This article appears in the November 2004 edition of the Catholic Medical Quarterly
The Suicide Crisis
Bengt J Safsten
Suicide is a crisis - for the individual, for the family and for the community. It is a unique kind of death, and the most malignant manifestation of depression. If ever a condition begged for an integrated understanding taking into account the social, theological, biological, clinical and subjective factors, this one does. Suicide and suicidal behaviour are the end result of an extremely complex interaction. It is very rare for suicide to be based on a simple and logical decision. Rather it is the culmination of a long process in which people in various ways try to reduce their profound emotional pain.
Many who commit suicide visit a non-mental health clinician, or others in the helping professions - including the Church - during the last months of their lives.
As the suicide crisis is so complex there are many ways to intervene and to prevent it. Another very important aspect - when the disaster has struck - is to care for the bereaved and especially for suffering children who may have been left. Although advances in medical technology bring more complex controversies regarding life and death, depression and suicide have been with mankind as long as there have been written records.
We tend to interpret events on the basis of our own perceptions. But we must also, within the confines of respect for the privacy of individuals, deal as openly as possible with the members of the community when dealing with depression and suicide. My presentation is based on my own daily work as a Swedish physician in a university city in Northern Europe, where suicide is treated as a medical and psychiatric emergency. But it is an incontrovertible fact that suicide is a world-wide major health problem with many different aspects to it.
There are international statistics describing the depression epidemic, and there is a hope that the crisis has been declining. However it has, in my opinion, in fact increased despite the availability of better knowledge and treatment options. We have heard that approximately one million people will die from suicide annually. But in the past 45 years suicide rates have increased 60% world-wide. One suicide is committed every 40 seconds around the world. In the U.S. a youth commits suicide every two hours. Suicide claims more adolescents than any disease or natural cause. It is among the three leading causes of death among those aged between 15 -44. and there are far more suicidal attempts and gestures than actual completed suicides There are approximately 10-20 times more attempted suicides than completed ones.
However, statistics are difficult to collate, and may be inaccurate, because of the sensitivity of the issue. In some countries is still an absolute taboo. Lost in the reporting are also mis-classifications of the cause of death, accidents of undetermined cause and so-called chronic or silent suicides such as substance abuse, or poor adherence to medical regimens. It is a paradox that while depressions are well defined medical entities, and as such regarded as official diagnoses and easier to evaluate statistically, suicides are not always treated as separate entities and therefore much harder about which to collate reliable statistics. Despite this, official statistics should not, as a rule, be believed to be misinterpretations. However, a word of caution is needed in relation to the interpretation of rates in countries with small populations, where a few more - or a few less - suicides can greatly modify rates.
Progression of suicidal behaviour
The route lies through suicidal thoughts, suicidal gestures, attempted suicide, and silent suicide mainly among the elderly, where self- starvation and medical non-compliance leads to death. Silent suicides are never found in the statistics.
Another type that is very seldom recognised is suicidal gestures in children, who for instance, may intentionally take an over dose of whatever pills they find in their parent's drawers, often to get attention for their problem.
Risk factors include previous attempts, a close family member who has committed suicide; past psychiatric hospitalisation, recent losses such as deaths, divorce, loss of job or an honourable position; social isolation, migration, drug or alcohol abuse, and exposure to violence; often in combination with male gender. Others include different types of childhood trauma, such as neglect, physical or sexual abuse. The single most important risk factor for a completed suicide is a previous attempt.
Often psychiatric disorders are components on the way towards suicide, mainly depressive disorders (50 - 90%) and/or alcoholism, and in some cases schizophrenia (5%). Depression is thus regarded as one main risk factor for suicidal behaviour. But depression is seldom sufficient in itself. Most suicidal victims have received no treatment; depression before death has been found in too many cases to be absent or inadequate. Feelings of hopelessness, helplessness, worthlessness and loneliness may be overwhelming. Anticipated or recent stressful events can finally trigger suicidal behaviour such as changing job or schools, or career changes.
It can never be said too often that all of us have the responsibility to be alerted by these warning signs.
Stages in Suicide Planning
In the resolution phase the individual is struggling with the moral and ethical issues surrounding suicide, asking themselves if it is a sin or not, and what effect it will have on loved ones and friends. Often those around them notice this as a period of extreme anxiety and agitation. This is succeeded by an initiation phase, in which the individual formulates actual plans. Finally, a stage of postponement ensues, often observed as a time when the individual, paradoxically, can relax and bide his time.
Work, family, parenthood and a stable social net-work, in general, serve as a protection. . Participation in religious activities may or may not be protective. Historically, suicide rates among Catholic populations have been lower than among Protestants and Jews. It accurate measure of risk in this category than simple institutional religious affiliation. It is, for instance, well known that Catholics who have migrated to another country, have a higher risk of suicidal behaviour than those left in the 'old' country.
Prevention and Intervention
The potential to suicide can be treated both at the individual level and in society. Protective factors should always be taken into account. Prevention includes education within the community about the problem of suicidal behaviour. Not only medical health care but all the organisations in the community can, and should, be involved in this work. Access to common means of suicide should be restricted such as poison control, controlled prescription of drugs, and gun safety.
An attempted or completed suicide can have a powerful effect on the surrounding community. There are indeed conflicting reports on the incidence of a contagious effect creating more suicides. Adequate steps have to be taken when there has been a suicide in the community. There ought to be clear plans and guidelines, involving staff members and administration with protocols and clear lines of communication. Such inventories should be made in advance so as to find professional medical, social and psychiatric help. These guidelines are necessities in schools, working places and in diocese and parishes.
Barriers to Treatment and Intervention
The attitudes towards suicidal behaviour vary between different regions. In some countries or cultures it is an absolute taboo but despite this, suicidal behaviour exists. And, at the individual level, for the untrained person, suicide may generate such a high anxiety rate that the problem is dealt with by thoughts of denial.
The current debate is centred on physician-assisted suicide rather than on euthanasia or 'proper' suicide. Some have argued that physician-assisted suicide is a human alternative to active euthanasia. Others believe that the distinction between physician assisted suicide and euthanasia is capricious. The intention in both cases is to bring about a patient's death. But it is well-known that in most cases there is a deep depression. Despite the abhorrence that many physicians and medical ethical experts express towards physician assisted suicide, poll after poll shows that many 'ordinary citizens' would favour assisted suicide in certain circumstances. Even if many professional associations of the medical community have opposed it, I must strongly urge that this should continue to be brought up on the agenda.
Other Forms of Suicidal Behaviour
Self mutilation can be regarded as another contemporary form of suicidal or self-destructive behaviour. People harm themselves in many ways, including burning or scratching, pulling out hair, hitting their bodies against something, drinking heavily or taking excessive amounts of drugs. We are here confronted with activities with a high physical risk, but for the individual not necessarily with a suicidal intent. But it is always an indication of an underlying problem and is often kept secret. It is a challenge for the medical profession.
The media are filled with reports of killings where 'suicide' is also included as a means to intentionally cause harm to other people for a political cause, sometimes under the guise of religion. We hear about so called 'suicide bombers' or 'suicide blasts'. This type of self sacrificing suicide has nothing to do with depression in the medical sense. Nevertheless, it has great impact on our attitude towards suicide, life and death.
Physician-assisted suicide and these latter forms of suicidal behaviour are thus not necessarily associated with depression in the medical context but are important aspects of present-day threats to human life.
The Swedish Experience
Sweden is a small country of only 8.9 million people. Today our standard of living is among the highest. Approximately 8 % of Sweden's gross national product amounts to health and medical services. Our people are among those who live longest. Almost 18% of Sweden's population are over 65 years old and 4.7%over 80 years old. The average life expectancy is 76.1 years for men and 81.4 years for women. The Swedish health and medical services are organised into a uniform, nation-wide programme that gives each person access and the right to the best available care.
Health care is regarded as the responsibility of the public sector stemming from traditions dating back to the 16th century. Only 8% of physicians work in private practice. The Ministry of Health and Social Affairs draws up general plans for services. The Government's National Board of Health and Welfare is the main agency for Swedish health care. It supervises public and private medical care and plans national services. There are about 27,400 physicians in Sweden. General Practitioners at health centres provide medical treatment, advisory services and preventive care. The school health services regularly check the health of school children.
In Sweden suicide is responsible for about 1,500 deaths each year. By way of comparison, approximately 600 persons are killed in traffic accidents yearly. Swedish women are likely to experience episodes of major depression twice as much as men. However, for suicide, male gender dominates. The rate among adolescents has increased markedly, and in the 15-44 age group suicide is the main cause of death. Depression is the most common experience in elderly suicide victims, while alcoholism is the most common diagnosis in the younger. Several professions have been noted as having suicide rates higher than would be expected. Surprisingly, female physicians are one example. But in general, higher rates of suicide are more frequent in occupations of lower prestige and salary.
Our national program for suicidal prevention is based on a national strategy developed by the Centre for Research and Prevention of Suicide and Mental Ill-Health (N.A.S.P.) in collaboration with the WHO, in Geneva, and has resulted in six regional networks.
Educational efforts are particularly aimed at psychiatrists, psychotherapists, psychologists and social workers, and general practitioners. There are guidelines available for suicide prevention in schools. A great deal of emphasis has been put on education, especially at the primary care level, and by removing barriers to treatment and increasing access to help. A successful project from the province of Gotland exemplifies this, but such efforts have to be ongoing.
Even if much of the function is interdisciplinary with an integrated approach, organisations like the Churches in Sweden have not been involved more than on a voluntary basis. However, this has resulted in several crisis telephone hotlines aimed at different groups - children, students, adults for example, but much more needs to be done.
Concluding Remarks. Future Perspectives
Suicide is a medical issue. But it is also social, moral, economic and a political issue as well. At least 10% of people who complete suicide do not have any known psychiatric diagnosis. People do not choose to be depressed. There are biological, biochemical, environmental and social factors that can lead to depression. Most suicidal persons do not want death. They just want their emotional pain to stop.
Open debate and honest exchange of viewpoints are needed. We must deal with the suicide crisis as a public health crisis. Health care policies must provide adequate insurance, home care, and hospice services to all appropriate patients. National and international efforts (W.H.O.) to prevent suicide must be encouraged. Prevention centres, crisis listening posts and telephone hot lines like wise. Not only patients, physicians and staff , but also organisations outside the health care systems need to be involved and educated about depression, pain management, palliative care and quality of life. Basic professional education and training programs need to treat death, dying and palliative care and give the attention these important aspects deserve. Young children especially must be taught how to cope with difficulties.
Community organisations including the Church should be involved in the prevention of suicide with their own established guidelines. Any parishioner who expresses suicidal ideas or a threat to end their life should be promptly referred to a doctor or a psychiatric service.
Helping victims to become survivors.
Victims, who are they - the committer, the person who tried to commit suicide but survived, or the family and friends around? No survivors walk the same path towards recovery. Survivors have different methods of coping, but must be encouraged to move forward on life's journey, and where applicable, also continuing as participating members of the Catholic Church or other congregations of faith.
Almost without exception a completed suicide leaves people with a complex process of grieving. We must reach out to the victims and their families and communicate sincere commitment for their spiritual and emotional well being. There is no doubt that individuals close to the suicide victim may have years of distress, because of the unanswered questions about the death and the assumptions of guilt for the persons actions. In a non-judgemental way we must relieve the tremendous burden of guilt and failure. And sadly, often a previously stable social network around the family too often disintegrates after a suicide, creating also secondary losses. Counselling and support are essential cornerstones.
Efforts must therefore be focused not only on medical depression but on other factors as well to prevent suicide - since even when effective treatment of depression is available it has failed to make a significant impact on suicide rates.
- Euthanasia and Physician assisted Suicide: Michael Manning SJ. Paulist Pres, New York/Mahaw, New Jersey, 1998. [ISBN 0-809-3804-2]
- Reducing Suicide: A National Imperative, SK Goldsmith et al, The National Academics Press, Washington D.C., 2002 [ISBN 0-309-08321-4]
- The Clinical Science of Suicide Prevention, Annals of the New York Academy of Sciences, Vol. 932 ISBN 1-57331-330-0
- Theme Issue: Depression. Ed.Glass. The Journal of the American Medical Association VOL.289, No.23, 2003
Dr Bengt J Safsten is from the department of Internal Medicine, University Hospital, Uppsala, Sweden
With acknowledgements to Dolentium Hominem No 55. 2004