2023 - Extracted - Final Chapter - Book

Complimentary Copy
Copyright © 2023 by Nova Science Publishers, Inc.

https://doi.org/10.52305/PCXD7083
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by
any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written
permission of the Publisher.
We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this
publication. Please visit copyright.com and search by Title, ISBN, or ISSN.
For further questions about using the service on copyright.com, please contact:
Copyright Clearance Center

Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470 E-mail: info@copyright.com
NOTICE TO THE READER
The Publisher has taken reasonable care in the preparation of this book but makes no expressed or implied warranty of any
kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential
damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any
special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this
material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the
extent applicable to compilations of such works.
Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no
responsibility is assumed by the Publisher for any injury and/or damage to persons or property arising from any methods,
products, instructions, ideas or otherwise contained in this publication.
This publication is designed to provide accurate and authoritative information with regards to the subject matter covered
herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional
services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A
DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR
ASSOCIATION AND A COMMITTEE OF PUBLISHERS.
Library of Congress Cataloging-in-Publication Data
ISBN: H%RRN
Published by Nova Science Publishers, Inc. † New York
Complimentary Copy
Contents
Preface ..................................................................................................................... vii

Chapter 1 Aggression: Causes and Management........................................................ 1
Swaleha Mujawar, Sadaf Aziz, Neelu Sharma,
Suprakash Chaudhury and Daniel Saldanha
Chapter 2 Stigma among Patients Suffering from Psychiatric Disorders .............. 21
Supriya Davis, Dolly Kumari, Parisha Kelkar,
Suprakash Chaudhury and Daniel Saldanha
Chapter 3 The Psychological Aspects of Rape........................................................... 61
Suprakash Chaudhury, Madhura Samudra, Rohita Vikash
and Ajay Kumar Bakhla
Chapter 4 Emotional Divorce ..................................................................................... 83
Anindita Bhattacharya
Chapter 5 The Causes, Consequences, and Cures of Domestic Violence
against Women: An Indian Perspective ................................................... 95
Suprakash Chaudhury, Sana Dhamija, Tahoora Ali,
Om Prakash and Supriya Davis
Chapter 6 The Etiopathological Issues of Suicide ................................................... 117
Santosh Kumar, Suprakash Chaudhury, Vidhata Dixit
and Deepak Kumar Giri
Chapter 7 Personality Traits Associated with ADHD Symptomology in
College Students ....................................................................................... 147
Jonathan Hammersley, Brooke K. Randazzo and Kristy M. Keefe
Chapter 8 Schizophrenia and the Frontal Lobe ...................................................... 163
Madhura Samudra, Suprakash Chaudhury, Daniel Saldanha
and Rupesh Ranjan
Chapter 9 Cognitive Impairment in Schizophrenia ................................................ 191
Mahesh Hembram, Pooja, V., Madhura Samudra, Richa
Priyamvada and Suprakash Chaudhury
Chapter 10 Delusional Misidentification Syndromes ............................................... 211
Tahoora Ali, Jaideep Patil, Rohita Vikash
and Suprakash Chaudhury
Complimentary Copy
vi Contents
Chapter 11 Cognitive Deficits in Alcohol Dependence ............................................. 223

Pooja, V., Richa Priyamvada, Suprakash Chaudhury
and Daniel Saldanha
Chapter 12 Individual Differences Affecting Smoking Cessation: Clinical
Implications and Future Directions........................................................ 237
Jonathan J. Hammersley and Bryant M. Stone
Chapter 13 The Psychological Aspects of Female Sexuality in the Context of
Schizophrenia ........................................................................................... 255
Sana Dhamija, Supriya Davis, Suprakash Chaudhury
and Soumaya Sharma
Chapter 14 Depression in Women and Its Relation to Domestic Abuse ................. 293
Tahoora Ali, Suprakash Chaudhury, Dolly Kumari
and Parisha Kelkar
Chapter 15 Perimenopause and Mental Health ........................................................ 319
Sadaf Aziz, Suprakash Chaudhury, Parisha Kelkar
and Deoshri Akhourie
Chapter 16 The Assessment, Management and Prevention of Suicide ................... 341
Supriya Davis, Anindita Bhattacharya, Parisha Kelkar
and Suprakash Chaudhury
Chapter 17 The Impact of COVID-19 on Youth Mental Health ............................. 375
Anindita Bhattacharya
Index ................................................................................................................... 389
About the Editor.................................................................................................................. 397
Complimentary Copy
Chapter 6
The Etiopathological Issues of Suicide
Santosh Kumar1
Suprakash Chaudhury2,*
Vidhata Dixit3
and Deepak Kumar Giri4
1Psychiatry Department, Indira Gandhi Institute of Medical Sciences, Patna, India
2Department of Psychiatry, Dr. D. Y. Patil Medical College, Hospital and Research Centre,
Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra, India
3Psychology Department, J.D. Womens College, Patna, Bihar, India
4 Consultant Psychiatrist, Jamshedpur, Jharkhand, India
Abstract
Suicide is a significant tragic public health issue globally. Individual vulnerability to

suicide is very complex and multidimensional. The pioneer researchers and scholars in the
field have attempted to explain various social, psychological, and biological issues
underlying suicidal behavior. The present work is a compilation of their significant
contributions to systematically explaining the etiopathogenesis of suicide. This will be
beneficial to develop therapeutic and preventive strategies for suicidal behavior, to guide
further research, and for teaching, and private study purposes. It is important to integrate
the concepts of leading theoretical models of suicide with the findings of evolving
neurobiological research on suicide.
Keywords: suicide, suicidal behaviour, models, biopsychosocial, Durkheim
Introduction
Suicide is an individual’s death caused by injuring oneself with the intent to die (Hedegaard et
al., 2020). It is a tragic global public health problem. According to the Global Burden of Disease
Collaborative Network (2017), suicide accounts for 1.4% of all deaths globally. World Health
Organization (WHO) reports that about∼8,00,000 persons die at their own hands every year
*
Corresponding Author’s Email: suprakashch@gmail.com.
In: A Guide to Clinical Psychology

Editor: Suprakash Chaudhury
ISBN: 979-8-88697-932-9
© 2023 Nova Science Publishers, Inc.
Complimentary Copy
118 Santosh Kumar, Suprakash Chaudhury, Vidhata Dixit et al.
(World Health Organization, 2014). National Crime Record Records Bureau (NCRB) is the
agency of the government of India which collects suicide data from police records and reports
annually. According to NCRB (National Crime Record Records Bureau, 2021), there were
1,64,033 deaths due to suicide in India in 2021, with an increase of 7.2% as compared to the
previous year. Though these figures are disturbing for many, the magnitude of the problem is
larger because a large number of cases are still not reported with the reasons being stigma and
other socio-political issues. Individual vulnerability to suicide is very complex and
multidimensional, with the involvement of multiple contributing sociodemographic, genetic
and environmental factors. The concept of suicidal thought and behaviour is also complex and
it can encompass suicidal ideation, suicidal attempt and/or suicidal death. The majority of
research work has been focused on suicidal ideation and suicide attempt than on suicide. In
general, the rates of suicidal ideation and suicide attempt are higher than that of suicide.
According to a WHO report, for every suicide death, there are approximately 20 individuals
with suicidal attempts, and many more with suicidal ideation (World Health Organization,
2014).
Comprehensive detail of all risk factors of suicidal thoughts/behaviours is not possible.
Certain variables related to them are worth mentioning:
Regional Differences
Low- and middle-income (LAMI) countries account for more than three fourth of all suicides
worldwide but the suicide rates are higher in high-income countries than in LAMI countries
(WHO, 2014). In India, the rates of suicide are not uniform across its states, with the highest
suicide rate of 39.7 cases per 1 lakh population in Andaman& Nicobar Islands and the lowest
rate of 0.7 suicides per 1 lakh population in Bihar, while the all-India average suicide rate was
12 cases-per1 lakh population (NCRB 2021). In India and other Asian countries, compared to
Europe and North America, social and situational factors play a greater role in the causation of
suicide (Parker et al., 2008). In India, over the last 15 years, family problems have risen to be
the commonest reason behind suicide. As per NCRB (2007) report family problems accounted
for 23.8% of cases of suicide (second in rank to the illnesses responsible for 24.2% of cases of
suicide) whereas the recent report of NCRB (2021) finds family problems (33.2%) to be the
most common reason far ahead of illnesses (18.6%) as the reason behind suicide.
Age
In general, the elderly aged 70 and above have higher suicide rates than children and young
adults but suicide as a cause of death is significantly higher in the later age group (Patton et al.,
2009). However, as per NCRB (2021) data, the age group of 18-45 years (of both genders)
accounted for 66.2% of all suicides in India during the year 2021.
Complimentary Copy
The Etiopathological Issues of Suicide 119
Gender
Suicide mortality in males is higher with an overall male: female suicide ratio of 1.7. This sex
ratio of completed suicide is comparatively lower in the LAMI (lower and middle income) and
Asian/Pacific countries than in the higher income countries and Western countries respectively
(WHO 2018). In India, NCRB (2021) reports a male: female ratio of suicide as 72.5:27.4 which
is much higher than the global figure. However, the sex ratio of non-fatal suicide
acts/behaviours is reversed across the globe. In general, males have a higher risk of completed
suicide with a possible higher suicidal intention in their attempts (Freeman et al., 2017).
Psychiatric Illnesses
Around 90% of all persons committing suicide have at least one psychiatric disorder
(Arsenault-Lapierre et al., 2004; Milner et al., 2012; De Berardis et al., 2018) and around 2-5%
of the patients with established psychiatric diagnosis commit suicide (Nordentoft et al., 2011;
Mortensen et al., 2000). The suicide risk is higher after the patients get discharged from
psychiatric hospitalization, and it gets down slowly over time (Walter et al., 2019). In general,
psychiatric disorders are important risk factors but the majority do not end in suicide (Yeh et
al., 2019). Common psychiatric disorders linked with suicidal behaviour include major
depression, bipolar disorder, schizophrenia, substance use disorders, alcohol abuse/
dependence, post-traumatic stress disorder, anorexia nervosa, sleep disorder, antisocial
personality disorder and borderline personality disorder (Mann, 2003; Meltzer et al., 2003;
Arsenault-Lapierre et al., 2004; Yoshimasu et al., 2008; Chesney et al., 2014; Panagioti et al.,
2015; Kumar et al., 2016; Yeh et al., 2019; Baldessarini, 2019). The risk of suicide increases
the patients with the coexistence of multiple psychiatric illnesses (Holmstrandet al., 2015).
However, the repeated claims of a strong association of discrete psychiatric diagnoses with
suicide risk may be exaggerated (Ribeiro et al., 2018) and it is also important to link suicidal
behaviours with specific symptom dimensions such as anhedonia (Ducasse et al., 2018a),
psychological pain (Ducasse et al., 2018b), psychotic experiences (Yates et al., 2019), sleep
deprivation (Porras-Segovia et al., 2019) independent of underlying psychiatric disorders.
Physical Illness
Apart from psychiatric disorders, many physical illnesses are also associated with increased
suicide risk (Qin et al., 2022). These are commonly the conditions with a chronic course, poor
prognoses and/or increased suffering. Important physical illnesses linked with suicidal
behaviours are HIV infection (Catalan et al., 2011), cancer (Henson et al., 2019), asthma and
allergic rhinitis (Qin et al., 2011; Barker et al., 2015), traumatic brain injury (Madsen et al.,
2018), and concussion (Fralick et al., 2019). Many of these chronic physical illnesses are
associated with increased suicide risk independent of concurrent psychiatric disorders (Porras-
Segovia et al., 2019; de Heer et al., 2018).
Complimentary Copy
Etiological Factors
Attempting to find out a specific cause for a person’s death by suicide is not only inappropriate
but also incorrect in most cases. Only limited progress has been made toward the goal of
constructing a comprehensive theory of life-threatening behavior. Various academics,
researchers, and clinicians specializing in psychology, psychiatry, sociology and biology have
proposed different theories to elucidate suicidal behavior. Such theories of suicide can be
conceptualized under the following headings: (a) Sociological aspects. (b) Psychological
aspects. (c) Neurobiological and Genetic aspects.
Sociological Aspects of Suicide
The initial theories of suicide causation were proposed by Sociologists. However, the role of
sociological theories of suicide, despite being a pioneer in the field, in identifying the solution
to suicide in terms of its prevention has been less prominent (Mueller et al. 2021). In classic
sociology, suicide is viewed as a social, not an individual, phenomenon. The sociological study
of suicide remains entrenched in Émile Durkheim’s (1897/1951) experiential study of suicide
(Joiner, 2005). Emile Durkheim’s sociological theory created a crucial model of the
sociological study of suicide that generated a major line of research and consequent theory
construction. Around Durkheim’s classic work, the sociological aspects of suicide can be
understood in three historical periods of interest (pre-Durkheim, Durkheim, and post-
Durkheim).
Pre-Durkheimian Period
Durkheim can be named as the person who taught the modern world how to think about suicide,
but his theory was based on the works of several earlier thinkers. In the late 19th century, several
European intellectuals were concerned to identify the social factors behind the apparent
increase in suicide rates coincident with the rise of modernity. First among these thinkers were
the moral statisticians like Quetelet (1842) and Morselli (1882) who attempted to collect and
analyze the large body of suicide statistics. They pointed out that rising suicide rates in the
modern world could be due to certain forces larger than individuals. Subsequently, Masaryk
(1970 [1880]) postulated that the increasing levels of education could be one of the forces of
modernization for rising rates of suicide. According to him, opting for rational reflection and
abandonment of traditional ways of thinking opened up the idea of suicide as a solution to
individual problems. Further, Tarde (1903 [1895]) proposed the Imitative Theory of Suicide
and claimed that such geographic and temporal clustering of suicides with rising modernity
could also be caused by various kinds of imitative behaviour. Imitation is a social behaviour
where humans often copy the actions and behaviours of their proximate environments in high
esteem, especially if those actions are meaningful. Suicides due to imitation at a given time and
place can provoke more suicides in a chain leading to the development of geographical
pocket(s) of suicide.
Complimentary Copy
Durkheimian Classic Work

Based on the observations made by the moral statisticians and Masaryk, Emile Durkheim
(1897) went further to analyze how the dramatic social changes of modernity were responsible
for inducing negative meanings and emotions in individuals and groups, making them
vulnerable to suicide. During the process, he denied Tarde’s imitation theory of suicide.
Durkheim claimed four distinct types of suicide based on the intersection of two social
constructs of individuals: integration and regulation. By social integration he meant the sense
of social belongingness, love and care coming from social ties while social regulation was about
the monitoring, oversight, and guidance coming from social ties. The under- and over-
integration and regulation can lead to suicide. Individuals remain in harmony with their own
needs and the demands of society only when these forces are balanced. The four basic types of
suicide as proposed by Emile Durkheim are:
(1) Egoistic suicide: A condition where social integration is too low. Here, the individual
does not feel well integrated into society (Ritzer & Goodman 2004). When social
integration is low, the individual starts feeling as if he/she is not a part of the
community, and the community also feels that the individual is not part of the lifestyle
of the community. This leads to a feeling of being isolated and the individual fails to
obtain the moral guidance required to function in their social environment. As per
Durkheim, persons not integrated into society are more prone to commit suicide
because for them suicide is an option to reduce their negative feelings.
(2) Altruistic suicide: A condition where social integration is too high (Ritzer & Goodman
2004). Altruistic suicide occurs when the individual is too integrated into society.
According to Durkheim, there is an overwhelming pressure to succeed for the greater
good when the individual is too integrated. Such individuals commit suicide because
they believe it is good for their society (i.e., suicide bombers). In another way, if there
is an overwhelming pressure to live up to the expectations of society but the individual
fails, he/she may commit suicide (e.g., Samurai warrior).
(3) Anomic suicide: A condition where social regulation is disrupted (Ritzer &Goodman
2004). Such disruptions, for example, can occur during an economic boom or
depression. Because of disruption in social regulation, individuals are unable to get
proper guidance over what norms and values they should be following. Such
individuals are in a fix to decide what norms and values still apply and what new norms
and values need to be followed.
(4) Fatalistic suicide: A condition where social regulation is too high. According to Ritzer
&Goodman (2004), fatalistic suicide has been discussed by Durkheim in a footnote
only. In this type of suicide, the individual has feelings that he/she has no control over
own life (e.g., a slave committing suicide because of his hopeless position)
Post-Durkheimian Period
Durkheim’s classic work On Suicide (2006 [1897]) stimulated suicide researchers across the
world in the first half of the 20th century. Overall, the post-Durkheimian period is difficult to
summarise. The sociologists of the period believed the central idea of social integration
resulting in suicide and this came out with different tags, such as social isolation (Trout, 1980),
social cohesion (Kawachi& Kennedy, 1997), or social support (Berkman et al., 2000).
Subsequently, multiple ecological models (Cavan, 1928; Schmid, 1928; Porterfield, 1949;
Complimentary Copy
Sainsbury, 1955) of urban suicide emerged based on the statistical data of suicide as well as the
community-based observations of how individuals and groups were influenced by their urban
environments. However, such ecological models lost their lustre with emerging views of the
period.
Gibbs & Martin (1964) developed the status integration theory of suicide and it was in
sharp contrast to Durkheim’s concept of two different social constructs- integration and
regulation. According to them, social integration depends upon an individual’s distinct social
role as influenced by his/her age, sex, occupation, and marital status. A break in social
integration is the critical defining feature of suicide. They argued that suicide rates increased in
social conditions in which subjects underwent a high degree of irresolvable role conflict. This
theory was more practical and testable to explain suicidal behaviour in comparison to
Durkheim’s notions of social integration and regulation. Despite a promising approach, this
theory was not well supported by subsequent theorists.
Baechler (1979) considered suicidal behavior as a way of responding to and trying to solve
a problem and thus divided suicide into four main types:
(1) Escapist Suicide: This can take three different forms: (a) As a means of flight from an
intolerable situation; (b) As a response to the grief generated out of the loss of
something highly significant; and (c) As a means of self-punishment for the feeling of
something done wrong.
(2) Aggressive Suicide: This can take different shapes with the central aim to harm others
by losing one’s life. In Vengeance suicides, the victims intend to make others feel
guilty or to bring condemnation on them from society. In Crime suicides, there is an
intention to kill another individual while doing their suicidal act. In Blackmail suicides,
there is a hidden intention by the victim to make others realize to change their
behaviour as per his/her wish. In Appeal suicides, the victim intends to show others
that he/she needs help.
(3) Oblative Suicide: There are two such suicides whereby the victim tries to achieve
something extremely valuable to him/her. In Sacrifice suicide, the victim prefers to
give their own lives to save another person. In Transfiguration suicide, the victim uses
the act of suicide to attain a more desirable state which is not possible while alive, for
example, a lover commits suicide to join his/her loved one in the afterlife.
(4) Ludic Suicides: Such suicides are characterized by taking deliberate self-harm risks
that might end in death.
Influenced by the insights from psychoanalytical theory, Henry & Short (1954) proposed
the aggression-frustration model of suicide and homicide. They argued that suicide and
homicide are two sides of the same coin - violent aggression. Frustration leads to aggression
which can further lead to lethal violence. If violence is directed towards the self, it produces
suicide while violence directed towards others produces homicide. According to Henry &
Short, the genesis of violent aggression could only be understood by taking into account
sociological and psychological variables. They claimed that people from low socioeconomic
status blame others for their frustration and so have low suicide rates while those from high
status blame themselves for the same and have high suicide rates. However, subsequent
sociologists (Gold, 1958; Rehkopf & Buka, 2006) produced inconsistent findings on social
status and suicide.
Complimentary Copy
Psychological Aspects of Suicide
Psychoanalytically Oriented Theories

The first important psychological insight into suicide came from Sigmund Freud. Freud (1920),
in his seminal work- Beyond the Pleasure Principle, talked about an individual’s two opposing
basic instincts- life drive and death drive. According to him, the life drive is aimed to reduce
the tension associated with one’s life while the death drive is aimed to eliminate the tension of
one’s life itself. He argued that the suicidal behavior of an individual is an earlier repressed
desire to destroy/eliminate a significant other individual (e.g., parent, lover), which he referred
to as retroflexed rage, i.e., hostile aggression turned inward. In line with the psychoanalytic
explanation of suicidal behavior by Sigmund Freud, many theorists (Menninger, 1938; Zilborg,
1936; Klein, 1948; Wahl, 1957; Adler, 1958; Rojtenberg, 1995) subsequently presented their
diverse psychoanalytical views behind the suicidal behaviour, but the Freudian approach has
been much talked about. The classical psychodynamic theories have been criticized because
they have emphasized too much the self-destructiveness as an integral biological need of the
human personality; further, they are mostly unsuitable for empirical testing. In a review and
analysis of common self-destructive tendencies, Baumeister and Scher (1988) found no
empirical evidence for primary self-destruction in humans and they suggested that only
distorted psychological conditions could result in suicide.
Cognitive and Behavioral Theories

The primary emphasis over the past 40 years has tended to center on cognitive and behavioural
aspects of suicide.
Shneidman’s Theory of Psychache

Shneidman (1993) was among the first to address the unique cognitive aspects of suicide. He
coined the term ‘psychache’ by which he meant the unbearable psychological pain arising
mainly from frustrated psychological needs and claimed it to be a precursor of suicide.
According to Shneidman, there are two types of needs in an individual: a) primary or biological
needs and b) secondary or psychological needs. In psychological needs, a person wishes for
love, belongingness, a sense of control, a positive self-image and a meaningful relationship
with others. The psychache develops if there is rejection, hate, failure or loss leading to
frustration of the psychological needs. To relieve the psychache, the person seeks a solution till
death. Shneidman has defined ten common characteristics (“communalities”) of completed
suicide:
(1) To seek a solution − a common purpose of suicide;

(2) Cessation of consciousness (i.e., the end of the conscious experience of an endless
stream of distressing thoughts) − a common goal of suicide;
(3) Intolerable psychological pain (e.g., excruciating negative emotions − including
shame, guilt, anger, fear, and sadness) − common stimuli in suicide;
(4) Frustrated psychological needs (e.g., high unemployment, failures, etc.) − common
stressors of suicide;
(5) Hopelessness and helplessness (e.g., a pervasive sense of pessimistic expectations
about the future and any help) − the common emotions in suicide;
Complimentary Copy
(6) Ambivalence towards life and death- a common internal attitude in suicide;
(7) Constriction of alternatives to live (e.g., a tunnel vision of self-destructiveness with
loss of problem-solving abilities) – the common cognitive state in suicide;
(8) Escape (i.e., a flight from life itself) - the common action in suicide;
(9) Communication of intent (i.e., verbal and/or behavioural clues of lethal intention) − the
common interpersonal act; and 10. Dysfunctional lifelong coping patterns (i.e.,
repetition of the same dysfunctional coping strategies that they have used in their
lifetime. For example − refusal to ask for help, etc.) − the common consistency in
suicide. Shneidman’s theory of Psychache laid the foundation of many contemporary
suicide models such as the escape theory (Baumeister, 1990) and the cry of pain model
(Williams, 1997). However, the theory was criticized later on because of its certain
limitations. It was unclear what cognitions and emotions constituted the psychache.
Further, the psychache was not easily differentiated from two commonly studied
constructs of suicide namely depression and hopelessness because of their strong
correlation (Troister & Holden, 2012).
Baumeister’s Escape Theory

Baumeister (1990) mentioned that the central motive behind the engagement in suicidal
behaviour is an escape from the aversive situation. He proposed six steps as causal chain
leading to suicide:
(1) a sense of personal failure because of a discrepancy between expected standards and
perceived reality;
(2) a state of self-blame because of attribution of the failure to his characteristics, qualities,
or skills;
(3) a distorted self-awareness because of unforgiving comparison of himself with relevant
standards;
(4) a negative affect (emotion) because of the distorted self-awareness;
(5) a state of cognitive deconstruction (by rejecting and avoiding meaningful thought) in
an attempt to escape the negative affect; and
(6) a state of behavioural disinhibition with passivity, absence of emotion and irrational
concepts leading to the emergence of suicide and other life-threatening behaviours.
Overall, this theory suggests that suicide is the final, rare step in the causal chain of a
particular set of decisions where there is an attempt to escape one’s aversive self-
awareness and heightened negative emotions. However, the empirical evidence of the
usefulness of all the components of the theory is not clear, as pointed out by subsequent
researchers. The concept of disinhibition leading to final suicidal behaviour, as
emphasized by Baumeister (1990), may not be in line with the emerging evidence that
the relationship between suicidal behaviour and impulsivity is indirect and distal
(Anestis et al. 2014).
Williams’ Theory of Arrested Flight (‘Cry of Pain’)

Williams (1997) further extended Baumeister’s definition of suicide as a desire to escape from
the self and suggested that suicidal ideation and behavior develop from perceptions of
entrapment triggered due to defeat and humiliation in stressful situations. According to
Complimentary Copy
Williams and Pollock (2000, 2001), when a person perceives his attempts to solve problems as
unsuccessful, a feeling of entrapment is generated and the suicidal behavior should thus be
considered a ‘cry of pain’ rather than a ‘cry for help’ in response to an intolerable emotional or
situational state. This arrested flight model suicide has three components:
(1) an oversensitivity to cues (actual events or similar themes) signaling defeat or

humiliation: it gives rise to an overwhelming feeling of need to escape;
(2) a sense of being unable to escape: it arises because of person’s problem-solving
difficulties and the associated tendency to retrieve personal memories
(autobiographical) from the past in an over-general way; and
(3) a sense of no possible rescue: it creates a perception that this poor state of affairs will
continue to indefinitely and that the future holds little opportunity, leading to
hopelessness. Overall, this model of suicide is important because it emphasizes an
interaction of emotions and cognitions in the genesis of suicide, where the roles of
entrapment and hopelessness are highlighted; and rescue factors can mediate such
interaction leading to a reduction in suicide risk. However, Williams’ theory has been
criticised too because all components of the model have not been tested simultaneously
in one sample, despite suicide being related to one or more specific components
(Taylor et al., 2009; Taylor et al., 2010).
Beck’s Hopelessness Theory of Suicide

Beck and colleagues (1975, 1985) considered hopelessness to be at the center of suicidal
behavior. Hopelessness was claimed to be an individual’s pervasive negative view of the future.
Because of the hopelessness, a person develops specific cognitive distortions whereby he/she
views one’s experiences negatively and starts believing that any attempt to attain the desired
goal would finally fail. Later on, Beck (1996) revised his theory by introducing the concept of
‘modes’. The ‘modes’ were conceptualized to be interconnected networks/systems of cognitive,
affective, motivational, physiological, and behavioral schemas which are activated
simultaneously by an individual’s internal or external events and thus decide his/her goal-
directed behaviour. The simultaneous activation of these five schemas means that the activation
of one leads to the activation of others. According to Beck (1986), thoughts of hopelessness
bring about a suicidal mode by supposedly negatively activating the network of schemas
leading to a toxic environment in which the suicidal thoughts and behaviour take birth.
Subsequent research suggested that hopelessness was a better predictor of suicide than
depression (Beck et al., 1990) corroborating Beck’s hopelessness theory. However, the theory
was later criticized by other theorists who claimed that hopelessness should not be considered
the stand-alone factor in suicidality where different other risk factors for suicide can also be
important (VanOrden et al., 2010). Further, it was found that hopelessness as a causative factor
of suicide has less specificity. Logically, if hopelessness can be an important risk factor for
suicide, its opposite hope can also be a protective factor (Anestis et al. 2014).
A-B-C-D-E Model of Suicide

This model talks about five important components of Rational Emotive Behavior Therapy
(REBT) developed by Albert Ellis and its application to treat suicidal behavior, especially in
adolescents. REBT is one of many different cognitive behavioral therapeutic models, all based
on certain similar primary assumptions that a person’scognition, emotion, and behavior are not
Complimentary Copy
disparate functions but are, instead, intrinsically integrated and holistic (Ellis & MacLaren,
1998). One assumption that differentiates REBT from other cognitive behavioral therapies is
that it takes the position that behavior and/or emotions are simply consequences of the patient's
core belief structure (Ellis & Bernard, 1983). Thus, other CBTs are simply problem-driven and
attempt to change and/or modify a patient's cognitions but they do not attempt to modify the
overall philosophy and assumptive world of clients whereas REBT does the latter through the
use of disputational methods (Ellis & Bernard, 1983). The usefulness of the REBT model as a
preferred therapeutic technique for suicidal adolescents lies in its five key components (Dryden,
1995) suggested by the acronym A-B-C-D-E.
(1) “A” refers to the activating event (for example, breakup issues of adolescent boys and
girls, poor performance in an examination) leading to the contemplation of suicide.
(2) “B” refers to the rational or irrational or evaluative belief about A. For example, an
adolescent boy with a breakup with his girlfriend can develop an irrational belief that
“he is no longer loveable” or “he is incapable of having another relationship” or he can
develop an evaluative belief that “he is a bad person and a loser.” The evaluative beliefs
are characteristically targeted in REBT models more than in other CBT models.
(3) “C” refers to the behavioral and/or emotional consequence of B. For example, an
adolescent boy with breakup with girlfriend may become depressed, angry, or suicidal.
(4) “D” refers to disputation- a method of directly challenging the adolescent's irrational
beliefs (B) with a prime motive to disrupt the idea of suicide. For example, in the last
case, the adolescent is requested for empirical evidence of how he is a loser or he will
be unable to have another relationship and thereby he can be helped to identify
irrationality surrounding the breakup as well as the idea of killing himself. Other
possible methods to disrupt the suicidal ideation might be to ask how he would develop
further relationships if he were dead. Additionally, he may be asked why does he need
to have a relationship with this girl if she is so “stupid” to dump him? A didactic
disputation strategy (Walen et al., 1980) can be another method of disputing the idea
of suicide in which the therapist can use mini-lectures, analogies, and parables which
revolve around suicide and its repercussions that typically occur when someone
commits suicide.
(5) “E,” refers to the effects (consequences) of D. The fourth step- Disruption is very
unique to REBT which, in comparison to Beck's Socratic questioning, is more direct,
easier to follow and more suitable for growing adolescents and thus capable of required
behavioral/affective/cognitive change in them (Elllis, 1999). Suicide from the
perspective of REBT has later been elaborated by Ellis & Ellis (2006) and it has been
claimed to be a simple, practical and suitable method to be applied in suicidal
individuals. However, there is insufficient research in this area and some of the
researchers like Weinrach (1990) have even questioned the applicability of REBT to
suicidal adolescents citing that it has the capability of rubbing individuals the wrong
way.
Emotion Dysregulation Theory

This theory was proposed by Linehan (1993) in the context of patients with borderline
personality disorder and the suicidal behaviour was claimed to be a distraction mechanism from
the negative intense emotional states (emotional dysregulation) of an individual and his/her
Complimentary Copy
critical environment (emotional invalidation). Based on this theory, Linehan (1993) developed
dialectical behaviour therapy (DBT) as a treatment for patients with borderline personality
disorder. There is growing empirical evidence of this therapy, including a randomized
controlled trial (Linehan et al., 2006), in reducing suicidal and other self-injurious behaviours
of such patients. However, targeting emotional dysregulation as a core feature behind suicidal
behaviour has been criticised by other researchers. Emotional dysregulation is not limited to
borderline personality disorder and it can be an underlying feature of many psychiatric
disorders but the majority of psychiatric disorders do not develop suicidal behaviour (Gross &
Munoz, 1995). Also, a person with emotional dysregulation may not be able to overcome the
fear of the daunting task of suicide (Anestis et al, 2011).
Interpersonal-Psychological Theory of Suicide

As proposed by Van Orden (2010, 2014), this theory claims that death due to suicide is possible
when an individual has both the desire and the ability to enact lethal self-injury. The desire to
commit suicide appears out of the interaction between two dynamic psychological constructs-
‘thwarted belongingness’ and ‘perceived burdensomeness.’ The thwarted belongingness can
have two dimensions- loneliness (e.g., lack of friends, living alone) and the absence of
reciprocal care (like reliable friends). The perceived burdensomeness can range from a belief
of a being burden to loved ones to a state of self-hate. The desire to commit suicide i.e., passive
suicidal ideation can arise out of these two psychological constructs, but these may not be
sufficient for the suicidal act. According to this theory, death by suicide is not easy because it
has to defy the human’s biological instinct for survival. So, for the enactment of lethal self-
injury, one should develop another psychological construct termed ‘acquired capability’ which
includes a lowered fear of death and elevated physical pain tolerance. This dimension of
‘acquired capability’ develops over time with exposure to painful and provocative experiences
like abuse in childhood, a history of parents committing suicide, etc. (Van Orden et al., 2010).
According to this theory of suicide, the three psychological constructs i.e., ‘thwarted
belongingness’, ‘perceived burdensomeness’ and ‘acquired capability’ are interactive and are
all supposed to be necessary for the suicidal act. A recent systematic review and meta-analysis
(Chu et al. 2017) of a decade of cross-national research on the interpersonal theory of suicide
claim that a person can develop suicidal ideation because of the interaction between ‘thwarted
belongingness’ and ‘perceived burdensomeness’ and the interaction of these two constructs
with ‘acquired capability’ is significantly related to a greater number of prior suicide attempts.
It has now been found that the acquired capability can have a genetic component (Smith et al.,
2012).
Integrated Motivational-Volitional (IMV) Model of Suicidal Behaviour

This model, as proposed by O’Connor (2011), presents a broader view of suicide where the
role of motivational and volitional factors is highlighted in the background of biopsychosocial
diatheses and triggering situations. According to this model, suicidal behaviour can have three
phases:
(1) the pre-motivational phase (characterised by background risk and protective factors
and triggering events);
(2) the motivational phase (characterised by the development of suicidal thoughts, desires,
and intentions); and
Complimentary Copy
(3) the volitional phase (characterised by development of the suicidal behaviours). An

individual transits between these three phases as moderated by his/her perceptions of
entrapment triggered by feelings of inescapable defeat and humiliation.
Critiques of Existing Theories of Suicide and Future Direction
Sociologists were first to decide the reasons behind the act of suicide followed by several
psychological theories to describe the suicide. Despite a rigorous effort by researchers around
the world over the last several decades, we are still short of a comprehensive model to describe
suicidal behavior. There have been several challenges in suicide research (Klonsky et al. 2016)
which are summarized below:
Use of Diverse Terms to Explain the Same Phenomenon of Suicide
The existing literature is filled with different terms used by different theorists without any
common consensus among themselves. With this, there is difficulty in integrating the findings
of various published research and deriving a conclusion.
Use of Diverse Measures to Assess the Phenomenon of Suicide
Such diverse measurement approaches (with different aims and tools) make it difficult to
analyse their findings.
Dilemma to Consider Suicidal Ideation/Attempt as a Trait or State
Suicidal ideation/attempt as a state means that the individual experiences the same at a moment
in time which may not be repeated subsequently. The same to consider as a trait means that
he/she is going to experience it repeatedly. Without resolving this dilemma, there can be drastic
differences in research designs and questions.
Stigma to Report Suicide
This can be due to cultural and religious differences across different nations and it can lead to
under-reporting of suicidal ideation/attempts by such individuals and their families.
Obstacles to Studying a Behaviour Like Suicide with a Fatal Outcome
This limits the planning of a longitudinal study or a psychological autopsy study with a higher
sample size and thus there is a poor generalization of the findings. The researchers are thus
Complimentary Copy
forced to suicidal thoughts and/or behaviors as proxy measures for suicide. However, the
correlates and predictors of suicidal ideation/behaviors can be very different from those of
suicide death.
Considering various challenges of existing approaches to studying suicidality, some
researchers have proposed certain fundamental changes in such approaches. Millner and
colleagues (2020) believe in a mechanistic understanding of suicide by applying two such
changes:
(1) There must be a formalization of theories of suicide so that they can be expressed as
mathematical or computational models, and
(2) There must be a launch of rigorous descriptive research works with an emphasis on
the precise measurement of suicidality and its correlates. The authors claim that such
fundamental changes can facilitate the construction of an abductive theory of suicide
which will be easily testable and of clinical utility.
Neurobiological Bases of Suicide
The majority of the research works have suggested that a combination of biological and
environmental factors is important in the causation of suicidal thoughts/behaviours. Multiple
recent research studies have presented a more in-depth understanding of the neurobiology of
suicide. In comparison to non-suicidal individuals, those with suicidality have been found to
have abnormalities in the monoamine system, hypothalamic-pituitary-adrenal (HPA) axis, lipid
metabolism, inflammation, neural plasticity and cell signalling pathways (Capuzzi et al. 2020).
Further, recent years have been devoted to multiple genetic and epigenetic studies related
particularly to the impact of early life experiences on developing brain functioning. The main
findings on potential biological mechanisms likely associated with suicide can be discussed
under the following headings:
Role of the Serotonergic System
Serotonin (5-HT), its metabolite- 5-hydroxy indole acetic acid (5-HIAA), its receptors- 5-
HTRs, and its transporter- SERT, all have been implicated in suicidal behavior.
Serotonin and Its Metabolite

The first evidence of a lower level of CSF 5-HIAA in patients of depression who attempted
suicide or died by suicide was reported by Asberg et al. (1976). Subsequently, a meta-analysis
by Lester (Lester 1995) supported the same citing that a low level of CSF 5-HIAA is associated
with individuals who attempted suicide with violent methods, as compared to controls with a
psychiatric disorder. Recently, another study has found an inverse relationship between the
levels of 5-HIAA and impulsivity in subjects at risk of suicidality (Picouto et al., 2015). As the
5-HT system components are similar in blood platelets and CNS, some studies have explored
significantly low platelet 5-HT concentrations in patients who attempted suicide compared with
Complimentary Copy
non-suicidal patients and controls (Cappuzi et al., 2020). Evidence of lower 5-HT and 5-HIAA
in the brain of subjects who died by suicide are few and inconsistent (Cappuzi et al., 2020).
Serotonin Receptors (5-HTRs)

Out of 13 subtypes of 5-HTRs, three serotonin receptors namely 5-HTR1A, 5-HTR2A and 5-
HTR2C have been commonly found to be associated with suicidal behavior. Post-mortem
studies have consistently reported higher binding of 5-HTR1A in the dorsal raphe nucleus in
suicidal individuals compared with non-suicidal patients and controls (Thompson et al., 2012;
Sullivan et al., 2015). The role of 5-HTR2A is inconsistently reported in post-mortem studies
(Gross-Isseroff et al., 1998) as well as in suicide attempters (Mann et al., 2019). However, a
recent study reports a possible relationship between 5-HTR2A binding and early-life adverse
experiences among patients with depression (Underwood et al., 2018). The role of 5-HTR2C
in suicidal behavior has been studied through mRNA which is subject to post-transcriptional
editing into 33 mRNA different isoforms by alternative pre-mRNA splicing. The risk of
suicidal behavior is higher with increased pre-mRNA editing of 5-HT2C receptors, regardless
of mental illness (Stamm et al., 2017). Earlier, the single nucleotide polymorphism in the
5-HTR1A receptor promoter region and 5-HTR2C allele was reported to be associated with a
higher risk of suicidal behaviour in psychiatric patients (Marshall et al., 1999). Recently, it has
been emphasized that there can be a direct relationship between 5-HTR2A gene polymorphisms
and susceptibility to suicide (Ghasemi et al., 2018).
Serotonin Transporters (SERTs)

A lower concentration of SERTs in the prefrontal cortex has been consistently found in studies
done on persons who committed suicide as well as in those who attempted suicide. Similarly,
lower platelet SERT binding sites have been reported in suicidal patients with mood disorders,
in comparison to non-suicidal counterparts or healthy controls (Miller et al., 2013). However,
the role of brain and platelet SERT parameters as potential biological markers for suicidal
behaviour has not been established.
Role of Hypothalamic-Pituitary-Adrenal (HPA) Axis
In our body, the HPA axis is the principal stress-response-system and its consistent activation
has been linked to tissue damage including brain structures and subsequent involvement in
psychopathology. The researchers have found significantly higher cortisol plasma and CSF
levels, increased cortisol response to ACTH as well as an impaired feedback mechanism of the
HPA axis in patients of depression (Keller et al., 2017). The subjects who died by suicide, in
comparison to the controls who died for other reasons were found to have higher adrenal weight
(Stein et al., 1993), elevated CRH levels in brainstem and CSF as well as lower mRNA CRH1
receptor levels in the frontal cortex (Zhao et al., 2015). Recent research workers have utilized
the Dexamethasone Suppression Test (DST) to assess suicidal behaviour and have found a non-
suppression DST to consistently predict future suicide in follow-up studies of individuals
affected by a major depressive disorder or previous suicide attempters (Lindqvist et al., 2016).
Further, a higher DST non-suppression leading to higher cortisol has been linked with higher
lethal means of suicidal behaviour as well as a higher risk of suicide completion (Yerevanian
et al., 2004). However, the use of DST to predict suicidality in clinical scenarios has been
Complimentary Copy
criticised because this may not adequately mimic the physiological HPA response to stressors
and its result should be judged based on other significant variables related to suicidal behaviour
in an individual (McGirr et al., 2011). In this regard, a recent meta-analysis (O’Connor et al.,
2016) reports that a higher frequency of completion of suicide in persons with DST-non-
suppression can be due to their failure to respond to antidepressants when used to treat
depression with suicidal tendencies. The meta-analysis also reports a significant direct
relationship between the cortisol level and suicidal behaviour as a function of age, i.e.,
individuals below 40 have a higher chance. However, there might be desensitization of HPA
axis to risky behaviors typical of adolescents leading to even a low level of cortisol (Beauchaine
et al., 2015). Earlier research works pointed toward a functional connection of the HPA axis
with the serotonergic system leading to suicidal behaviors in individuals. However, some recent
researchers suggest that the connection is complex and should be understood through genetic
polymorphism of the 5-HTTLPR (serotonin-transporter-linked promoter region) gene that
codes for the serotonin transporter. Particularly the persons who carry long polymorphism (LL)
of the 5-HTTLPR gene can be more vulnerable to having high cortisol responsiveness to
psychosocial stress in comparison to those carrying at least one short (S) allele (Aleknaviciute
et al., 2018).
Role of Lipids
Cholesterol and Triglycerides

The lipid content of the cell membrane of neurons helps to maintain its fluidity. The lipid rafts
created with a typical grouping of cholesterol in the membrane help to stabilize the receptors,
enzymes and G-proteins and thereby facilitates various membrane functions like signal
transduction, intracellular trafficking and communication with the cytoskeleton (da
GracaCantarelli et al., 2015). Thus, a low lipid content can lead to reduced presentation of
serotonin receptors (5-HTRs) on the neuronal cell membrane which brings about reduced
serotonergic signalling (Yang, 2003) and generation of impulsivity and violent suicidal
behaviour (Capuzzi et al., 2018). Logically, the use of the 3-hydroxy-3-methyl-glutaryl-CoA
reductase inhibitors or statins, the lipid lowering agents, has been tested to increase the risk of
suicidality (Muldoon et al., 1990). A subsequent meta-analysis by the same authors (Muldoon
et al., 2001), however, denies such an association. In addition, the symptoms like aggression,
mood changes, and intentional injuries have been reported as adverse reactions of lipid-
lowering drugs in some observational studies and pharmacovigilance databases (Tatley et al.,
2007). Further, individual factors like age, BMI (basal metabolic index), physical activities,
dietary factors, comorbidities of various psychiatric and medical conditions, and their
treatments can affect lipid metabolism, and so can be possible confounding factors in the
relationship between suicide attempt and serum lipid levels (Capuzzi et al., 2018). Also, some
recent researchers think that serum lipid levels may not be reliable markers of lipid present in
the brain, and they cannot be considered biological markers of suicide (Capuzzi et al., 2020).
Polyunsaturated Fatty Acids

The omega-3 (n-3) and omega-6 (n-6) polyunsaturated fatty acids (PUFAs) exert important
functions in the central nervous system such as synapse formation, neurotransmission, and
signal transduction (Yu et al., 2016), and they have been postulated to have a role in the onset
Complimentary Copy
of psychiatric disorders and suicidal behavior (Simopoulos et al., 2008, Lewis et al., 2011). An
alteration of the ratio of n-3 PUFAs and cholesterol can affect the lipid rafts of the neuronal
cell membrane leading to disturbances in the proper functioning of the receptors, ion channels
and transporters embedded in the membrane (Daray et al., 2018). Further, it has been suggested
that an increase in the ratio of n-6 PUFAs and n-3 PUFAs may cause the activation of Toll-like
receptors (TLR) and nuclear transcription factors in the neurons along with a dysregulation of
the Hypothalamic-Pituitary-Adrenal (HPA) axis (Daray et al., 2018). Such intracellular
changes are supposed to generate various neuroinflammatory processes, which may explain
any possible association between PUFAs and suicidality. However, the direct link between low
serum PUFAs and suicide risk is inconclusive (Capuzzi et al., 2020) and so is the role of
adequate consumption or prescription of PUFAs as a preventive measure for suicide risk.
Role of Inflammation
Neuroimmune System
Dysregulation of cytokines has been reported in different psychiatric disorders, including
depression, bipolar disorder and schizophrenia (Dubois et al., 2018). An alteration of
inflammatory markers like interleukin (IL)-2, IL-4 and transforming growth factor (TGF)-β
have also been hypothesized to be associated with suicidal behavior independently from a
mental disorder (Ducasse et al., 2015). In some port-mortem studies of the brains of suicide
victims, increased levels of mRNA transcript as well as various inflammatory cytokines like
IL-1β, IL-6 and tumour necrosis factor (TNF)-α have been found in certain cortical regions and
the CSF (Pandey et al., 2012). Overall, the role of inflammatory reactions appears to be similar
across persons with suicidal ideation, suicidal attempters and completers, although with
different degrees (Brundin et al., 2017).
The Kynurenine Pathway Metabolites

Tryptophan is a precursor of the neurotransmitter- serotonin and a disturbed metabolism of
tryptophan, because of neuroinflammation, may be related to increased suicidality (Capuzzi et
al., 2020). Two by-products of the given metabolic pathway, namely, quinolinic acid (QUIN)
and kynurenic acid (KYNA) are known to affect the glutamatergic neurotransmission where
the QUIN induces glutamate release while KYNA inhibits glutamate release in the extracellular
brain regions and thus, they respectively promote and avoid the release of inflammatory
cytokines. Studies have suggested higher plasma and CSF levels of QUIN in suicide attempters
(Steiner et al., 2011) while a lower or no alteration in KYNA levels in suicidal patients
(Carlborg et al., 2013). A twofold increase in the ratio of CSF QUIN/KYNA was found in
suicide attempters compared with healthy controls (Erhardt et al. 2013, Bay-Richter et al.,
2015).
Role of Neuronal Plasticity
Among the trophic factors responsible for neuronal plasticity, the BDNF (brain- derived
neurotrophic factor) and its receptor (tyrosine receptor kinase B-TrkB) are the two most
Complimentary Copy
commonly studied factors to be associated with suicidal behavior (Pandey et al., 2012). Since
BDNF is mainly produced by brain structures, its plasma level, and not the serum level, is the
more reliable biological sample of CNS activity. Recent meta-analyses have suggested an
association between low plasma BDNF and increased suicidality (Salas-Magan et al., 2017,
Eisen et al., 2015). A lower level of BDNF and Trk-B signalling has also been reported in the
brain tissue of suicide victims compared to healthy controls (Khan et al., 2019). Given the
robust role of BDNF in multiple neuronal activities, the BDNF gene has been labeled as one of
the candidate genes responsible for suicide risk. BDNF polymorphism like the Val/Val
genotype may favour suicidal behavior in Asians whereas the Met alleles may favour suicidal
behaviour in Caucasians (Gonza´lez-Castro et al., 2017). Further, it has been claimed that early
childhood adverse experiences may promote different BDNF gene polymorphisms leading to
increased suicidality in them and thus supporting the role of gene-environment interactions in
the causation of suicidal behavior (Zai et al., 2019).
Neuroimaging Findings and Suicidal Behaviour
Recent decades have seen reports of neuroimaging biomarkers of suicide in terms of structural
and functional abnormalities in several brain regions. Principal brain regions implicated to be
affected in individuals with a history of suicidal behavior are the prefrontal, cingulate, and
striatal areas (vanHeeringen et al., 2014). A recent review of neuroimaging studies of suicidal
behaviour and non-suicidal self-injury in psychiatric patients concludes that frontal cortex
volume reduction and insular cortex changes are consistently linked to suicidality in patients
with major depressive disorder (Domínguez-Baleón et al., 2018).
In the frontal lobe, the left ventrolateral, orbitofrontal, and dorsolateral regions of the
prefrontal cortex are commonly affected in suicidal patients (Ding et al., 2015). Functional MRI
(fMRI) based neuropsychological assessments have found a reduced prefrontal cortical
activation during a verbal fluency task to be associated with suicidal ideation (Pu et al., 2017).
Similarly, an altered prefrontal cortical activation on fMRI has been found, in persons with a
history of suicide attempts, to be associated with impaired decision-making during their risk-
reward assessment and social assessment (Ding et al., 2015; Olié et al., 2015; Sudol& Mann,
2017). Post-mortem studies too claim that the prefrontal cortex is involved in subjects who died
by suicide in terms of alterations of serotonin (5-HT) receptors (Underwood et al., 2018), and
an increased TNF-α expression (Wang et al., 2018) in the region. These findings further support
the role of the serotoninergic and inflammatory systems in suicidal behaviour.
Apart from the prefrontal cortex, the involvement of the insular cortex in suicidal behaviors
in cases of depression has recently been reported (Peng et al., 2014; Taylor et al., 2015; Jollant
et al., 2018). In a PET (positron emission tomography) scan-based prospective study, as
observed over 2 years, significantly higher lethal suicidal attempts in patients with depression
were related to a higher 5HT1A receptor binding potential in the insular cortex (Oquendo et
al., 2016). Recently, in a cross-sectional study (Rizk et al., 2019), the grey matter volume in
the insula was significantly higher in those patients with major depression who were violent
suicide attempters than those with non-violent suicide attempts. A recent voxel-wise meta-
analysis has reported that a history of suicidal attempts in patients with depression is linked to
increased brain activation in the left insula, and decreased brain activations in the bilateral
fusiform gyrus (Li et al., 2019).
Complimentary Copy
The striatum region of the brain is also affected by different suicidal behaviors in patients
with depression. The alterations in this part of the brain have been claimed to predict suicidal
ideation (Ho et al., 2018), suicide attempts (Gifuni et al., 2016), and completed suicide
(Willeumier et al., 2011). However, such changes in the striatum have not been detected using
traditional neuroimaging approaches, such as magnetic resonance tomography but with more
advanced neuroimaging techniques like SPECT, etc.
Further, with the advancement of neuroimaging techniques, researchers have targeted
different functional neurocircuitries to be affected by suicidal behaviour. Abnormalities in the
amygdala–pre-cuneus/cuneus and frontal-subcortical functional connectivity have been
highlighted in patients with suicidal ideation (Wei et al., 2018). However, there is a lack of
robust and consistent structural neuroimaging markers for all suicidal behaviours, as reported
in a recent meta-analysis of 12 different neuroimaging studies with almost 700 participants
(Jollant et al., 2018). It is important to take into account the different comorbidities, in
comparatively larger studies, to clarify the exact role of the brain network connectivity in
suicidal behaviors.
Genetic Basis of Suicide
Over the last decade, the genetic research on suicide has shifted from a single construct of
suicidal thought/behavior to three significantly different heritable phenotypes: suicidal
ideation, suicide attempt, and suicide death (DiBlasi et al., 2021). Generally, genetic study
designs have treated these suicidal thoughts and behaviours as traits, to determine which genes
and neurobiological pathways confer risk and protection. Such psychiatric genetics approaches
have enabled researchers to quickly estimate shared molecular genetic covariances across many
phenotypes as well as the examination of potential causes of heterogeneity relative to
epidemiological observations (DiBlasi et al., 2021). However, the field of genetics of
psychiatric conditions, including suicide, is still growing, and the causal link between the risk
factors and the underlying biology of vulnerability to suicide are still not fully known
(Lengvenyte et al., 2019). The involvement of genetic factors in suicide risk is supported by
the findings of family, twin and genetic studies (Levey et al., 2019; Tidemalm et al., 2011).
Family, Twin, and Adoption Studies
A total population study in Sweden aimed to compare the rates of suicide among relatives of
83951 persons who died by suicide between 1952 and 2003, as reported in the national registers,
with the relatives of the control population. It was found that the children, full siblings, and
monozygotic twins of suicide descendants, respectively had 2, 3, and 15 times higher relative
risk of suicide (Tidemalm et al., 2011). An adoption study in Denmark found that, in
comparison to the siblings of adoptees who never attempted suicide (i.e., the control group),
there was >3 times higher risk of suicide among the siblings of adoptees who attempted suicide
(Petersen et al., 2014). Certain familial traits have also been found to be risk factors for suicide.
For example, in a family study, impulsive aggressive behaviour appeared as the mediator factor
in suicidal behaviour when the first-degree relatives of depressed patients with suicidal
Complimentary Copy
behaviour were compared with first-degree relatives of depressed patients without suicidal
behaviour (Mcgirr et al., 2009). Another study reported that the first-degree relatives of persons
who committed suicide had subtle decision-making deficits, as assessed on cognitive
performance tests, which were not demonstrable in such relatives of two control groups- i.e.,
the patients with major depressive disorder and the healthy control subjects (Hoehne et al.,
2015). However, the effect size of the group differences of familial traits linked with suicidal
behaviour has been low. This indicates that there can be more than one predisposing factor
contributing to an increased risk of suicidal behaviour in family members. This is further
supported by the findings of different candidate-gene studies that the role of each gene in
deciding different suicidal behaviours is very small.
Epigenetic Studies
Epigenetics deal with gene-environment interactions where the role of one’s behaviour and
environment on the functioning of genes are studied. Epigenetic studies can contribute
significantly to gaining insight into the pathways leading to suicide. In general, epigenetic
changes, unlike genetic changes, are reversible with no impact on the DNA sequence, but they
can alter the way our body reads a DNA sequence. Epigenetic changes can produce heritable
phenotypic changes by modulating the gene expression of suicidal behaviour in response to
environmental stimuli (Roy & Dwivedi, 2017). Such epigenetic changes have been found to
start during intra-uterine life and perinatal periods and can persist throughout life. A recent
meta-analysis about the in-utero and perinatal influences on suicide risk, claims that the
epigenetic changes during the perinatal period may mediate the association between increased
suicide risk during the entire lifetime but the underlying mechanisms of the reported
associations and their causal nature are still unclear (Orri et al., 2019). Important epigenetic
changes associated with suicidal behaviour include DNA methylation, histone modification
(methylation or acetylation), and microRNA (miRNA) (Zhang et al., 2020). There is epigenetic
regulation of important biological substrates of suicidal behaviour like BDNF, Trk-B, HPA
axis components, and GABA-A receptors (Kouter et al., 2019; Autry & Monteggia, 2009;
Misztak et al., 2020). In persons who died by suicide, there is evidence of epigenetic
mechanisms playing an important role in suicidality. In post-mortem studies, the total DNA
hypermethylation in the Wernicki cortex and prefrontal cortex as well as the increased
expression of DNA methyltransferase (DNMT), the enzyme which methylates DNA in the
frontal cortex, are important findings (Poulter et al., 2008; Taurecki, 2014; Autry and
Monteggia, 2009, Misztak et al., 2020). Overall, the epigenetic aspect of suicidal behaviour is
a growing field of research.
Molecular Genetics and Genome-Wide Association Studies
The establishment of genetic loci for various suicidal behaviours can be important to better
understand the biological mechanisms and drug targets. The genome-wide association studies
have helped the international research community to establish thousands of common genetic
variants contributing, to varying degrees, to psychiatric disorders in general (Sullivan &
Geschwind, 2019). For various suicidal behaviours (suicidal ideation, suicidal attempt, and
Complimentary Copy
completed suicide), the results of these genome-wide association studies, limited mostly to
European ancestry populations, appear promising but with limited clinical utility (DiBlasi et
al., 2021). The major challenges in this direction have been the low predictive powers of various
suicidal thoughts and behaviour along with their overall low base rates.
Conclusion
Suicide is an unnatural phenomenon to end own’s life and its incidence is increasing day by
day across the globe. Researchers and philosophers have proposed multiple explanations of its
occurrence but its exact prediction is still challenging. Starting with the contributions of
sociologists including the landmark work of Emil Durkheim, multiple eminent psychologists
have tried to explain the phenomenon of suicide. With the advancement of biological sciences,
researchers around the world are continuously trying to establish the link of suicidality with
significant biological changes/markers in living beings as well as in those who died by suicide.
However, the conclusive proofs are still awaited. Suicide is not only the result of psychiatric
disorders like major depression but it may be associated with other psychiatric and physical
disorders and can happen even alone. Suicide should be considered a complex biopsychosocial
phenomenon based on the involvement of different combinations of biological, psychological
and social factors of an individual. However, despite the landmark achievements by human
beings in almost all spheres of life, we are still struggling to discover the way(s) to predict and
stop suicide.
References
Adler, A. (1958). Suicide. Journal of Individual Psychology, 14, 57–61.

Aleknaviciute, J., Tulen, J. H. M., de Rijke, Y. B., van der Kroeg, M., Kooiman, C. G., and Kushner, S. A.
(2018). The 5-HTTLPR genotype, early life adversity and cortisol responsivity to psychosocial stress in
women. British Journal of Psychiatry Open, 4(4), 180–185. https://doi.org/10.1192/bjo.2018.23.
Anestis, M. D., Bagge, C. L., Tull, M. T., and Joiner, T. E. (2011). Clarifying the role of emotion dysregulation
in the interpersonal-psychological theory of suicidal behavior in an undergraduate sample. Journal of
Psychiatric Research, 45(5), 603–611. https://doi.org/10.1016/j.jpsychires.2010.10.013.
Anestis, M. D., Moberg, F. B., and Arnau, R. C. (2014). Hope and the interpersonal-psychological theory of
suicidal behavior: Replication and extension of prior findings. Suicide and Life-Threatening Behavior,
44(2), 175–187. https://doi.org/10.1111/sltb.12060.
Anestis, M. D., Soberay, K. A., Gutierrez, P. M., Hernandez, T. D., and Joiner, T. E. (2014). Reconsidering the
link between impulsivity and suicidal behavior. Personality and Social Psychology Review, 18(4), 366-
386.
Asberg, M., Träskman, L., and Thorén, P. (1976). 5-HIAA in the cerebrospinal fluid. A biochemical suicide
predictor? Archives of General Psychiatry, 33(10), 1193–1197. https://doi.org/10.1001/
archpsyc.1976.01770100055005.
Baechler, J. (1979). Suicides. Blackwell Publishing.
Baldessarini, R. J. (2019). Epidemiology of suicide: Recent developments. Epidemiology and Psychiatric
Sciences, 29, e71. https://doi.org/10.1017/S2045796019000672.
Barker, E., Kõlves, K., and De Leo, D. (2015). The relationship between asthma and suicidal behaviours: A
systematic literature review. European Respiratory Journal, 46(1), 96–106. https://doi.org/10.1183/
09031936.00011415.
Complimentary Copy
Baumeister, R. F., and Scher, S. J. (1988). Self-defeating behavior patterns among normal individuals: Review
and analysis of common self-destructive tendencies. Psychological Bulletin, 104(1), 3–22.
https://doi.org/10.1037/0033-2909.104.1.3.
Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 97(1), 90–113_113.
https://doi.org/10.1037/0033-295x.97.1.90.
Bay-Richter, C., Linderholm, K. R., Lim, C. K., Samuelsson, M., Traskman-Bendz, L., Guillemin, G. J.,
Erhardt, S., and Brundin, L. (2015). A role for inflammatory metabolites as modulators of the glutamate
N-methyl-D-aspartate receptor in depression and suicidality, Brain Behavior and Immunity, 43, 110–117.
Beauchaine, T. P., Crowell, S. E., and Hsiao, R. C. (2015). Post-dexamethasone cortisol, selfinflicted injury,
and suicidal ideation among depressed adolescent girls. Journal of Abnormal Child Psychology, 43(4),
619–632. https://doi.org/10.1007/s10802-014-9933-2.
Beck, A. T. (1986). Hopelessness as a predictor of eventual suicide. Annals of the New York Academy of
Sciences, 487, 90–96. https://doi.org/10.1111/j.1749-6632.1986.tb27888.x.
Beck, A. T. (1996). Beyond belief: A theory of modes, personality, and psychopathology. In P. Salkovskis
(Ed.), Frontiers of cognitivetherapy (pp. 1–25). Guilford Press.
Beck, A. T., Brown, G., Berchick, R. J., Stewart, B. L., and Steer, R. A. (1990). Relationship between
hopelessness and ultimate suicide: A replication with psychiatric outpatients. American Journal of
Psychiatry, 147(2), 190–195_195. https://doi.org/10.1176/ajp.147.2.190.
Beck, A. T., Kovacs, M., and Weissman, A. (1975). Hopelessness and suicidal behavior: An overview. JAMA,
234(11), 1146–1149. https://doi.org/10.1001/jama.1975.03260240050026.
Beck, A. T., Steer, R. A., Kovacs, M., and Garrison, B. (1985). Hopelessness and eventual suicide: A 10-year
prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 142(5),
559–563_563. https://doi.org/10.1176/ajp.142.5.559.
Berkman, L. F., Glass, T., Brissette, I., and Seeman, T. E. (2000). From social integration to health: Durkheim
in the new millennium. Social Science and Medicine, 51(6), 843–857. https://doi.org/10.1016/s0277-
9536(00)00065-4.
Brundin, L., Bryleva, E. Y., and Rajamani, K. T. (2017). Role of inflammation in suicide:from mechanisms to
treatment. Neuropsychopharmacology, 42(1), 271–283. https://doi.org/10.1038/npp.2016.116.
Capuzzi, E., Caldiroli, A., Capellazzi, M., Tagliabue, I., Buoli, M., and Clerici, M. (2020). Biomarkers of
suicidal behaviors: A comprehensive critical review. Advances in Clinical Chemistry, 96, 179–216.
https://doi.org/10.1016/bs.acc.2019.11.005.
Capuzzi, F., Bartoli, C., Crocamo, M. R., Malerba, M., and Clerici, G. (2018). Carra, Recent suicide attempts
and serum lipid profile in subjects with mental disorders: A cross-sectional study. Psychiatry Research,
270, 611–615.
Carlborg, A., Jokinen, J., Jönsson, E. G., Erhardt, S., and Nordström, P. (2013). CSF kynurenic acid and suicide
risk in schizophrenia spectrum psychosis. Psychiatry Research, 205(1–2), 165–167.
https://doi.org/10.1016/j.psychres.2012.08.021.
Catalan, J., Harding, R., Sibley, E., Clucas, C., Croome, N., and Sherr, L. (2011). HIV infection and mental
health: Suicidal behaviour–systematic review. Psychology, Health and Medicine, 16(5), 588–611.
https://doi.org/10.1080/13548506.2011.582125.
Cavan, R. (1928). Suicide. University of Chicago Press.
Chesney, E., Goodwin, G. M., and Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders:
A meta-review. World Psychiatry, 13(2), 153–160. https://doi.org/10.1002/wps.20128.
Chu, C., Buchman-Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R., Rogers, M. L.,
Podlogar, M. C., Chiurliza, B., Ringer, F. B., Michaels, M. S., Patros, C. H. G., and Joiner, T. E. (2017).
The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national
research. Psychological Bulletin, 143(12), 1313–1345. https://doi.org/10.1037/bul0000123.
da GraçaCantarelli, M., Nardin, P., Buffon, A., Eidt, M. C., Antônio Godoy, L., Fernandes, B. S., Gonçalves,
C. A. (2015). Serum triglycerides, but not cholesterol or leptin, are decreased in suicide attempters with
mood disorders, Journal of Affective Disorders, 172 (1), 403–409.
Daray, F. M., Mann, J. J., and Sublette, M. E. (2018). How lipids may affect risk for suicidal behaviour. Journal
of Psychiatric Research, 104, 16–23. https://doi.org/10.1016/j.jpsychires.2018.06.007.
Complimentary Copy
De Berardis, D., Fornaro, M., Valchera, A., Cavuto, M., Perna, G., Di Nicola, M., Serafini, G., Carano, A.,
Pompili, M., Vellante, F., Orsolini, L., Fiengo, A., Ventriglio, A., Yong-Ku, K., Martinotti, G., Di
Giannantonio, M., and Tomasetti, C. (2018). Eradicating suicide at its roots: Preclinical bases and clinical
evidence of the efficacy of ketamine in the treatment of suicidal behaviors. International Journal of
Molecular Sciences, 19(10), 2888. https://doi.org/10.3390/ijms19102888.
de Heer, E. W., Ten Have, M., van Marwijk, H. W. J., Dekker, J., de Graaf, R., Beekman, A. T. F., and van der
Feltz-Cornelis, C. M. (2020). Pain as a risk factor for suicidal ideation. A population based longitudinal
cohort study. General Hospital Psychiatry, 63, 54-61.
Di Blasi, E., Kang, J., and Docherty, A. R. (2021). Genetic contributions to suicidal thoughts and behaviors.
Psychological Medicine, 51(13), 2148–2155. https://doi.org/10.1017/S0033291721001720.
Ding, Y., Lawrence, N., Olié, E., Cyprien, F., le Bars, E., Bonafé, A., Phillips, M. L., Courtet, P., and Jollant,
F.(2015). Prefrontal cortex markers of suicidal vulnerability in mood disorders: A model-based structural
neuroimaging study with a translational perspective. Translational Psychiatry, 5, e516–e516.
https://doi.org/10.1038/tp.2015.1.
Domínguez-Baleón, C., Gutiérrez-Mondragón, L. F., Campos-González, A. I., and Rentería, M. E. (2018).
Neuroimaging studies of suicidal behavior and non-suicidal self-injury in psychiatric patients: A
systematic review. Frontiers in Psychiatry, 9, 500. https://doi.org/10.3389/fpsyt.2018.00500.
Dryden, W. (1995). Brief rational-emotive behaviour therapy. John Wiley & Sons.
Dubois, T., Reynaert, C., Jacques, D., Lepiece, B., Patigny, P., and Zdanowicz, N. (2018). Immunity and
psychiatric disorders: Variabilities of immunity biomarkers are they specific? Psychiatria Danubina,
30(Suppl. 7), 447–451.
Ducasse, D., Holden, R. R., Boyer, L., Artéro, S., Calati, R., Guillaume, S., Courtet, P., and Olié, E. (2018b).
Psychological pain in suicidality: A meta-analysis. Journal of Clinical Psychiatry, 79(3).
https://doi.org/10.4088/JCP.16r10732.
Ducasse, D., Loas, G., Dassa, D., Gramaglia, C., Zeppegno, P., Guillaume, S., Olié, E., and Courtet, P. (2018a).
Anhedonia is associated with suicidal ideation independently of depression: A meta-analysis. Depression
and Anxiety, 35(5), 382–392. https://doi.org/10.1002/da.22709.
Ducasse, D., Olié, E., Guillaume, S., Artéro, S., and Courtet, P. (2015). A meta-analysis of cytokines in suicidal
behavior. Brain, Behavior, and Immunity, 46, 203–211.https://doi.org/10.1016/j.bbi.2015.02.004.
Eisen, R. B., Perera, S., Banfield, L., Anglin, R., Minuzzi, L., and Samaan, Z. (2015). Association between
BDNF levels and suicidal behaviour: A systematic review and meta-analysis. Systematic Reviews, 4, 187.
https://doi.org/10.1186/s13643-015-0179-z.
Ellis, A. (1999). Working with difficult adolescents. Symposium conducted at the Philadelphia College of
Osteopathic Medicine, Philadelphia, PA.
Ellis, A., and Bernard, E. M. (1983). An overview of rational-emotive approaches to the problems of childhood.
In A. Ellis & M .Bernard (Eds.), Rational-emotive approaches to the problems of childhood (pp. 1–43).
Plenum Press.
Ellis, A., and Ellis, T. E. (2006). Suicide from the perspective of rational emotive behavior therapy. In T.E.
Ellis(Ed.), Cognition and suicide(pp. 75–90). American Psychological Association.
Ellis, A., and MacLaren, C. (1998). Rational-emotive behaviour therapy: A therapist’s guide. Impact
Publications.
Erhardt, S., Lim, C. K., Linderholm, K. R., Janelidze, S., Lindqvist, D., Samuelsson, M., Lundberg, K.,
Postolache, T. T., Träskman-Bendz, L., Guillemin, G. J., and Brundin, L. (2013). Connecting
inflammation with glutamate agonism in suicidality. Neuropsychopharmacology, 38(5), 743–752.
https://doi.org/10.1038/npp.2012.248.
Fralick, M., Sy, E., Hassan, A., Burke, M. J., Mostofsky, E., and Karsies, T. (2019). Association of
concussionwith the risk of suicide: A Systematic Review and Meta-analysis. JAMA Neurology, 76(2),
144–151. https://doi.org/10.1001/jamaneurol.2018.3487.
Freeman, A., Mergl, R., Kohls, E., Székely, A., Gusmao, R., Arensman, E., Koburger, N., Hegerl, U., and
Rummel-Kluge, C. (2017). A cross-national study on gender differences in suicide intent. BMC
Psychiatry, 17(1), 234. https://doi.org/10.1186/s12888-017-1398-8.
Freud, S. (1920). Beyond the pleasure principle. International Psychoanalytic Publisher.
Complimentary Copy
Ghasemi, A., Seifi, M., Baybordi, F., Danaei, N., and Samadi Rad, B. (2018). Association between serotonin
2A receptor genetic variations, stressful life events and suicide. Gene, 658, 191–197.
https://doi.org/10.1016/j.gene.2018.03.023.
Gibbs, J. P., and Martin, W. T. (1964). Status integration and suicide: A sociologicalstudy. Univ. Or. Press.
Gifuni, A. J., Ding, Y., Olié, E., Lawrence, N., Cyprien, F., Le Bars, E., Bonafé, A., Phillips, M. L., Courtet,
P., and Jollant, F. (2016). Subcortical nuclei volumes in suicidal behavior: Nucleus accumbens may
modulate the lethality of acts. Brain Imaging and Behavior, 10(1), 96–104.
https://doi.org/10.1007/s11682-015-9369-5.
Global Burden of Disease Collaborative. (1789–1858). Network (2017). Global burden of disease study 2017.
Lancet, 392(10159).
Gold, M. (1958). Suicide, homicide, and the socialization of aggression. American Journal of Sociology, 63(6),
651–661.https://doi.org/10.1086/222360.
González-Castro, T. B., Salas-Magaña, M., Juárez-Rojop, I. E., López-Narváez, M. L., Tovilla-Zárate, C. A.,
&Hernández-Díaz, Y. (2017). Exploring the association between BDNF Val66Met polymorphism and
suicidal behavior: Meta-analysis and systematic review. Journal of PsychiatricResearch, 94, 208–217.
https://doi.org/10.1016/j.jpsychires.2017.07.020.
Gross, J. J., and Muñoz, R. F. (1995). Emotion regulation and mental health. Clinical Psychology: Science and
Practice, 2(2), 151–164. https://doi.org/10.1111/j.1468-2850.1995.tb00036.x.
Gross-Isseroff, R., Biegon, A., Voet, H., and Weizman, A. (1998). The suicide brain: A review of postmortem
receptor/transporter binding studies. Neuroscience and Biobehavioral Reviews, 22(5), 653–661.
https://doi.org/10.1016/s0149-7634(97)00061-4.
Hedegaard, H., Curtin, S. C., and Warner, M. (2020). Increase in suicide mortality in the United States, 1999–
2018. NCHS Data Brief, 362(362), 1–8.
Henry, A. F., and Short, J. F. (1954). Suicide and homicide: Some economic, sociological and
psychologicalaspects of aggression. Free Press.
Henson, K. E., Brock, R., Charnock, J., Wickramasinghe, B., Will, O., and Pitman, A. (2019). Risk of suicide
after cancerdiagnosis in England. JAMA Psychiatry, 76(1), 51–60. https://doi.org/10.1001/
jamapsychiatry.2018.3181.
Ho, T. C., Cichocki, A. C., Gifuni, A. J., Catalina Camacho, M., Ordaz, S. J., Singh, M. K., and Gotlib, I. H.
(2018). Reduced dorsal striatal gray matter volume predicts implicit suicidal ideation in adolescents.
Social Cognitive and Affective Neuroscience, 13(11), 1215–1224. https://doi.org/10.1093/scan/nsy089.
Hoehne, A., Richard-Devantoy, S., Ding, Y., Turecki, G., and Jollant, F. (2015). First-degree relatives of
suicide completers may have impaired decision-making but functional cognitive control. Journal of
Psychiatric Research, 68, 192–197. https://doi.org/10.1016/j.jpsychires.2015.07.004.
Holmstrand, C., Bogren, M., Mattisson, C., and Brådvik, L. (2015). Long-term suicide risk in no, one or more
mental disorders: The Lundby Study 1947–1997. Acta Psychiatrica Scandinavica, 132(6), 459–469.
https://doi.org/10.1111/acps.12506.
Joiner, T. (2005). Why peopledie by suicide. Harvard University Press.
Jollant, F., Wagner, G., Richard-Devantoy, S., Köhler, S., Bär, K. J., Turecki, G., and Pereira, F. (2018).
Neuroimaging-informed phenotypes of suicidal behavior: A family history of suicide and the use of a
violent suicidal means. Translational Psychiatry, 8(1), 120. https://doi.org/10.1038/s41398-018-0170-2.
Kawachi, I., and Kennedy, B. P. (1997). Health and social cohesion: Why care about income inequality? BMJ,
314(7086), 1037–1040. https://doi.org/10.1136/bmj.314.7086.1037.
Keller, J., Gomez, R., Williams, G., Lembke, A., Lazzeroni, L., Murphy, G. M., Jr., and Schatzberg, A. F.
(2017). HPA axis in major depression: Cortisol, clinical symptomatology and genetic variation predict
cognition. Molecular Psychiatry, 22(4), 527–536. https://doi.org/10.1038/mp.2016.120.
Khan, M. S., Wu, G. W. Y., Reus, V. I., Hough, C. M., and Lindqvist, D. (2009). Role of valgus osteotomy
and fixation with dynamic hip screw and 120 degrees double angle barrel plate in the management of
neglected and ununited femoral neck fracture in young patients. Journal of Orthopaedics and
Traumatology, 10(2), 71–78. https://doi.org/10.1007/s10195-009-0049-3.
Khan, M. S., Wu, G. W. Y., Reus, V. I., Hough, C. M., Lindqvist, D., Westrin, Å., Nier, B. M., Wolkowitz, O.
M., and Mellon, S. H. (2019). Low serum brain-derived neurotrophic factor is associated with suicidal
Complimentary Copy
ideation in major depressive disorder. Psychiatry research, 273, 108–113.

https://doi.org/10.1016/j.psychres.2019.01.013.
Kim, C., and Turecki, G. (2004). Psychiatric diagnoses in 3275 suicides: A meta-analysis. BMC Psychiatry, 4,
37. https://doi.org/10.1186/1471-244X-4-37.
Klein, M. (1948). Contributions to psychoanalysis, 1921–1945. Hogarth Press.
Klonsky, E. D., May, A. M., and Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal ideation. Annual
Review of Clinical Psychology, 12(1), 307–330. https://doi.org/10.1146/annurev-clinpsy-021815-
093204.
Kumar, S., Kuchhal, A., Dixit, V., and Jaiswal, S. (2016). Suicidal ideation and its correlates in patients of
alcohol dependence syndrome. International Journal of Contemporary. Medical Research, 3(5), 1392–
1397.
Lengvenyte, A., Conejero, I., Courtet, P., and Olié, E. (2021). Biological bases of suicidal behaviours: A
narrative review. European Journal of Neuroscience, 53(1), 330–351. https://doi.org/10.1111/ ejn.14635.
Lester, D. (1995). The concentration of neurotransmitter metabolites in the cerebrospinal fluid of suicidal
individuals: A meta-analysis. Pharmacopsychiatry, 28(2), 45–50. https://doi.org/10.1055/s-2007-979587.
Levey, D. F., Polimanti, R., Cheng, Z., Zhou, H., Nuñez, Y. Z., Jain, S., He, F., Sun, X., Ursano, R. J., Kessler,
R. C., Smoller, J. W., Stein, M. B., Kranzler, H. R., and Gelernter, J. (2019). Genetic associations with
suicide attempt severity and genetic overlap with major depression. Translational Psychiatry, 9(1), 22.
https://doi.org/10.1038/s41398-018-0340-2.
Lewis, M. D., Hibbeln, J. R., Johnson, J. E., Lin, Y. H., Hyun, D. Y., and Loewke, J. D. (2011). Suicide deaths
of active-duty US military and omega-3 fatty-acid status: A case-control comparison. Journal of Clinical
Psychiatry, 72(12), 1585–1590. https://doi.org/10.4088/JCP.11m06879.
Li, H., Chen, Z., Gong, Q., and Jia, Z. (2020). Voxel-wise meta-analysis of task-related brain activation
abnormalities in major depressive disorder with suicide behavior. Brain Imaging and Behavior, 14(4),
1298–1308. https://doi.org/10.1007/s11682-019-00045-3.
Lindqvist, D., Fernström, J., Grudet, C., Ljunggren, L., Träskman-Bendz, L., Ohlsson, L., and Westrin, Å.
(2016). Increased plasma levels of circulating cell-free mitochondrial DNA in suicide attempters:
associations with HPA-axis hyperactivity. Translational Psychiatry, 6 (12), e971.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E.,
Tutek, D. A., Reynolds, S. K., and Lindenboim, N. (2006). Two-year randomized controlled trial and
follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and
borderlinepersonality disorder. Archives of General Psychiatry, 63(7), 757–
766.https://doi.org/10.1001/archpsyc.63.7.757.
Madsen, T., Erlangsen, A., Orlovska, S., Mofaddy, R., Nordentoft, M., and Benros, M. E. (2018). Association
between traumatic brain injury and risk of suicide. JAMA, 320(6), 580–588.
https://doi.org/10.1001/jama.2018.10211.
Mann, J. J. (2003). Neurobiology of suicidal behaviour. Nature Reviews Neuroscience, 4(10), 819–828.
https://doi.org/10.1038/nrn1220.
Mann, J. J., Metts, A. V., Ogden, R. T., Mathis, C. A., Rubin-Falcone, H., Gong, Z., Drevets, W. C., Zelazny,
J., and Brent, D. A. (2019). Quantification of 5-HT1A and 5-HT2A receptor binding in depressed suicide
attempters and non-attempters. Archives of Suicide Research, 23(1), 122–133.
https://doi.org/10.1080/13811118.2017.1417185.
Marshall, S. E., Bird, T. G., Hart, K., and Welsh, K. I. (1999). Unified approach to the analysis of genetic
variation in serotonergic pathways. American Journal of Medical Genetics, 88(6), 621–627.
https://doi.org/10.1002/(sici)1096-8628(19991215)88:6<621::aid-ajmg9>3.0.co;2-h.
Masaryk, T. G. (1881). Suicide and the meaning of civilization, 1970. University of Chicago Press.
McGirr, A., Diaconu, G., Berlim, M. T., and Turecki, G. (2011). Personal and family history of suicidal
behaviour is associated with lower peripheral cortisol in depressed outpatients. Journal of
AffectiveDisorders, 131(1–3), 368–373. https://doi.org/10.1016/j.jad.2010.10.050.
Mcgirr, A., Alda, M., Séguin, M., Cabot, S., Lesage, A., Phil, M., and Turecki, G. (2009) Familial aggregation
of suicide explained by Cluster B traits: a three-group family study of suicide controlling for major
depressive disorder. American Journal of Psychiatry, 166, 1124–1134.
Complimentary Copy
Meltzer, H. Y., Li, Z., Kaneda, Y., and Ichikawa, J. (2003). Serotonin receptors their key role in drugs to treat
schizophrenia. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 27(7), 1159–1172.
https://doi.org/10.1016/j.pnpbp.2003.09.010.
Menninger, K. (1938). Man against himself. Harcourt Brace.
Miller, J. M., Hesselgrave, N., Ogden, R. T., Sullivan, G. M., Oquendo, M. A., Mann, J. J., and Parsey, R. V.
(2013). Positron emission tomography quantification of serotonin transporter in suicide attempters with
major depressive disorder. Biological Psychiatry, 74(4), 287–295. https://doi.org/10.1016/
j.biopsych.2013.01.024.
Millner, A. J., Robinaugh, D. J., and Nock, M. K. (2020). Advancing the understanding of suicide: The need
for formal theory and rigorous descriptive research. Trends in Cognitive Sciences, 24(9), 704–716.
https://doi.org/10.1016/j.tics.2020.06.007.
Milner, A., Sveticic, J., and De Leo, D. (2013). Suicide in the absence of mental disorder? A review of
psychological autopsy studies across countries. International Journal of Social Psychiatry, 59(6), 545–
554. https://doi.org/10.1177/0020764012444259.
Morselli, E. A. (1882). Suicide: An essay on comparative moral statistics. Appleton.
Mortensen, P. B., Agerbo, E., Erikson, T., Qin, P., and Westergaard-Nielsen, N. (2000). Psychiatric illness and
risk factors for suicide in Denmark. Lancet, 355(9197), 9–12. https://doi.org/10.1016/s0140-
6736(99)06376-x.
Mueller, A. S., Abrutyn, S., Pescosolido, B., and Diefendorf, S. (2021). The social roots of suicide: Theorizing
how the external social world matters to suicide and suicide prevention. Frontiers in Psychology, 12,
621569. https://doi.org/10.3389/fpsyg.2021.621569.
Muldoon, M. F., Manuck, S. B., and Matthews, K. A. (1990). Lowering cholesterol concentrations and
mortality: A quantitative review of primary prevention trials. BMJ, 301(6747), 309–314.
https://doi.org/10.1136/bmj.301.6747.309.
Muldoon, M. F., Manuck, S. B., Mendelsohn, A. B., Kaplan, J. R., and Belle, S. H. (2001). Cholesterol
reduction and non-illness mortality: Meta-analysis of randomized clinical trials. BMJ, 322(7277), 11–15.
https://doi.org/10.1136/bmj.322.7277.11.
National Crime Records Bureau. (2007). Accidental deaths and Suicides in India 2007. Ministry of Home
Affairs, Government of India.
National Crime Records Bureau. (2021). Accidental deaths and Suicides in India 2007. Ministry of Home
Affairs, Government of India.
Nordentoft, M., Mortensen, P. B., and Pedersen, C. B. (2011). Absolute risk of suicide after first hospital
contact in mental disorder. Archives of General Psychiatry, 68(10), 1058–1064.
https://doi.org/10.1001/archgenpsychiatry.2011.113.
O’Connor, D. B., Ferguson, E., Green, J. A., O’Carroll, R. E., and O’Connor, R. C. (2016). Cortisol levels and
suicidal behavior: A meta-analysis. Psychoneuroendocrinology, 63, 370–379.
https://doi.org/10.1016/j.psyneuen.2015.10.011.
O’Connor, R. C. (2011). Towards an integrated motivational-volitional model of suicidal behavior. In R.C.
O’Connor, S. Platt & J. Gordon (Eds.), International handbook of suicide prevention: Research, policy,
and practice (Vol. 32, pp. 181_198). John Wiley & Sons, Ltd.
Olié, E., Ding, Y., Le Bars, E., de Champfleur, N. M., Mura, T., Bonafé, A., Courtet, P., and Jollant, F. (2015).
Processing of decision-making and social threat in patients with history of suicidal attempt: A
neuroimaging replication study. Psychiatry Research, 234(3), 369–377.
https://doi.org/10.1016/j.pscychresns.2015.09.020.
Oquendo, M. A., Galfalvy, H., Sullivan, G. M., Miller, J. M., Milak, M. M., Sublette, M. E., Cisneros-Trujillo,
S., Burke, A. K., Parsey, R. V., and Mann, J. J. (2016). Positron emission tomographic imaging of the
serotonergic system and prediction of risk and lethality of future suicidal behavior. JAMA Psychiatry,
73(10), 1048–1055. https://doi.org/10.1001/jamapsychiatry.2016.1478.
Panagioti, M., Gooding, P. A., Triantafyllou, K., and Tarrier, N. (2015). Suicidality and posttraumatic stress
disorder (PTSD) in adolescents: A systematic review and meta-analysis. Social Psychiatry and Psychiatric
Epidemiology, 50(4), 525–537. https://doi.org/10.1007/s00127-014-0978-x.
Complimentary Copy
Pandey, G. N., Rizavi, H. S., Ren, X., Fareed, J., Hoppensteadt, D. A., Roberts, R. C., Conley, R. R., and
Dwivedi, Y. (2012). Proinflammatory cytokines in the prefrontal cortex of teenage suicide victims.
Journal of Psychiatric Research, 46(1), 57–63. https://doi.org/10.1016/j.jpsychires.2011.08.006.
Parkar, S. R., Dawani, V., and Weiss, M. G. (2008). Gender, suicide, and the socioculturalcontext of
DeliberateSelf-harm in an Urban General Hospital in Mumbai, India. Culture, Medicine and Psychiatry,
32(4), 492–515. https://doi.org/10.1007/s11013-008-9109-z.
Patton, G. C., Coffey, C., Sawyer, S. M., Viner, R. M., Haller, D. M., Bose, K., Vos, T., Ferguson, J., and
Mathers, C. D. (2009). Global patterns of mortality in young people: A systematic analysis of population
health data. Lancet, 374(9693), 881–892. https://doi.org/10.1016/S0140-6736(09)60741-8.
Peng, H., Wu, K., Li, J., Qi, H., Guo, S., Chi, M., Wu, X., Guo, Y., Yang, Y., and Ning, Y. (2014). Increased
suicide attempts in young depressed patients with abnormal temporal-parietal limbic gray matter volume.
Journal of Affective Disorders, 165, 69–73. https://doi.org/10.1016/j.jad.2014.04.046.
Petersen, L., Sørensen, T. I. A., Kragh Andersen, P., Mortensen, P. B., and Hawton, K. (2014). Genetic and
familial environmental effects on suicide attempts: A study of Danish adoptees and their biological and
adoptive siblings. Journal of Affective Disorders, 155, 273–277. https://doi.org/10.1016
/j.jad.2013.11.012.
Picouto, M. D., Villar, F., and Braquehais, M. D. (2015). The role of serotonin in adolescent suicide:
Theoretical, methodological, and clinical concerns. International Journal of Adolescent Medicine and
Health, 27(2), 129–133. https://doi.org/10.1515/ijamh-2015-5003.
Porras-Segovia, A., Pérez-Rodríguez, M. M., López-Esteban, P., Courtet, P., Barrigón M, M. L., López-
Castromán, J., Cervilla, J. A., and Baca-García, E. (2019). Contribution of sleep deprivation to suicidal
behaviour: A systematic review. Sleep Medicine Reviews, 44, 37–47.
https://doi.org/10.1016/j.smrv.2018.12.005.
Porterfield, A. L. (1949). Indices of suicide and homicide by states and cities: Some Southern-non-Southern
contrasts with implications for research. American Sociological Review, 14(4), 481–490.
https://doi.org/10.2307/2087211.
Pu, S., Setoyama, S., and Noda, T. (2017). Association between cognitive deficits and suicidal ideation in
patients with major depressive disorder. Scientific Reports, 7(1), 11637. https://doi.org/10.1038/s41598-
017-12142-8.
Qin, P., Mortensen, P. B., Waltoft, B. L., and Postolache, T. T. (2011). Allergy is associated with suicide
completion with a possible mediating role of mood disorder – A population-based study. Allergy, 66(5),
658–664. https://doi.org/10.1111/j.1398-9995.2010.02523.x.
Qin, P., Syeda, S., Canetto, S. S., Arya, V., Liu, B., Menon, V., Lew, B., Platt, S., Yip, P., and Gunnell, D.
(2022). Midlife suicide: A systematic review and meta-analysis of socioeconomic, psychiatric and
physical health risk factors. Journal of Psychiatric Research, 154, 233–241.
https://doi.org/10.1016/j.jpsychires.2022.07.037.
Quetelet, A. J. (1842). A treatise on man and the development of his faculties. Chambers.
Rehkopf, D. H., and Buka, S. L. (2006). The association between suicide and the socio-economic characteristics
of geographical areas: A systematic review. Psychological Medicine, 36(2), 145–157.
https://doi.org/10.1017/S003329170500588X.
Ribeiro, J. D., Huang, X., Fox, K. R., and Franklin, J. C. (2018). Depression and hopelessness as risk factors
for suicide ideation, attempts and death: Meta-analysis of longitudinal studies. British Journal of
Psychiatry, 212(5), 279–286. https://doi.org/10.1192/bjp.2018.27.
Ritzer, G., and Goodman, D. J. (2004). Sociological theory (6th ed). McGraw-Hill.
Rizk, M. M., Rubin-Falcone, H., Lin, X., Keilp, J. G., Miller, J. M., Milak, M. S., Sublette, M. E., Oquendo,
M. A., Ogden, R. T., Abdelfadeel, N. A., Abdelhameed, M. A., and Mann, J. J. (2019). Gray matter
volumetric study of major depression and suicidal behavior. Psychiatry Research. Neuroimaging, 283,
16–23. https://doi.org/10.1016/j.pscychresns.2018.11.007.
Rojtenberg, S. L. (1995). Death as a way out. World Psychiatry, 3, 2–5.
Roy, B., and Dwivedi, Y. (2017). Understanding epigenetic architecture of suicide neurobiology: A critical
perspective. Neuroscience and Biobehavioral Reviews, 72, 10–27.
https://doi.org/10.1016/j.neubiorev.2016.10.031.
Sainsbury, P. (1955). Suicide in London: An ecologicalstudy. MaudsleyMonographs, 1. Chapman & Hall.
Complimentary Copy
Salas-Magaña, M., Tovilla-Zárate, C. A., González-Castro, T. B., Juárez-Rojop, I. E., López-Narváez, M. L.,
Rodríguez-Pérez, J. M., and Ramírez Bello, J. (2017). Decrease in brain-derived neurotrophic factor at
plasma level but not in serum concentrations in suicide behavior: A systematic review and meta-analysis.
Brain and behavior, 7(6), e00706. https://doi.org/10.1002/brb3.706.
Schmid, C. (1928). Suicide in Seattle: 1914–1925. Wash. Univ. Press.
Shneidman, E. S. (1993). Suicide as psychache. Journal of Nervous and Mental Disease, 181(3), 145–147.
https://doi.org/10.1097/00005053-199303000-00001.
Shneidman, E. S., and Farberow, N. L. (Eds.), Clues to suicide. NewYork: McGrraw-Hill.
Simopoulos, A. P. (2008). The importance of the omega-6/omega-3 fatty acid ratio in cardiovascular disease
and other chronic diseases. Experimental Biology and Medicine, 233(6), 674–688.
https://doi.org/10.3181/0711-MR-311.
Smith, A. R., Ribeiro, J. D., Mikolajewski, A., Taylor, J., Joiner, T. E., and Iacono, W. G. (2012). An
examination of environmental and genetic contributions to the determinants of suicidal behavior among
male twins. Psychiatry Research, 197 (1-2), 60–65. https://doi.org/10.1016/j.psychres. 2012.01.010.
Stamm, S., Gruber, S. B., Rabchevsky, A. G., and Emeson, R. B. (2017). The activity of the serotonin receptor
2C is regulated by alternative splicing. Human Genetics, 136(9), 1079–1091. https://doi.org/10.1007/
s00439-017-1826-3.
Stein, E., McCrank, E., Schaefer, B., and Goyer, R. (1993). Adrenal gland weight and suicide. Canadian
Journal of Psychiatry, 38(8), 563–566. https://doi.org/10.1177/ 070674379303800807.
Steiner, J., Walter, M., Gos, T., Guillemin, G. J., Bernstein, H. G., Sarnyai, Z., Mawrin, C., Brisch, R., Bielau,
H., Meyer zuSchwabedissen, L. M. z., Bogerts, B., and Myint, A. M. (2011). Severe depression is
associated with increased microglial quinolinic acid in subregions of the anterior cingulate gyrus:
Evidence for an immune-modulated glutamatergic neurotransmission? Journal of Neuroinflammation, 8,
94. https://doi.org/10.1186/1742-2094-8-94.
Sudol, K., and Mann, J. J. (2017). Biomarkers of suicideattemptbehavior: Towards a biologicalmodel of risk.
Current Psychiatry Reports, 19(6), 31. https://doi.org/10.1007/s11920-017-0781-y.
Sullivan, G. M., Oquendo, M. A., Milak, M., Miller, J. M., Burke, A., Ogden, R. T., Parsey, R. V., and Mann,
J. J. (2015). Positron emission tomography quantification of serotonin(1A) receptor binding in suicide
attempters with major depressive disorder. JAMA Psychiatry, 72(2), 169–178.
https://doi.org/10.1001/jamapsychiatry.2014.2406.
Tarde, G. D. (1895). The laws of imitation, 1903. H. Holt.
Tatley, M., and Savage, R. (2007). Psychiatric adverse reactions with statins, fibrates and ezetimibe:
Implications for the use of lipid-lowering agents. Drug Safety, 30(3), 195–201.
https://doi.org/10.2165/00002018-200730030-00003.
Taylor, P. J., Wood, A. M., Gooding, P., and Tarrier, N. (2010). Appraisals and suicidality: The mediating role
of defeat and entrapment. Archives of Suicide Research, 14(3), 236–247.
https://doi.org/10.1080/13811118.2010.494138.
Taylor, P. J., Wood, A. M., Gooding, P., Johnson, J., and Tarrier, N. (2009). Are defeat and entrapment best
defined as a single construct? Personality and Individual Differences, 47(7), 795–797.
https://doi.org/10.1016/j.paid.2009.06.011.
Taylor, W. D., Boyd, B., McQuoid, D. R., Kudra, K., Saleh, A., and MacFall, J. R. (2015). Widespread white
matter but focal gray matter alterations in depressed individuals with thoughts of death. Progress in Neuro-
Psychopharmacology and Biological Psychiatry, 62, 22–28. https://doi.org/10.1016/
j.pnpbp.2015.05.001.
Thompson, P. M., Cruz, D. A., Olukotun, D. Y., and Delgado, P. L. (2012). Serotonin receptor, SERT mRNA
and correlations with symptoms in males with alcohol dependence and suicide. Acta Psychiatrica
Scandinavica, 126(3), 165–174. https://doi.org/10.1111/j.1600-0447.2011.01816.x.
Tidemalm, D., Runeson, B., Waern, M., Frisell, T., Carlström, E., Lichtenstein, P., and Längström, N. (2011).
Familial clustering of suicide risk: A total population study of 11.4 million individuals. Psychological
Medicine, 41(12), 2527–2534. https://doi.org/10.1017/S0033291711000833.
Troister, T., and Holden, R. R. (2012). A two-year prospective study of psychache and its relationship to
suicidality among high-risk undergraduates. Journal of Clinical Psychology, 68(9), 1019–1027.
https://doi.org/10.1002/jclp.21869.
Complimentary Copy
Trout, D. L. (1980). The role of social isolation in suicide. Suicide and Life-Threatening Behavior, 10(1), 10–
23. https://doi.org/10.1111/j.1943-278x.1980.tb00693.x.
Underwood, M. D., Kassir, S. A., Bakalian, M. J., Galfalvy, H., Dwork, A. J., Mann, J. J., and Arango, V.
(2018).Serotonin receptors and suicide, major depression, alcohol use disorder and reported early life
adversity. Translational Psychiatry, 8(1), 279. https://doi.org/10.1038/s41398-018-0309-1.
Underwood, M. D., Kassir, S. A., Bakalian, M. J., Galfalvy, H., Dwork, A. J., Mann, J. J., and Arango, V.
(2018). Serotonin receptors and suicide, major depression, alcohol use disorder and reported early life
adversity. Translational Psychiatry, 8(1), 279. https://doi.org/10.1038/s41398-018-0309-1.
van Heeringen, K., Bijttebier, S., Desmyter, S., Vervaet, M., and Baeken, C.(2014). Is there a neuroanatomical
basis of the vulnerability to suicidal behavior? A coordinate-based metaanalysis of structural and
functional MRI studies. Frontiers in Human Neuroscience, 8, 1–8.
Van Orden, K. A. (2014). The Interpersonal Theory of Suicide: A useful theory? In D.A. Lamis & N. J. Kaslow
(Eds.), Advancing the science of suicidalbehavior: Understanding and intervention. Nova Science
Publishers.
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., and Joiner, T. E., Jr. (2010).
The interpersonal theory of suicide. Psychological Review, 117(2), 575–600_600.
https://doi.org/10.1037/a0018697.
Wahl, C. W. (1957). Suicide as a magical act. Bulletin of the Menninger Clinic, 21(3), 91–98.
Walen, R. S., DiGisuppee, R., and Dryden, W. (1980). A practitioner’s guide to rational-emotivetherapy.
Oxford University Press.
Walter, F., Carr, M. J., Mok, P. L. H., Antonsen, S., Pedersen, C. B., Appleby, L., Fazel, S., Shaw, J., and
Webb, R. T. (2019). Multiple adverse outcomes following first discharge from inpatient psychiatric care:
A national cohort study. Lancet Psychiatry, 6(7), 582–589. https://doi.org/10.1016/S2215-
0366(19)30180-4.
Wang, Q., Roy, B., Turecki, G., Shelton, R. C., and Dwivedi, Y. (2018). Role of complexepigeneticswitching
in tumornecrosisfactor-α upregulation in the prefrontalcortex of suicidesubjects. American Journal of
Psychiatry, 175(3), 262–274. https://doi.org/10.1176/appi.ajp.2017.16070759.
Wei, S., Chang, M., Zhang, R., Jiang, X., Wang, F., and Tang, Y. (2018). Amygdala functional connectivity in
female patients with major depressive disorder with and without suicidal ideation. Annals of General
Psychiatry, 17, 37. https://doi.org/10.1186/s12991-018-0208-0.
Weinrach, S. G. (1990). Obstacles to a wider acceptance of RET. Keystone, CO. Paper presented at the World
Congress on mental health counselling/35th anniversary conference on Rational Emotive Therapy.
Willeumier, K., Taylor, D. V., and Amen, D. G. (2011). Decreased cerebral blood flow in the limbic and
prefrontal cortex using SPECT imaging in a cohort of completed suicides. Translational Psychiatry, 1,
e28–e28. https://doi.org/10.1038/tp.2011.28.
Williams, J. M. G. (1997). Cry of pain: Understanding suicide and self-harm. Penguin Books.
Williams, J. M. G., and Pollock, L. (2000). Psychology of suicide behaviour. In K. Hawton & K. vanHeeringen
(Eds.), The international handbook of suicide and suicidal behaviour (pp. 79–93). John Wiley & Sons.
Williams, J. M. G., and Pollock, L. (2001). Psychological aspects of the suicidal process. In van
Heeringen(Ed.), Understanding suicidal behaviour: The suicidal process approach to research, treatment
and prevention (pp. 76–94). John Wiley & Sons.
World Health Organization. (2014). Suicide prevention: A global imperative. WHO Press.
World Health Organization. (2018). https://www.who.int/mental_health/suicide-prevention/en/[WWW
document].
Yang, C. C., Jick, S. S., and Jick, H. (2003). Lipid-lowering drugs and the risk of depression and suicidal
behavior. Archives of Internal Medicine, 163(16), 1926–1932. https://doi.org/10.1001/archinte.
163.16.1926.
Yates, K., Lång, U., Cederlöf, M., Boland, F., Taylor, P., Cannon, M., McNicholas, F., DeVylder, J., and
Kelleher, I. (2019). Association of psychoticexperienceswithsubsequentrisk of suicidalideation,
suicideattempts, and suicidedeaths: A Systematic Review and Meta-analysis of Longitudinal Population
Studies. JAMA Psychiatry, 76(2), 180–189. https://doi.org/10.1001 /jamapsychiatry. 2018.3514.
Yeh, H. H., Westphal, J., Hu, Y., Peterson, E. L., Williams, L. K., Prabhakar, D., Frank, C., Autio, K., Elsiss,
F., Simon, G. E., Beck, A., Lynch, F. L., Rossom, R. C., Lu, C. Y., Owen-Smith, A. A., Waitzfelder, B.
Complimentary Copy
E., and Ahmedani, B. K.(2019). Diagnosed mental health conditions and risk of suicide mortality.
Psychiatric Services, 70(9), 750–757. https://doi.org/10.1176/appi.ps.201800346.
Yerevanian, B. I., Feusner, J. D., Koek, R. J., and Mintz, J. (2004). The dexamethasone suppression test as a
predictor of suicidal behavior in unipolar depression. Journal of Affective Disorders, 83(2–3), 103–108.
https://doi.org/10.1016/j.jad.2004.08.009.
Yoshimasu, K., Kiyohara, C., Miyashita, K., and Stress Research Group of the Japanese Society for Hygiene.
(2008). Suicidal risk factors and completed suicide: Meta-analyses based on psychological autopsy
studies. Environmental Health and Preventive Medicine, 13(5), 243–256. https://doi.org/10.1007/s12199-
008-0037-x.
Yui, K., Imataka, G., Kawasak, Y., and Yamada, H. (2016). Increased ω-3 polyunsaturated fatty
acid/arachidonic acid ratios and upregulation of signaling mediator in individuals with autism spectrum
disorders. Life Sciences, 145, 205–212. https://doi.org/10.1016/j.lfs.2015.12.039.
Zai, C. C., George, J., Cheema, S. Y., Zai, G. C., Fonseka, T. M., Danesi, M., Shaikh, S. A., Irwin, D.,
Tampakeras, M., Freeman, N., Rehm, J., Wells, S., and Kennedy, J. L. (2019). An examination of genes,
stress and suicidal behavior in two First Nations communities: The role of the brain-derived neurotropic
factor gene. Psychiatry Research, 275, 247–252. https://doi.org/ 10.1016/j.psychres. 2019.02.034.
Zhao, J., Qi, X. R., Gao, S. F., Lu, J., van Wamelen, D. J., Kamphuis, W., Bao, A. M., and Swaab, D. F. (2015).
Different stress-related gene expression in depression and suicide. Journal of Psychiatric Research, 68,
176–185. https://doi.org/10.1016/j.jpsychires.2015.06.010.
Zilboorg, G. (1936). Suicide among civilized and primitive races. American Journal of Psychiatry, 92(6),
1347–1369. https://doi.org/10.1176/ajp.92.6.1347.
Complimentary Copy

2023 - Extracted - Final Chapter - Book

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2023 - Extracted - Final Chapter - Book

Uploaded by

Copyright:

Available Formats

Complimentary Copy

Copyright © 2023 by Nova Science Publishers, Inc.

Copyright Clearance Center

NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

ISBN:  H%RRN

Published by Nova Science Publishers, Inc. † New York

Preface ..................................................................................................................... vii

Chapter 11 Cognitive Deficits in Alcohol Dependence ............................................. 223

The Etiopathological Issues of Suicide

Suicide is a significant tragic public health issue globally. Individual vulnerability to

Keywords: suicide, suicidal behaviour, models, biopsychosocial, Durkheim

In: A Guide to Clinical Psychology

Sociological Aspects of Suicide

Durkheimian Classic Work

Psychological Aspects of Suicide

Psychoanalytically Oriented Theories

Cognitive and Behavioral Theories

Shneidman’s Theory of Psychache

(1) To seek a solution − a common purpose of suicide;

Baumeister’s Escape Theory

Williams’ Theory of Arrested Flight (‘Cry of Pain’)

(1) an oversensitivity to cues (actual events or similar themes) signaling defeat or

Beck’s Hopelessness Theory of Suicide

A-B-C-D-E Model of Suicide

Emotion Dysregulation Theory

Interpersonal-Psychological Theory of Suicide

Integrated Motivational-Volitional (IMV) Model of Suicidal Behaviour

(3) the volitional phase (characterised by development of the suicidal behaviours). An

Critiques of Existing Theories of Suicide and Future Direction

Use of Diverse Terms to Explain the Same Phenomenon of Suicide

Use of Diverse Measures to Assess the Phenomenon of Suicide

Dilemma to Consider Suicidal Ideation/Attempt as a Trait or State

Stigma to Report Suicide

Obstacles to Studying a Behaviour Like Suicide with a Fatal Outcome

Neurobiological Bases of Suicide

Role of the Serotonergic System

Serotonin and Its Metabolite

Serotonin Receptors (5-HTRs)

Serotonin Transporters (SERTs)

Role of Hypothalamic-Pituitary-Adrenal (HPA) Axis

Cholesterol and Triglycerides

Polyunsaturated Fatty Acids

The Kynurenine Pathway Metabolites

Role of Neuronal Plasticity

Neuroimaging Findings and Suicidal Behaviour

Genetic Basis of Suicide

Family, Twin, and Adoption Studies

Molecular Genetics and Genome-Wide Association Studies

Adler, A. (1958). Suicide. Journal of Individual Psychology, 14, 57–61.

ideation in major depressive disorder. Psychiatry research, 273, 108–113.

You might also like

ISBN: H%RRN