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Suicide


Suicide

The process of purposely ending one’s own life is called suicide. Based on culture and religion, the way societies view suicide varies widely. For instance, killing oneself is viewed as quite negative by the mainstream Christianity, Islam and Judaism, in addition to many Western cultures.

Considering suicide to always be the result of a mental illness is one myth about suicide that may be the result of this view. A suicide attempt is also viewed by some societies as if it were a crime. However, in some circumstances, suicide could be seen as understandable or even honorable, such as part of battle or resistance, or in protest of persecution, or as a way of preserving the honor of a dishonored person such as killing oneself to preserve the honor or safety of family members.

Worldwide, there are about 10 to 20 million suicide attempts. About one million people commit suicide each year. However, because some deaths are thought to be an accident, such as shooting, a single-car accident, or overdose, they are not recognized as being a suicide, which means that the true number or suicides is probably higher than the one mentioned above. In males, suicide is the 8th leading cause of death, while in women, the 16th. The higher frequency of completed suicides in males versus females is consistent across the life span.

The World Health Organization (WHO) estimates that each year approximately one million people die from suicide, which represents a global mortality rate of 16 people per 100,000 or one death every 40 seconds. It is predicted that by 2020, the rate of death will increase to one every 20 seconds.

The WHO further reports that:

  • In the last 45 years, suicide rates have increased by 60% worldwide. Suicide is now among the three leading causes of death among those aged 15-44 (male and female). Suicide attempts are up to 20 times more frequent than completed suicides.
  • Although suicide rates have traditionally been highest amongst elderly males, rates among young people have been increasing to such an extent that they are now the group at highest risk in a third of all countries.
  • Mental health disorders, particularly depression and substance abuse, are associated with more than 90% of all cases of suicide; but in Asian countries, impulsiveness plays an important role.
  • However, suicide results from many complex sociocultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis, such as the loss of a loved one, unemployment, sexual orientation, difficulties with developing one's identity, disassociation from one's community or other social/belief group, and honor.

 

The WHO also states that:

  • In Europe, particularly Eastern Europe, the highest suicide rates are reported for both men and women. 
  • The Eastern Mediterranean Region and Central Asia republics have the lowest suicide rates.
  • Nearly 30% of all suicides worldwide occur in India and China.
  • Globally, suicides by age are as follows: 55% are aged between 15 to 44 years and 45% are aged 45 years and over.
  • Youth suicide is increasing at the greatest rate.

Deliberately hurting oneself without meaning to cause one’s own death is known as self-mutilation. Cutting any part of the body, usually of the wrists, is an example of self-mutilating behaviors. Scratching, pinching, self-burning and head banging are some other examples of self-injurious behaviors.

Ending the life of a person who is terminally ill in a way that is either minimally painful or painless, for the purpose of ending suffering of the individual is called physician-assisted suicide, mercy killing or euthanasia. Compared to euthanasia that is done by a non-physician, physician-assisted suicide seems to be less offensive to people. However, the acceptability of both means to end life seems to increase with the number of times the person who desired their own death repeatedly asks for such assistance, or as people age.

SOME POSSIBLE CAUSES OF SUICIDE:

The time period of at least a week after discharge from a psychiatric hospital or a sudden change in how the person feels such as much better or much worse are some of the life circumstances that may immediately precede someone committing suicide. However, the reasons why people commit suicide are complex and multifaceted. A real or imagined loss is an example of a possible trigger for suicide such as loss of freedom, loss of other privileges, the breakup of a romantic relationship, moving, or loss of a friend especially if by suicide.

Accounting for nearly 60% of suicide deaths per year, firearms are the most common means by which people take their life. Compared with younger people, older people are more likely to kill themselves using a firearm. Threatening police officers, sometimes even with an unloaded gun or fake weapon, is yet another method of suicide. This is called “suicide by cop”. Trying to overdose on a medication is the most common way that people attempt to kill themselves, but firearms are the most common way people complete suicide.

PROTECTIVE FACTORS AND RISK FACTORS OF SUICIDE:

Worldwide, the highest suicide rates have the former Eastern Bloc countries, while South America has the lowest. Geographical patterns of suicides are such that individuals who live in a rural area versus urban area are at higher risk for killing themselves. During the spring is when the majority of completed suicides take place.

Women continue to attempt suicide more often in most countries, but men tend to complete suicide more often. Furthermore, elderly Caucasian males continue to have the highest suicide rates despite the fact that the frequency of suicides among young adults has been increasing in recent years.

Low income, being physically or sexually abused, being single, unemployment, a personal history of suicidal thoughts, a family history of attempting suicide, or a mental illness are some of the other risk factors of suicide.

The probability of suicide attempts and completions is increased by depression, substance abuse, manic depression, eating disorders, severe anxiety and schizophrenia, based on data regarding mental illnesses as risk factors.

A diagnosable mental-health problem is present in 9 out of 10 people who commit suicide, and 3 out of 4 people who commit suicide have a physical illness when committing suicide. Violence against others and self-mutilation such as burning oneself or slitting one’s wrists or other body parts are behaviors that are usually linked with suicide attempts and completions.

Being a male, having access to firearms, substance abuse, being an older caregiver, and separation or divorce are some of the risk factors for adults who commit murder-suicide.

An increased risk of suicidal behaviors in children and adolescents seem to be associated with bullying and being bullied. Additionally, being bullied may play a significant role in putting male teens at risk of committing murder-suicide, such as by school shootings.

Children and teens who have someone they know commit suicide are more at risk of suicide compared to adults, a phenomenon known as cluster formation or contagion.

The likelihood of suicide is decreased with the absence of substance abuse and mental illness, and with the presence of a strong social support system. In the case of mothers committing suicide, it seems that having children younger than 18 years is a protective factor.

SIGNS AND SYMPTOMS OF SUICIDE:

Writing a suicide note, making a will, suddenly visiting friends or family members (one last time), a significant decline or improvement in mood, getting the affairs in order, and buying instruments of suicide such as a rope, hose, medications or a gun, are some of the warning signs that a person is imminently planning to kill him/herself. Contrary to popular belief, in the months before they kill themselves, many people don’t tell their therapist or any other mental-health professional that they are planning to commit suicide. However, if they do tell their plan of committing suicide to anyone, it is usually to a friend, a family member, or some other person with whom they are personally close.

Hopelessness, moderate alcohol abuse, persistent thoughts about the possibility of something bad happening, severe agitation, insomnia and loss of interest in activities they used to enjoy (anhedonia) are some of the symptoms of anxiety from which people who commit suicide tend to suffer from. To allow a person who is planning on committing suicide take some time to think more clearly and perhaps choose a more rational way of coping with their plan, knives, firearms, medications and other instruments people usually use to kill themselves should be removed, because suicide is usually quite impulsive.

HOW ARE SUICIDAL THOUGHTS AND BEHAVIORS ASSESSED??

An evaluation of the presence, severity and duration of suicidal feelings in the individuals being treated are involved in the risk assessment for suicidal thoughts and behaviors performed by mental-health professionals as part of a comprehensive evaluation of the person’s mental health. Because of this, practitioners frequently ask the people they evaluate about any past or present suicidal thoughts, plans, intent and dreams, in addition to asking questions about family mental-health history and about the symptoms of a variety of emotional problems including mood swings, substance abuse, any history of being traumatized, anxiety, bizarre thoughts, eating disorders, and depression. In case the person has already attempted suicide, the mental-health professional may explore the circumstances that surrounded the attempt, in addition to the level of dangerousness of the method and the outcome of the attempt along with any other history of violent behavior. Usually, the practitioner will also inquire about the person’s accessibility to weapons, sources of support and current circumstances such as recent stressors; for example, family problems or end of a relationship. During an evaluation, the mental-health professional will also explore what kind of treatment the person may be receiving and how he/she has responded to treatment recently and in the past.

An assessment scale is sometimes used to assess suicide risk. The SAD PERSONS Scale is one of those scales that identifies the risk factors of suicide as:

  • Sex (male)
  • Age younger than 19 or older than 5 years of age
  • Depression (severe enough to be considered clinically significant)
  • Previous suicide attempt or received mental-health services of any kind
  • Excessive alcohol or drug use
  • Rational thinking lost
  • Separated, divorced, or widowed (or other ending of significant relationship)
  • Organized suicide plan or serious attempt
  • No or little social support
  • Sickness or chronic medical illness


HOW ARE SUICIDAL THOUGHTS AND BEHAVIORS TREATED
??

When mental-health professionals treat people who attempt suicide, they tend to adapt immediate treatment to the person’s individual needs. Only a brief crisis-oriented intervention may be needed in the case of people who have a responsive and intact family, generally good social supports and good friendships, a history of being hopeful, and a desire to resolve conflicts.

People who are at higher risk and may need psychiatric hospitalization and long-term mental-health services are those who have made previous suicide attempts, seem to be suffering from either severe depression or other mental illnesses, have families who are unwilling to commit to counseling, have shown a high degree of intent to kill themselves or those who are abusing alcohol or other drugs.

Mental-health professionals try to implement a comprehensive outpatient treatment plan prior to the individual being discharged by putting in place suicide prevention measures following a psychiatric hospitalization. Because many people fail to comply with outpatient therapy after leaving the hospital, this step is very important. Since the individual may still find access to guns and other dangerous objects stored in their home, even if locked, it is usually recommended that all firearms and other weapons be removed from the home. As a result of the attempt of suicide, it is also recommended that sharp objects and potentially lethal medications be locked up.

To decrease the long-term and short-term risk, vigorous treatment of the underlying psychiatric disorder is quite important. In preventing suicidal behavior, contracting with the person against suicide has not been shown to be especially effective; however, this technique could still be helpful in assessing risk because the person may indicate an intent to harm him/herself when refusing to agree to refrain from harming him/herself or failing to agree to tell a specified person.

Concerns have been raised about the possibility that antidepressant medications increase the frequency of suicide attempts, but mental-health professionals try to put those concerns in the context of the need to treat the severe emotional problems that are usually associated with attempting suicide and the fact that the number of suicides that are completed by mentally ill individuals seems to decrease with treatment. Research supports the effectiveness of medication treatment for depression in teens, especially when psychotherapy is combined with those medications.

After a decade of steady decrease, the reason behind the increase may be due to the reduction of antidepressant prescribing since the FDA required that warning labels be placed on these medications. It has also been discovered that the likelihood of suicide is decreased with the use of mood-stabilizing medications such as lithium, as well as medications that address bizarre thinking and/or severe anxiety such as aripiprazole, clozapine and risperidone.

ELECTRIC CONVULSIVE THERAPY (ECT):

A clinical indication for ECT is prominent suicidality. Much of the rationale for this practice is indirect and based primarily on the established and superior efficacy of ECT in treating severe depression that is usually associated with suicidal ideation and behaviors. Particularly in severe, acute major depression, with or without psychotic features, ECT affords a more rapid and robust clinical antidepressant response than psychosocial, psychopharmacological or other treatments.

PSYCHOTHERAPIES:

Psychodynamic and psychoanalytic psychotherapies: 

Experience with psychodynamically and psychoanalytically oriented psychotherapies is extensive in patients with suicidal behaviors, and lends support to the use of such approaches in clinical practice.

Cognitive behavior therapy:

People with suicidal behaviors are expected to benefit from this therapy since cognitive behavior therapy is quite effective in treating depression and related symptoms such as hopelessness.

Dialectical behavior therapy:

This therapy is a psychological treatment for borderline personality disorder. It combines group practice of behavioral skills with individual psychotherapy. It has been studied in a randomized fashion with respect to its effects on self-injurious behaviors.

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Prepared By: Dr. Mehyar Al-khashroum
Edited By: Miss Araz Kahvedjian




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