摘要：Suicide prevention must be transformed by integrating injury prevention and mental health perspectives to develop a mosaic of common risk public health interventions that address the diversity of populations and individuals whose mortality and morbidity contribute to the burdens of suicide and attempted suicide. Emphasizing distal preventive interventions, strategies must focus on people and places—and on related interpersonal factors and social contexts—to alter the life trajectories of people before they become suicidal. Attention also must be paid to those in the middle years—the age with the greatest overall burden. We need scientific and social processes that define priorities and assess their potential for reducing what has been a steadily increasing rate of suicide during the past decade. Preventing suicide is very challenging, especially when seeking to shift the modal behaviors of large populations. 1,2 Talented, dedicated people have made extraordinary efforts to reduce suicide in the United States during these first years of the 21st century, but the overall rate has risen steadily. The 1990s was a decade of decline; the crude suicide rate was 10.46 per 100 000 people in 1999, with an age-adjusted rate of 10.48. 3 In 2008 suicide became the 10th leading cause of death in our nation, up from its long-held position of 11th. In 2010 suicide accounted for 38,364 deaths, with a crude rate of 12.43 and an age-adjusted rate of 12.08 per 100 000, respectively, 4 the latter being 15.26% higher than the comparable 1999 figure. Preliminary reports indicate 38,235 deaths in 2011. By comparison, there were 37,233 lives lost in 2010 from transportation accidents. 5 Suicide far surpasses more publically noted challenges, such as homicide—the 16th leading cause of death—which took 16 259 lives in 2010. In 2010 suicide was the third leading cause of death for those aged 15 to 24 years (4600), after unintentional injury (12 341) and homicide (4678); second among those aged 25 to 34 years (5735), between unintentional injury (14 573) and homicide (4258); and fourth (6571) among those aged 35 to 44 years. For those aged 35 to 64 years, there have been steady annual increases in age-adjusted rates from 1999 to 2010: men climbed from 21.48 to 27.64 suicides per 100 000 and women from 6.19 to 8.21, for a combined change in those ages from 13.70 to 17.75 per 100 000, an increase of nearly 30%. 3 This far outweighed all other changes in rates during the same period. For those aged 10 to 24 years, rates tended to remain relatively stable during the first decade of the 21st century: males had an age-adjusted rate of 11.64 in 1999 and 11.56 in 2010, whereas females had rates of 2.17 and 2.83, respectively. Among those aged 25 to 34 years, males had rates of 20.74 in 1999 and 22.50 in 2010, an increase of 8.5%, with comparable rates for females of 4.58 and 5.34 (16.6% more). The age-adjusted suicide rate for those aged 65 years and older declined from 15.81 in 1999 (33.80 for men; 4.34 for women) to 14.89 per 100 000 in 2010 (29.00 for men; 4.19 for women), a drop of 5.8%. 3 Although the use of firearms as a method of suicide remained relatively stable from 1999 to 2010 (age-adjusted rates of 5.96 in 1999 and 6.06 in 2010, with a brief dip in mid-decade), the rate of poisoning suicides grew steadily (1.76 in 1999 and 2.06 in 2010), with the greatest increase in the middle years. Taken together, these statistics only hint at the devastation wreaked by suicide on the lives of families, friends, coworkers, and communities. Between 2000 and 2010, 3 suicide was the fifth leading cause of years of potential life lost (YPLL) for those younger than 65 years in the United States (5.9% of the total; nearly 8.23 million YPLL), more than homicide (5.0%; 6.94 million), and following unintentional injury (18.9%), malignant neoplasms (16.2%), heart disease (12.1%), and deaths during the perinatal period (7.9%). By 2010, suicide accounted for 6.9% of YPLL (764,776 of 11,043,870) for those younger than 65 years whereas homicide was 4.7% (522,701) of YPLL, reflecting the continued changes in the distribution of these premature deaths. Furthermore, fundamental factors that contribute to the contexts for suicide, especially during the early and middle years of life, also relate to unintentional deaths owing to alcohol poisoning, drug overdose, and motor vehicle accidents as well as to interpersonal violence and homicide. 2 Identifying and mitigating or preventing such common risks potentially serve as the foundation for public health and injury prevention approaches to preventing suicide and attempted suicide. The costs of suicide and attempted suicide are economic as well as personal and social. For 2005, the estimated cost of suicide was more than $34.6 billion arising from 32 637 deaths and including medical costs and inferred lost work 3 ; by comparison, that same year 18 124 homicides were projected to cost about $25.3 billion. Since then, suicides have risen by nearly 6000 and homicides have declined by nearly 2000, obviously altering the cost projections further toward a greater burden from the less-attended problem. The hospitalization and emergency department costs arising from self-harm in 2005 were nearly $6.4 billion. Thus, suicide and attempted suicide, in addition to involving deaths, damaged lives, and broad ramifications for family and friends, damage our collective economic well-being.
