Over time, it has become evident that suicide involves a complex mix of genetics, temperament, circumstances, external support, and access to means.
Joseph H. Baskin, MD
Editor’s note: This is a column by Joseph H. Baskin, MD, a staff psychiatrist with Cleveland Clinic Foundation and a clinical assistant professor at the Cleveland Clinic Lerner School of Medicine. The presented analysis reflects his views, not necessarily those of the publication.
Health care professionals and researchers interested in responding to this piece or similarly contributing to MD Magazine® can reach the editorial staff by submitting a request here.
The US Centers for Disease Control and Preventions (CDC) recently reported an increase in the US suicide rate since 1999. Their data is evidentiary, but what’s harder to elucidate is whether this represents an increase in suicides or more precision in our reporting.
Suicide is viewed through lenses other than medical or actuarial. Religious and societal factors play a role in our consideration of an individual’s ultimate exercise of free will. While further study can clarify trends, our focus must now be on prevention and treatment.
For the past 8 years, I’ve served as medical director on a high acuity psychiatric unit. Our specialty is suicide, from ideation to attempt, and I’ve come to appreciate the multifactorial underpinnings that lead a person to attempt to end their lives. I have lost patients, and I have learned that suicide involves a complex mix of genetics, temperament, circumstances, external support, and access to means.
How does suicide happen?
Research is actively uncovering the genetic contribution to suicidality. Full exploration of the current data is outside the scope of this article, but we know dysregulation of serotonin and its transporter genes in addition to hypothalamic pituitary adrenal (HPA) axis dysfunction increase risk of suicide. Family studies also demonstrate a heritable aspect to suicidality.
Born with a particular genetic matrix, an individual’s environment and happenstance shape which genes are expressed, versus those which are suppressed. A predilection towards mental illness coupled with developmental stress raises risk. Life events, especially traumatic, and their perception to the individual (i.e. internalized versus externalized locus of control) conspire to move a person closer to their breaking point.
If life’s stressors overwhelm the ability to effectively manage or to see a way through, especially in the context of major depression, they will consider suicide as an escape of their predicament.
Integral to depression is the sense of self—if esteem is chronically problematic, it will be especially low during a major depressive episode. The depressive person will see no effective way out of their current condition, losing hope for a reprieve and viewing suicide as the best option. Protective factors, that is those elements in their life that keep them tethered to Earth, whether family, religion, or responsibility, fade away.
Ancillary contributing characteristics include a person’s tendency towards selfishness versus selflessness. Those who compensate low self-esteem with pathological investment in others can hit a wall and require contribution from loved ones, but find them wanting. Individuals who protect themselves in a narcissistic cocoon are a very high risk of suicide in the event of a calamitous loss of face, such as a politician caught in a scandal. Schizophrenics are at high risk for suicide given the difficulties they experience, notably the social decline associated with the illness.
This is a brief overview of the contributing factors that can lead to suicide. Human behavior is infinitely complex and multivariable; adding in the element of free will renders us powerless to make predictions. However, mental health professionals are required to assess risk and implement treatment plans to ameliorate bad outcomes to the extent possible. It begins with the identification of those in danger. Depression being a major risk factor, screens for mood and suicidality can help. Invariably it selects for those willing to be honest about their feelings. Many who harbor suicidal feelings, especially intent, will not be amenable to disclosing their plans.
How do we stop it?
Humans have a decent sense of picking up warning signs from others. Changes in habit, routine, withdrawal from societal or work obligations are all warning signs. Increase in drug and alcohol use raise concern. Suicide hotlines, referral to mental health centers, or even hospitalization are options for treatment. There are numerous community resources available to provide guidance once they are approached.
However, what are we to do with the most reticent individual, the person who is unwilling to accept help? In that case identifying the risk moves us to crux of the problem — how do you intervene when the person refuses treatment? Intervention should follow a path similar to addiction. When a problem is identified, the key is gathering as many stockholders in that person’s life and intervening early.
We fear invading a person’s privacy, perhaps being wrong or nosy. But the regret of intervention never approximates the heart-wrenching lament that follows the failure to act after a suicide.
One final note about the attempts themselves. The greater the lethality, the less chance of surviving an attempt. The presence of firearms ratchets up the stakes. As a society, we’ve honed in on the destructive capacity of guns in the context of suicide, but overdoses, hanging, and CO poisoning from cars can also be lethal.
Isolating means as a method for suicide prevention is ultimately dubious if a person is intent on killing themselves. Regardless, inquiring about the presence of firearms, or other lethal means, and securing them is necessary.
An aspect to suicidality that is skyrocketing in prominence is heroin and other opiates. An individual in the throes of addiction will see overdose as an option for escaping their predicament. Dosing themselves with a ‘devil may care’ attitude is effectively a suicide attempt, especially in the context of the heroin epidemic in which we are mired. Dual diagnosis treatment is necessary to combat both the substance and mood issues that predominate in this population.
Suicidal individuals can be broken down rudimentarily into 3 groups: those who will never attempt (or re-attempt), those who will never cease attempting until they are successful, and the great middle who can be swayed with the right support and treatment. It is for this last group that intervention is key and referral to mental health evaluation and treatment, whether for medications and/or psychotherapy is a start.