sections include: recognizing suicidal feelings, mechanisms, diagnosis and treatment
Suicidal feelings are not uncommon. Many people experience transient thoughts of death during a crisis. People under great stress or threat may fleetingly wish they were dead; we call these “passive” suicidal thoughts or feelings.
Suicidal feelings become a cause for more concern if a person experiences them often or starts to consider specific details about ending his or her life. Prolonged or recurring thoughts of suicide are frequently a serious indication of psychiatric illness. And, of course, taking any action to commit suicide is a sign that a person needs mental health treatment. Most suicide attempts are not lethal, but they are much more than an emotional “cry for help.”
Because we often associate suicidal thoughts or behavior with life stresses, we may not realize that the vast majority of suicide victims have an actual psychiatric illness. That condition renders them incapable of coping with stress or loss in healthy ways. Suicidal thoughts are relatively common as a manifestation of clinical depression. A person suffering from severe depression may experience persistent strong impulses to end his or her life, making specific plans to use highly lethal methods.
Suicidal feelings are not tied to one psychiatric disorder alone, however, but occur most commonly in a range of disorders, including bipolar disorder, alcoholism, schizophrenia and severe forms of borderline personality disorder. Suicidal people frequently display depressive symptoms, no matter what primary diagnosis their doctors make. Often physicians find that patients meet the criteria for more than one diagnosis at the same time, a condition called comorbidity. People at risk for suicide also often have a history of impulsive behavior or agitation (physical hyperactivity often associated with anger or anxiety). This may be associated with a history of substance abuse.
Though symptoms of depression are a common thread, there is no one type of person at risk for suicide. Different individuals experience or express their feelings in different ways. Some examples are:
- Severe hopelessness coupled with anguish experienced as “psychic pain”; in this condition, a person may suffer in silence, without complaint. Increasing anxiety over physical symptoms, either those of a diagnosable medical illness or those that doctors cannot pinpoint, along with symptoms of depression.
- A history of substance abuse, followed by the loss of an important relationship because of that behavior.
- Severe personality disorder, which makes people impulsive and very demanding, quick to feel that others do not support them, and unable to soothe their anger over feelings of rejection. If they face a discharge from a hospital, a therapist’s vacation, or the loss of a relationship, they may make repeated suicide attempts, usually by hanging or asphyxiation, escalating the danger each time.
In the United States, suicide is the eighth most common cause of death among adults, with the rate of suicide increasing dramatically in men after age 65. The suicide rate for females is about one fourth the rate in males, but females have a much higher rate of suicide attempts. Women, however, choose methods that are less often lethal.
Recognizing Suicidal Feelings
How do the conditions that can lead to suicide or suicide attempts first appear to others? Depressive illness can begin at any age, but people most commonly show its signs first in young adulthood or adolescence. Often their first symptoms are social withdrawal and a loss of interest in activities that they previously enjoyed. They may experience persistent insomnia or inability to sleep and sometimes a loss of appetite coupled with weight loss. About half the time clinical depression begins after a major life stress or setback, such as the loss of a relationship or physical illness. In a depressed state, people commonly feel increased fatigue, have trouble concentrating, and express hopelessness about life ever improving. While this condition commonly leads to suicidal feelings, not every depressed person is suicidal, and only a small percentage ever complete a suicide. However, an untreated clinical depression can worsen in severity and lead to such problems as lost jobs, financial stresses, and fractured relationships. It is a serious disorder, and people of all ages can get help.
How can we tell the difference between depressed patients who are at an immediate risk of suicide and the majority who may not be at risk? This judgment is difficult even for professionals. Certainly expressing a suicidal idea or feelings of hopelessness is an important sign. Other behaviors that indicate a person faces an increased danger of attempting suicide are:
- Abusing alcohol or other drugs.
- Impulsive behavior, such as tantrums, violent outbursts, or episodes of agitation.
- A history of rapid mood swings between hyperactivity and depression.
- Recurrent severe anxiety, often in the form of incessant worry and rumination.
- Recurrent panic attacks in addition to symptoms of depression.
Again, not every depressed person who shows one of these signs will commit suicide, but it is cause for extra concern.
It is not uncommon for people who have suicidal feelings to mention them to loved ones or friends. A classic study of suicide in adults reported that over 90 percent of individuals who committed suicide had a diagnosable psychiatric illness at the time of their death, and over 60 percent of those had communicated their suicidal feelings to others— three people, on average—in the year before they died. On the other hand, the same study found that only 18 percent of this group conveyed their suicidal thoughts to a helping professional, such as a physician or mental health counselor. This shows the importance of taking a friend’s suicidal feelings seriously and reporting them to the person’s doctor or therapist. You cannot assume that the doctor or counselor will have heard about them.
While individuals who commit suicide have a range and often a combination of diagnoses, there is some evidence that the vulnerability to kill oneself may run in families independent of any one diagnosis. Studies have similarly shown that such traits as impulsivity and anxious depression also run in families. It is therefore possible that impulsivity, severe anxiety or panic symptoms, or even the degree of hopelessness a person feels while depressed may have a genetic component that confers increased risk of suicide to people in certain families.
Studies of serotonin function that measure receptors in the brains of suicide victims have shown evidence of up-regulated—that is, hyperactive—receptors, suggesting that serotonin was functioning less than normally in their brains. We do not know if these findings apply to nonsuicidal patients with depression.
Other researchers have found increased corticotrophin- releasing hormone (CRH) in the brains of suicide victims. That is important because CRH stimulates the release of adrenocorticotrophic hormone (ACTH) from the pituitary, which in turn stimulates adrenal enlargement and hyperfunction of the adrenal gland, which has been shown to be associated with suicide. Also, CRH may stimulate cells in the brain stem to release norepinephrine, which is associated with emotional arousal. This would fit with doctors’ observation of severe anxiety and agitation in many people talking about or attempting suicide.
There are also studies that show a correlation between low cholesterol levels and suicidal behavior, as well as deaths from suicide, accidents, and violence. It is not clear what those findings mean. There could be some interaction between our cholesterol metabolism and neural membranes, resulting in altered brain function relating to depression and perhaps an increase in impulsive behavior.
Diagnosis and Treatment
If a friend or relative shows signs of being suicidal, do not leave that person alone until he or she has been assessed by a mental health professional. Remove any dangerous implements from the person’s access, including guns, knives, car keys, and toxic substances. This support can be life-saving. The person may seem to change his or her mind and deny such thinking. Emphasize that it is still important to seek psychiatric help. It is not unusual for individuals who have expressed suicidal feelings to deny such thoughts to loved ones and doctors or counselors shortly before they actually attempt suicide. If necessary, walk the person to an emergency room or call 911.
Doctors and counselors will try to identify what conditions are causing a person to consider suicide, while at the same time taking steps to prevent that act and relieve the acute suicidal feelings. There are several levels of treatment and approaches to avert suicide. Sometimes, a severely depressed and acutely suicidal individual must be hospitalized for protection and treatment. The successful treatment of depression or other major underlying illness can reduce the risk of suicide, but it may rise again if the person relapses. Treating severe anxiety symptoms, panic attacks, or agitation in depressed individuals can reduce acute suicide risk.
For people with recurrent episodes, such as patients with bipolar disorder or recurrent depression, there is evidence that taking lithium reduces suicide by seven to nine times. Further research should lead to further advances in detecting acute suicide risk and preventing needless loss of life.
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