeaways

1. Global rate ~9/100,000; US rate ~14/100,000 (higher than global average, high-income country pattern).
2. Men complete more (higher lethality methods, esp. firearms in US); women attempt more.
3. Rates generally rise with age, peaking >70, except South-East Asian females (young adult peak).
4. Western Pacific/South-East Asia are the regions where female rates approach or exceed male rates.
5. Method distribution is region-specific and central to prevention strategy (means restriction).
6. US has one of the widest intra-country rate variations of any high-income nation (rural mountain-west vs. urban Northeast).

Suicide Epidemiology — Exam "Defence" (CTP + Indian Studies + Worldwide Studies)

A. Base Reference: Kaplan & Sadock's Comprehensive Textbook of Psychiatry (CTP), Ch. 31.1

• WHO 2019: >700,000 deaths/year globally, ~1.5% of all deaths, global age-standardized rate 9.39/100,000 (males 13.25, females 5.74).
• Regional rates: Europe highest (12.08), then South-East Asia (11.19), Africa (10.28); Eastern Mediterranean lowest (6.01).
• Suicide is the 4th leading cause of death in 15-29 year-olds worldwide.
• CTP explicitly flags a reliability caveat that you can use as a "defence" point in exam: "only 60 of 194 WHO Member States have good-quality mortality registration data... suicides can be misclassified as accidents, homicides, or unknown causes." This is the textbook basis for why official figures (including India's) are considered underestimates.
• Kaplan & Sadock's Synopsis of Psychiatry adds a directly India-relevant line worth quoting in an exam: "when epidemiologists used a verbal autopsy in South India, the observed rates for suicide exceeded official national estimates 10-fold." This is your strongest textbook-level citation for under-reporting in India specifically.

B. Indian Studies (for "Indian data" defence)

• Estimated ~187,000 suicide deaths in India in 2010 — far higher than the Government of India's official NCRB figure of ~134,600 for the same year.
• Suicide is disproportionately a young-adult phenomenon: it was among the leading causes of death in the 15-29 year age group.
• Poisoning (mainly organophosphate pesticides) was the leading method, accounting for ~92,000 deaths in those ≥15 years.
• Notably, female suicide rates in India were unusually high relative to global patterns — one of very few countries where young female rates approach or exceed male rates, contrary to the male-predominant pattern seen in most CTP-cited WHO regions.

• Verbal-autopsy studies in rural India report suicide rates of 82-95/100,000 — up to 8-fold higher than official NCRB rates (this independently corroborates the Synopsis of Psychiatry's "10-fold" claim above — use both together as convergent evidence in an exam answer).
• Peak age: 20-29 years.
• Female rates exceed male rates under age 30; the reverse (male-predominant) is true after 30 — a distinctly Indian crossover pattern versus the uniformly male-predominant global pattern in CTP.
• Hanging and organophosphate ingestion are the leading methods; self-immolation is a relatively India-specific method among women.
• Compared to high-income countries, Indian suicide is more strongly linked to poverty and low socioeconomic status, and less strongly linked to diagnosed mental illness (alcohol misuse being the exception) — an important point of contrast with Western/CTP epidemiology, where psychiatric illness (especially depression) accounts for ~90% of completions.

• 2023: 171,418 suicides, national rate 12.3/100,000 (2022 peak was 12.4).
• Two-thirds of victims are aged 18-45; below-18 suicides rose 5.68% in 2023 — a growing concern flagged in current Indian public health literature.
• 66% of victims belonged to households earning <₹1 lakh/year, supporting the poverty-suicide link noted above.
• Massive state-level variation: Kerala highest among major states (30.6/100,000), followed by Telangana (27.7) and Chhattisgarh (26.0); Bihar lowest (0.7). This state-level heterogeneity mirrors (and exceeds) the US inter-state variation cited from CTP.
• Male:female ratio of victims ~72:27 — but NCRB's own definitional and reporting methodology is criticized in the literature (Ransing et al., PMC9022909) as producing systematically lower estimates than WHO or Million Death Study figures, which is your "defence" point for why multiple sources must be triangulated.
• WHO's independent 2019 estimate for India: age-standardized rate 12.9/100,000 (men 14.7, women 11.1) — higher than the NCRB figure of 10.4 for the same year, again demonstrating official under-ascertainment.

C. Worldwide Studies (systematic reviews/meta-analyses for global defence)

• Meda et al. 2025, Frontiers in Psychiatry (PMID 40873674) — systematic review/meta-analysis across 71 countries over 122 years concluding the WHO's commonly cited 727,000/year figure likely understates true suicide mortality, reinforcing the under-reporting theme from both CTP and Indian verbal-autopsy data.
• An et al. 2023, Asian J Psychiatry (PMID 36634498) — systematic review/meta-analysis on global suicide prevalence by latitude, useful if your exam explores geographic/climatic correlations.
• Knipe et al. 2019, PLoS Medicine (PMID 31597983) — systematic review/meta-analysis of psychiatric morbidity and suicidal behaviour specifically in low- and middle-income countries including India and China, a good comparative citation showing that the depression-suicide link, while present, is weaker in LMICs than in high-income countries — directly consistent with the Indian data above.
• Jain et al. 2024 (PMID 39099300) — systematic review on the economic burden of suicide in LMICs, useful for a "public health impact" angle in your answer.

Suggested exam-answer synthesis line