Suicide and Deliberate Self-harm 117Background factors
1 Disrupted home circumstances, for example, abuse, marital discord, broken
home, deaths.
2 Family members with a psychiatric history, mainly relating to:
(a)alcohol and drug abuse;
(b)depression and other emotional disorders;
(c)suicide and self-harm.
3 Psychiatric disorder in the individual. Among adolescents and young adults,
retrospective assessments by means of ‘psychological autopsies’ suggest
that around 60% had some psychiatric disorder, with affective disorders
being especially common in both sexes, and with substance abuse and
conduct disorder also being common, especially in males. The link
between depression and suicidal ideation may be mediated by lack
of hope about the future. Up to half of those who kill themselves
have been in contact with professionals for their mental health prob-
lems. The proportion with a psychiatric disorder is probably somewhat
lower in younger teenagers, who are correspondingly more likely to
be responding to a recent upset or an impending threat, for example,
being left by a boy/girlfriend, or the imminent arrival of a bad school
report.
4 Models of successful or attempted suicide. These include family, friends, and
the media, particularly television.
5 One or more previous episodes of deliberate self-harm in about 40% of
cases. In addition, many have made suicidal threats or shown suicidal
behaviour in the 24 hours prior to the suicidal act.
6 Availability of highly lethal means. For example, guns that have not been
adequately locked away are the most commonly used means in the
USA, but are relatively rare means in the UK, where far fewer families
possess guns.
Precipitating factors and motivation
Few adolescent suicides are carefully planned long in advance: most are
impulsive responses to a precipitating stress. For younger teenagers, the
commonest precipitant is a disciplinary crisis, with the individual having
got into trouble with the school or the police, and the parents being about
to find out. Other precipitants include problems with a psychotic parent
or rows with parents, friends, or boy/girlfriend. Adolescents who are out
of school at the time may be at particular risk because of lack of social
support. Judging from suicide notes, the desire to escape from a recent
crisis is a common motivation, with expressed anger more often being
directed outwards towards other people or adverse circumstances than
inwards towards the self.
Biological risk
Adoptees who kill themselves are more likely to have biological relatives
who have killed themselves. This suggests that the clustering of suicides