Suicidal behavior is one of the most serious outcomes of psychiatric illness and is particularly associated with major depression. Standardized tools for classifying mental disorders () list suicidal cognitions as one of the key symptoms of depression. They can range in severity from “recurrent thoughts of death” or “thinking that you would be better off dead,” to thoughts or images of suicide and/or having a detailed plan for a suicide attempt. Sometimes patients find their symptoms vary from one episode of depression to the next, but alongside the two core symptoms of depression (low mood and loss of interest), suicide ideation is the symptom most likely to recur across depressive episodes.
It is often supposed that if a person talks openly of suicide, then he or she is less likely to actually attempt or commit suicide, but the opposite is more generally the case. Most people who commit suicide have expressed a wish to die to someone and may have had a history of recurrent episodes of depression in which they experienced suicidal cognitions.
Clinically, suicidal ideation and planning is assessed by asking directly about the extent of such thoughts and plans. There is no evidence that talking openly about suicidal cognitions puts the “idea of suicide into people’s heads.” A common measure used to discuss the extent to which people are experiencing suicide ideation is the Scale for Suicide Ideation by Beck and Steer (). Example questions can be seen in Table Example Items from the Suicide Ideation Scale. An alternative version of this scale asking about past cognitions is also available, as it has been found that asking about the worst-ever point in the past — how close a person came at that point to suicide — is a better indicator of future risk of suicide than asking about a person’s current suicide ideation.
Table Example Items from the Suicide Ideation Scale
- People are instructed to answer as they feel now.
- What is your current desire to make an active suicide attempt, to actively harm yourself, actively kill yourself? Is there no desire at all?
- Today do you have any passive suicidal feelings? For instance, on the one hand would you, in fact, take precautions necessary to save your life? Would you take medicine to save your life if you needed it?
Antidepressants as means of committing suicide
Concerns are often expressed about the elevated risk of suicide and attempted suicide associated with the treatment of depression with antidepressant drugs. The danger that certain antidepressants are more toxic than others and may, in the event of an overdose, have severe consequences and even be lethal should not, of course, be underestimated.
The older tricyclic antidepressants have relatively high overdose toxicity; the newer antidepressants are less toxic. But, even the newer agents can be used for self-destructive purposes. What counts here, obviously, is not only the properties of the tablets ingested but also the patient’s intention as expressed in the quantity of tablets swallowed.
Doctors and relatives alike should bear in mind that there is a risk of suicidal acts at the commencement of treatment with antidepressants before the full effect is achieved (), since patients’ symptoms improve after approximately 2–3 weeks’ treatment and their psychomotor inhibitions diminish, while their negative perceptions of the illness and (very often) poor psychosocial situation still persist. Moreover, one should be mindful of the fact that anxiety, which is a powerful impetus towards suicidal acts, is intensified at the beginning of treatment with certain antidepressants. Active follow-up with face-to-face supportive discussions is, therefore, important.
Suicide mortality is significantly associated with contact and psychiatric admissions in the preceding year. Mortality due to suicide is highest in persons with bipolar, affective, and personality disorders. In both treatment and prevention, one should also focus on so-called distal risk factors, like low educational achievement, low occupational status and unemployment, along with proximal psychiatric risk factors for suicidality in order to achieve the best effect.
Although assessing the suicide preventive effects of various treatments is subject to several methodological difficulties (partly because of the divergent selection factors used in different studies, and partly because of information bias and random fluctuations in suicide rates in small populations), the results of existing studies and clinical experience are clearly promising. Both psychotherapeutical and pharmacological treatments have good effects.
Unfortunately, although some 60% of people seek help shortly before committing suicide, only about 15% receive antidepressant prescriptions and, of these, half show poor compliance to treatment and discontinue their medication 2–3 weeks before the suicide. For others, the dosage is often insufficient. One of the reasons being not only inadequate dosage, but also inherited genetic differences in metabolic pathways. Moreover, psychotherapeutic treatment is not always available. Electroconvulsive therapy is not commonly used and treatment with lithium requires knowledgeable follow-up. According to a Finnish study, only 3% of people who died from suicide had received electroconvulsive therapy and 3% had received lithium treatment.
Effective treatment of depression with both pharmacological and psychological methods is the foremost strategy of suicide prevention among young people, the middle-aged, and the elderly alike. Treatment of depression appears, however, to be of more benefit in preventing suicide in women than in men.
Keeping problems to oneself; Jussi, age 40
Jussi, a 40-year-old Finnish-born factory worker, had moved to Sweden several years ago in search of a better job. He was engaged to, and lived with, a Finnish woman who was one year his senior and with whom he was expecting a child. The woman’s four children from a previous marriage were in their father’s care. Jussi was described as taciturn, placid, reliable, helpful, and concerned about his family. Married once previously, he had a child from the marriage, who was looked after by his ex-wife.
In the past six months, his duties at the factory had changed and he no longer enjoyed his job. Although he had not striven to keep his ordinary duties, he felt hurt and disappointed when a colleague was chosen to replace him.
Over the past months, his private life had also changed. He had stopped seeing his siblings, who also lived in Sweden, and he refused to visit his parents in Finland although they had warmly invited him, his fiancee and her children to a big family gathering. From time to time he complained of pain in the same part of his back that he had strained while renovating a boat.
In the past four weeks, Jussi had begun losing interest in everything. Even painting his beloved boat did not appeal to him, although the sailing trips of the spring and summer were approaching. He could be deeply despondent one moment and irritable and restless the next. Previously very even-tempered, he had on one occasion hit his fiancee’s 5-year-old son, who was briefly visiting them. This was the impetus for his fiancee’s suggestion that Jussi should see a doctor.
Jussi went to see his general practitioner. During the consultation he was reserved and obviously unaccustomed to talking about his situation at work and in his private life. He did not tell the doctor that he felt very lonely and under pressure because of his fiancee’s pregnancy, nor did he refer to his worry about how they would cope financially, having to support not only the child from his first marriage but also the baby they were expecting and his fiancee’s other children. He shared neither with the doctor nor with anyone else his intensive brooding about what kind of a mother his fiancee would turn out to be, since she had not looked after her own children from her previous relationship.
Jussi also omitted to tell the doctor that everything had felt black and difficult over the past month. The idea of hanging himself kept coming back to him. A colleague had taken his own life one year before and his maternal grandfather, who had been depressed, had hanged himself when Jussi was a child. These ideas were not conveyed to the doctor, who prescribed a painkiller.
The prescription did not help, and the fiancee sensed Jussi’s growing dependency and inactivity. Besides backache, he began getting headaches and stomach aches, and his eating habits deteriorated. In three weeks, he lost several kilograms in weight. Jussi became more and more detached from his family. He began resorting to alcohol to get to sleep. No longer interested in anything, he became passive, withdrawn, and sluggish.
One day he refused to see an assistant from the Finnish housing agency whom he and his fiancee had an appointment with to hear about opportunities for getting a better flat. In despair his fiancee turned to the Finnish church, and the parson promised to visit them at home. Jussi always felt uneasy in the presence of the parson, whom he feared and considered stern.
On the day before the parson’s visit, Jussi went out early in the morning to the garden and hanged himself. He was found by a passing factory guard and cut down. After resuscitation, he was admitted to a psychiatric unit. After his suicide attempt, Jussi was treated with electroconvulsive therapy, followed by antidepressants, and underwent family therapy with his fiancee.
Selections from the books: “The international encyclopedia of depression” Edited by Rick E. Ingram. 2009; “Suicide: an unnecessary death”. Edited by Danuta Wasserman. 2016