How to manage the specific risk factors of people prone to commit suicide

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1. Overview


Suicide is the process by which a person ending their own lives intentionally. How the society perceives suicide varies greatly, depending on the culture and religion.

For example, many Western cultures, such as Judaism, Islam and Christianity, considered that suicide is a negative thing. A related myth promotes the idea that suicide is a result of mental illness.

Some societies treat suicide as being similar to murder. However, suicides are often difficult to understand, and in some cases may have honorable character (such as in protest to persecution or as part of the fight for a cause).


Contents

1. Overview
2. Effects of suicide
3. When to worry about suicidal ideas
4. Risk factors
5. Other measures


2. Effects of suicide

The effects of suicidal behavior or suicide, for the friends and family members of the deceased are devastating. People who have lost a loved one are at risk of becoming preoccupied with suicide and why deny or accept the death, they will feel guilty and will blame that failed to prevent suicide, but also for the problems that preceded it and will feel stigmatized by others.

Survivors may experience a range of conflicting emotions about the deceased, from intense emotional pain, hurt and sadness about the loss of their loved one in good conscience caused by the fact that they could not prevent suicide and anger as the man who committed suicide decided to take his own life (especially if suicide took place after a long time of physical and mental illness of a loved one).

This is understandable given the fact that the person who is grieving can be both victim, but could have a influence on the fatal act. Those who remain alive, tend to experience complicated types of pain in response to this loss.

Pain symptoms include intense emotions, the desire to know what was the motivation of the person that took his life, sleep disturbance, feelings of isolation and emptiness, avoiding doing things or actions arousing memories, lack of interest in various activity.

In people with major depression, suicide risk increases by 20% compared with the general population. Major depression is present in about 60% of the medical history of those who were able to complete the act of suicide. It is estimated that 8% of those who committed suicide suffered from depression at some point in their lifetime. This rate increases in patients with comorbid anxiety disorders.


3. When to worry about suicidal ideas

Some doctors are concerned that if they ask their patients about their suicidal thoughts, the investigation could lead to a suicide attempt. However, this has not been demonstrated scientifically.

In contrast, patients with such thoughts often try to externalize them, but cannot verbalize their concerns without being stimulated. Although some people may be reluctant to disclose their intention to commit suicide if doctors communicate on the subject with them, they will share their plans.

Recognition of a patient with suicidal tendencies can be challenging for any physician. There are studies showing that screening related to this can reduce the rate of suicide or suicidal intent of a person.

Beside this, in the investigation can be further introduced methods for assessing depression. However, since there are no tools and techniques to properly predict which patients will have suicidal ideas suicide attempt, the doctor is the one who will decide the necessity of further investigations and other types of interventions.


4. Risk factors

Understanding the risk factors can facilitate recognition of patients who have a high risk of suicide, which is important for their evaluation. Characteristics of the person who has an increased risk of suicide include:

- Previous attempts – half of those who succeed to commit suicide have had previous attempts to take their life. Many survivors of suicide attempt, die by suicide within the next year, with a risk 100 times higher than the rest of the population for this to materialize.

- Psychiatric disorders – people with mental illness seem more prone to suicide than those with uncomplicated depression or anxiety disorders. Psychiatric disorders most commonly associated with suicide include depression, bipolar disorder, alcoholism or substance abuse, schizophrenia, personality disorders, anxiety disorders, posttraumatic stress disorder and delirium.

Those who suffer from anxiety disorders exhibit a double risk of suicide, but the combination of depression and anxiety increases the risk even more. The correlation between depression and comorbid personality disorders are strongly linked to suicide attempts. In addition, between 20-25% of those who commit suicide are drunk at the time of suicide.

- Age, sex and race – although there are more young people who attempt suicide than the elderly, the risk increases with age. Men are three times more likely to complete suicide, although the number of women who commit suicide, compared with the men is four times higher. These differences result in lethality of the method chosen. Speaking about the race, most people who commit suicide are white.

- Work – unemployed and unskilled workers have an increased risk compared to those independent and qualified. Doctors, especially females have higher chances of being subjects of suicidal acts.

- Impulsiveness – impulsiveness increases the likelihood of action, and the combination of despair, impulsivity and substance abuse may be particularly lethal. This combination occurs most often in young adult.

- Health status – there are higher chances to commit suicide people who suffer from chronic pain or illness or had a major surgery recently.

- Family – a first degree relative who committed suicide increases up to six times the likelihood of a person to commit suicide. Heredity has an influence between 30-50% in the case of suicide, although it is uncertain whether genetics contributes to underlying mental disorders or suicide act itself.

People who are not married commit suicide more often than married, followed in descending order by those who are widowed, separated or divorced, married without children, and married with children.

The risk increases for those who live alone, those who lost a loved one or have had a relationship that failed, lasting less than one year. Sad anniversary events can be a high risk. In addition to these, a parent who committed suicide may increase the risk of suicide in his child.

- Abuse and other negative situations in childhood – these conditions can increase the risk of suicide in adults, especially if accompanied by alcoholism, depression, illicit drug use, factors that are strongly associated with adverse events in childhood.

- Access to tools and resources that can facilitate suicide – in many countries, most suicides are caused by firearms, while in other cases, suicide is by hanging or poisoning.

- The lack of hope – hope is a concept that could contribute to the suicide decision of a person, independent of depression. It was found that this is more important than depression and it may mediate the relationship between interpersonal loss, loneliness, low self-esteem and suicide. Those who suffer from persistent hopelessness when depression is solved, continue to have an increased risk of suicide.

- Protective factors – strong connections within the family and social support decreases the chances of suicide, while family discord may increase the rate of suicide actions. Presence of a child to a mother or pregnancy, reduces the risk of suicide.

Participation in religious activities and religious beliefs are associated with lower suicide probabilities. Knowledge of risk and protective factors above can be used to assess patients who are at a high risk of suicide or for whom this is a concern.


5. Other measures

Once suicide potential is admitted in a patient’s case, the next step is to assess the presence, frequency, duration, content control and suicidal thoughts.

Investigation could start by giving the patients the possibility to share if they think it would be better if they were dead, though they have lost interest in life or if they have a serious thought about suicide. Inquiries regarding the expectations of death can be useful.

In this way the motivations that could be the basis of suicidal act might be revealed, like punish individuals or escape from a painful situation. The discovery and study of detail about suicidal plan can be helpful in assessing the severity of a person’s intention to commit suicide.

Among the questions of interest might include:
- Do you have a plan that you made or that you implemented, including a specific method, time and place?
- Have you made any preparation?
- Have you ever tried to kill yourself (in a real way)?
- What is the anticipated outcome of the plan?
- Are there any available means of suicide?
- Do you know how to use these tools?
- How lethal is your plan?
- How serious are the plans and suicide intent, including the ability to control your impulses?

Among the aims of the investigation should be the identification of any events that might precipitate the implementation of suicidal plans (death of a loved one, breakup of a marriage, no job, deception school, workplace, sexual identity crisis or trauma).

Knowing the details of lifestyle involving the use or substance abuse, impulsivity, lack of social support and various factors that favor stress may be helpful in selecting an appropriate management plan.

Other important elements require more effective collaboration of the physician with his patient and the inclusion in the treatment strategy, presence or absence of stressful situations that could threat a person’s ability to cope with difficulties, but also any previous suicide attempts.

In accordance with the above information, the risk of suicide should be expected and managed accordingly, as follows:

- Imminent – patients have an active plan or intent to take his own life and have easy access to lethal means. Those who suffer from mental illness, cognitive impairment or who have no discernment are at a higher risk of suicide. These patients require hospitalization and electroconvulsive therapy immediately; this can change their life.

- Increased but not imminent – this group needs aggressive treatment but should not be involved hospitalization. Interventions could include psychiatric treatment, substance use control, family and social support, limiting access to firearms or other potentially lethal drugs and ensuring frequent contact with professionals. Risk factors which will be given special attention are: comorbid psychiatric disorders, events that may precipitate the suicidal act, difficulties in everyday life.

For a higher rate of success it is recommended a good communication and strong relationship between therapist and patient and frequent reassessment. Other methods of intervention that may help involve psychotherapy, counseling, religious support, but also community and family support. Cognitive behavioral therapy can be helpful in people who lack of hope becomes a concern.

The doctor will permanently observe and will maintain the contact with his patients (identified as having an increased risk of suicide) as close as possible. Risk of suicide fluctuate and should be reviewed constantly. As part of monitoring those who have attempted suicide, the clinician should determine if there were changes, such as recurrence of events that could precipitate suicidal plans, adverse circumstances in life or worsening mental disorders.

Primary care has an important role in reducing the chances of suicide. Among patients who commit suicide 75% did not came into contact with their doctor and haven’t received primary care in the year that preceded their death.

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