Depression and Suicide - Preventing Suicidal Attempts

Types of Suicidal Behavior

The concept of suicide is relatively straightforward, as it is defined by a legal judgment where there is clear evidence that the person intended to take his or her own life. Cases where clear evidence is lacking but the suspicion is of suicide are usually recorded as undetermined deaths and are often included in the suicide statistics. Non-fatal suicidal behavior is more complicated because of the range of behaviors encompassed and the variety of terms used.

The terms usually imply something about the level of intent to die; for example, ‘attempted suicide’ implies a strong intention to die, whereas ‘deliberate self-harm’ does not. It is tempting to make judgments about the level of intent, but this is difficult to do in practice.

People are often unaware of the medical lethality of the overdose they have taken (by far the most common type of self-harm), thus rendering this a poor criterion. Moreover, when asked, most commonly, people simply say they wanted to escape; they may not be clear about whether they wanted to die or not. Finally, individuals with more than one episode of self-harm are quite likely to have a mixture of levels of intent across different episodes. One solution suggested by Kreitman (1977) was to use the term ‘parasuicide’ as a descriptive term to cover all deliberate but non-fatal acts of self-harm, thus, remaining neutral about level of intent to die.

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Signs of Possible Suicidal Intentions

Although suicide is very hard to predict, there are some reliable indicators of risk.
  • Those who are seriously depressed are quite likely to have thoughts of suicide. (NOTE: 'thoughts' does not necessarily imply an attempt or even a desire to act on the thoughts.)
  • Other emotional illnesses such as severe anxiety or confusion can lead to the idea that "life is not worth living."
  • The person is always talking or thinking about death. It might be even perceived as obsession.
  • Anyone who has previously attempted suicide is at increased risk.
  • Recent losses, particularly deaths of close relatives or friends, heighten vulnerability.
  • Alcohol and drugs can dissolve inhibitions against suicide.
  • Having a "death wish," tempting fate by taking risks that could lead to death such as driving fast or running red lights.
  • Preparations for death, such as giving away possessions or acquiring a gun, are cause for great concern. It might show up as putting affairs in order, tying up loose ends, changing a will, or visiting or calling people to say goodbye.
  • A sudden lift in spirits in a depressed person can mean a decision has been reached that will "end the misery."
Factors associated with increased suicide risk after acts of deliberate self-harm

The individual, who has performed an actual self-harm attempt, can be considered as stepping closer in the group of risk, whose mere thoughts have been already translated to the practical actions. Watch for the following behavioral factors that are associated with higher risk of the suicide. 
  • Act of deliberate self-harm planned long in advance.
  • Suicide note written.
  • Acts taken in anticipation of death (e.g. writing a will).
  • Being alone at the time of deliberate self-harm.
  • Patient making attempts to avoid discovery.
  • Not seeking help after deliberate self-harm.
  • Stating a wish to die.
  • Believing the act of deliberate self-harm would prove fatal.
  • Being sorry the act of deliberate self-harm failed.
  • Continuing suicidal intent.
Two particular groups of patients are at significantly increased risk of suicide: those with a history of suicide attempts; and those recently discharged from psychiatric inpatient care. About 1% of all deliberate self-harm patients commit suicide within 12 months of a suicide attempt, and up to 10% may eventually die by suicide. In addition 10–15% of patients in contact with health services following a suicide attempt will eventually die by suicide, this risk being greatest during the first year after an attempt. Up to 41% of suicide victims have received psychiatric inpatient care in the year prior to death, and up to 9% of suicide victims kill themselves within 1 day of discharge.

Depression and Suicidal Attempts

Those with depression have a greater risk of deliberate self-harm and suicide. A recent meta-analysis estimated the standardized mortality ratio for completed suicide of those who had previously attempted suicide to be over 4000, higher than the risk attached to any particular psychiatric disorder, including major depression or alcoholism. Other risk factors for suicide include:
  • older age
  • male gender
  • single status
  • personality disorder
  • history of aggression
  • suicidal thoughts
  • social isolation
  • physical illness
  • alcohol abuse
  • recent suicide attempt
Suicide and Bereavement (loss of something or someone that one loves)

There is an increased risk of suicidal gestures, completed suicide and death from accidents following the death of a spouse or a parent. The suicide risk for those widowed was first observed over a century ago by Durkheim who found that suicide was higher amongst those widowed compared to those married.

When compared to the general population Mergenhagen and colleagues found the mortality ratio for suicide in young widowers (45–64 years of age) was about four and a half times the rate for married men of similar age. Most studies have found a gender bias with younger men being at the greatest risk of suicide, although Heikkinen and coworkers found evidence of an association between widowhood and women aged 60–69 years.
Several longitudinal studies have found that the risk of suicide is greatest for the period immediately following the loss. The risk of suicide among the widowed population was generally higher in the first 4 years after the death of the spouse, the risk of suicide in the first year was 2.5 times higher, and in the first, second and third years about 1.5 times higher.

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Relation between depression and suicide

There is a strong link between depression and suicidal behavior, but there is also high divergence, as shown especially by the fact that the vast majority of depressed people do not commit or attempt suicide. The presence or absence of other factors might help explain this divergence. Factors such as other psychiatric diagnoses, especially personality disorder; protective factors; and other psychological factors, such as personality and affective traits, and problem-solving skills, have all been shown to distinguish suicidal from non-suicidal depressed individuals.

The relationship between depression and suicide is mainly dependent on one particular facet of depression—hopelessness about the future. Hopelessness appears to consist mainly of a lack of positive thoughts about the future rather than preoccupation with a negative future. Risk assessment and intervention in suicidal behavior are difficult because of the relatively low base rate of suicidal behavior and the heterogeneity of those who engage in it. Predictive models, whether using depressive hopelessness or a range of factors, are able to identify those at risk only through incorrectly classifying unacceptably high numbers of people as at risk. Because of predictive inaccuracy, the emphasis has shifted to assessment of relative risk rather than absolute risk.

Treatments of depression are themselves never likely to be effective treatments for suicidal behavior per se. The majority of studies testing specific interventions for suicidal behavior have shown no benefit over treatment as usual, though a number of studies have shown positive results. There is no obvious pattern to the successful interventions in terms of their content, though they do seem either to target a specific subgroup of parasuicides or to involve a brief, flexible treatment delivered at home. Both these strategies potentially limit the problem of heterogeneity. A modular approach provides a framework for incorporating a range of treatment strategies derived from the interface between basic and applied research. Developing strategies to tackle depressive hopelessness, particularly lack of positivity about the future, is one of the most needed and promising lines for future research.



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