Dr.
Neil Fernando & Dr Ruwan M Jayatunge
Suicide
is a psychiatric emergency and needs immediate intervention. It has been
recognized as a major health problem and a leading cause of death worldwide. Suicide
does not occur in a vacuum; it’s a fatal outcry and a highly complex and
multifaceted phenomenon.
Suicide
is the most severe and final manifestation of psychological pain (Rahman et al., 2010). Suicide is
a social malady with far-reaching impact. Suicide is defined as an act of
intentionally terminating one’s own life (Nock et al., 2008). The National
Institute of Mental Health defines suicide as a death caused by self-directed
injurious behavior with intent to die as a result of the behavior. Suicides result
from the complex interaction of many factors (O’Connor et al., 2014).
Suicidal behavior has a unique trajectory and the behavior
pattern is clearly in the medical domain. Suicidal behavior encompasses a spectrum of
behavior from suicide attempt and preparatory behaviors to completed suicide.
Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for
further consideration and potential acceptance into the diagnostic system. Many
mental health clinicians recognize suicidal
behavior as an independent construct.
According
to the French sociologist Emile Durkheim, the term suicide is applied to all
cases of death resulting directly or indirectly from a positive or negative act
of the victim himself, which he knows will produce this result. For Emile
Durkheim suicide is not a personal act. He believed that the more socially
integrated and connected a person is, the less likely he or she is to commit
suicide. Durkheim identifies four different types of suicide which are egoistic
suicide, altruistic suicide, anomic suicide and fatalistic suicide.
Psychodynamics of the pathway to suicide is complex. According to Menninger (1938) suicide is caused by unconscious drives. Depression, psychic pain, impulsiveness, anger, anxiety, despair, loneliness, panic, violence, revenge, and a host of other factors are acting in a complex and almost infinite combination to produce the catastrophic behavior and it leads to suicide (Gibbons, 2024). Some experts propose the relationship between attachment styles and suicide ideation. Silva Filho and team (2023) highlight that disruptive attachments are related to emotional dysregulation and mental disorders throughout life.
Suicide
and suicidal behavior have become a public health concern in Sri Lanka. The
suicide rate in Sri Lanka in 2022 was 27 per 100 000 and 5 per 100 000, in
males and females, respectively, with an overall suicide rate of 15 per 100 000
populations. However, incidence of suicide is underreported in Sri Lanka due to
legal and stigma-associated factors. According to the World Health
Organization-based statistics, suicide occurs in approximately 16.7 per 100,000
persons per year and is the 14th-leading cause of death worldwide.
For the development of suicide risk,
biological, psychological, social, and environmental factors have been
identified (Turecki, et al., 2019). The link between suicide and mental
disorders is well established. There is a correlation between suicidality and
psychopathology (Gvion &Apter, 2011). Psychopathology, biological
vulnerability, family characteristics, and stressful life events play a key
role in suicidal behaviors. The most common psychiatric conditions
associated with suicide or serious suicide attempts are mood disorders, but
personality disorders, alcohol and substance abuse, anxiety disorders, and
schizophrenia are also frequently associated with suicidal behavior.
(Sher,2004). Other risk factors such as unemployment, marital disruptions and
financial crises also play a crucial role.
Suicides have a rippling effect. As described
by Pirkis and Nordentoft (2011), media reporting of suicide can influence
suicide rates. According to the social learning theory one person's suicide can influence another's suicidal
behavior. The aftermath of suicide touches the
lives of family and friends of the victim. The ripple effect can impact
individuals and their families and friends. The
ripple effect can extend to something known as "vicarious suicidality”.
The evidence suggests that suicidal behavior is “contagious” (Gould & Lake
2013).
Suicide is preventable and preventing requires strategies at all levels of
society with a comprehensive public health approach. Promoting mental health education and de-stigmatisation
efforts are highly essential. Suicide prevention is an emotive, complex goal for clinicians
and health systems (Larkin et al., 2023).
Clinical
suicidology” emphasizing suicide risk assessment, treatment, training, and the
management of suicide-related liability. For there to be suicidal behavior
there needs to be an established intent to die and a measurable medical
lethality associated with the behavior (Silverman,2006). Clinical suicidology
identifies suicide an act with a fatal outcome which the deceased, knowing or
expecting a potentially fatal outcome, has initiated and carried out with the
purpose of bringing about wanted changes (DeLeo et al., 2004).
Psychotherapeutic,
pharmacological, or neuromodulatory treatments of mental disorders can often
prevent suicidal behavior (Turecki et al., 2016). antidepressants are widely used in suicide prevention
pharmacotherapy. For psychotherapeutic methods mental health clinicians
recommend dialectical behavior
therapy, cognitive therapy prolonged
grief therapy and attachment based family therapy.
Implementing effective public health programs,
promote wellness and removing stigma around suicide related behaviors can
reduce the risk of suicide contagion. Furthermore, identifying risk factors and
recognizing the warning signs for suicide can help prevent suicide. Media
reporting on suicide can affect suicidal behavior and responsible reporting
help prevent the suicide contagion effect. There should be a comprehensive
national strategy to prevent suicide.
(Dr. Neil Fernando is a consultant Psychiatrist and Dr.
Ruwan M Jayatunge is a Clinical Psychologist)
References
De Leo, D., & Spathonis, K. (2004).
Suicide and Suicidal Behaviour in Late Life.
Suicidal Behaviour: Theories and Research Findings.
Gibbons, R. (2024).
Understanding the psychodynamics of the pathway to suicide. International
Review of Psychiatry, 36(4-5), 508–516.
Gould, M., & Lake, A.
M. (2013). The contagion of suicide behavior: Impact of
media reporting on suicide. Forum on Global Violence Prevention:
Based on Global Health Institute of Medicine, National Research Council:
Washington DC: ational Academics Press.
Gvion Y, Apter A. Aggression, impulsivity and
suicide behavior: a review of the literature. Suicide Life Threat Behav.
2011;15:93-112.
Larkin C, Arensman E,
Boudreaux ED. Preventing Suicide in Health Systems: How Can Implementation
Science Help? Arch Suicide Res. 2023 Oct-Dec;27(4):1147-1162. doi:
10.1080/13811118.2022.2131490. Epub 2022 Oct 20. PMID: 36267036
Nock MK, Borges G, Bromet EJ, Alonso J,
Angermeyer M, Beautrais A, et al. Cross-national prevalence and risk factors
for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192:98-105.
O'Connor RC, Nock MK. The psychology of
suicidal behaviour. Lancet Psychiatry. 2014 Jun;1(1):73-85. doi:
10.1016/S2215-0366(14)70222-6. Epub 2014 Jun 4. PMID: 26360404.
Pirkis
J, Nordentoft M. Media influences on suicide and attempted suicide. In:
O’Connor RC, Platt S, Gordon J, editors. International handbook of suicide
prevention: research, policy and practice. Chichester; Malden, MA: John Wiley
& Sons; 2011. pp. 531–44.
Rahman B., Shirin V ., Mitra. N (2010). The
relationship between attachment styles and suicide ideation: the study of
Turkmen students, Iran, Procedia - Social and Behavioral Sciences, Volume
5, Pages 1190-1194, ISSN 1877-0428,
Sher,L.(2004).
Preventing suicide, QJM: An International Journal
of Medicine, Volume 97, Issue 10
Pages 677–680, https://doi.org/10.1093/qjmed/hch106
Silva Filho OCD, Avanci JQ, Pires TO, de Vasconcellos
Carvalhaes Oliveira R, Assis SG. Attachment, suicidal behavior, and self-harm
in childhood and adolescence: a study of a cohort of Brazilian schoolchildren.
BMC Pediatr. 2023 Aug 17;23(1):403. doi: 10.1186/s12887-023-04215-7. PMID:
37592202; PMCID: PMC10433545.
Silverman.
M.M. (2006). The Language of
Suicidology.Suicide Life Threat Behav. 2006 Oct;36(5):519-32.
Turecki,
G., Brent, D.A., Gunnell, D. et al. Suicide and suicide risk. Nat
Rev Dis Primers 5, 74 (2019).
https://doi.org/10.1038/s41572-019-0121-0
Turecki
G, Brent DA. Suicide and suicidal behaviour. Lancet. 2016 Mar
19;387(10024):1227-39. doi: 10.1016/S0140-6736(15)00234-2. Epub 2015 Sep 15.
PMID: 26385066; PMCID: PMC5319859.
