Heading Off Suicidality at the Pass

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Next week is National Suicide Prevention Week, with World Suicide Prevention Day beginning the week on Sunday. The goal is to reduce the likelihood of suicide because it is irreversible and usually leaves loved ones with much anguish and guilt.

Over 20 years, from around 2000-2020, the suicide rate dropped significantly globally, but increased significantly in the United States. There was a record high in 2022. In particular, the rate has been increasing in teenage girls, while physicians seem to top the list of professions at risk. Guns are increasingly used as the lethal method.

Fortunately, there is some emerging good news as far as addressing suicidality earlier and better.

In society, there is the new 988 suicide helpline. Though the public still needs to learn about it, it has proven useful for not only suicidal concerns, but other mental health needs.

As exemplified at Yale, there is some change for the better for suicidal students. After a suicide in 2021, Yale activists ended up suing the school and achieved a recent settlement that provides more support and care instead of the suicidal student being sent away and not easily welcomed back in.¹ Adequate mental health services in schools seems to lower suicide risk.

We do need to consider how to reduce the causes of the increase in suicides and attempts. The pandemic and other risk factors include job loss, social isolation, loneliness, financial stress, and discrimination.

However, suicide and other self-destructive tendencies usually begin in individuals long before any public expression or call for help. The basic point is that most everybody on occasion will have suicidal or other self-destruction thoughts or actions. Take myself. Although I have never had a suicidal thought or even casually or exasperatingly said “I wished I was dead,” I was quite self-destructive as a youth, leading me to be named Most Accident Prone for my high school graduation. That ended when I met and dated my wife of 55 years early in college at the University of Michigan. Interpret that as you will. (If you read my column on Tuesday, you will know she is a natural therapist.)

Having an overly critical inner voice is at the root of much self-destructive behavior, thinking of such internal criticisms as “you are stupid” or “you are not attractive.” This inner negativity usually comes from parents who berate their children, and sometimes teachers do, too. Children also naturally blame themselves for parental problems. This inner criticism often escalates with being discriminated against, big losses, chronic physical pain, major life changes, housing problems, addiction, postpartum depression, and the antidepressant and antipsychotic medication side effect of akathisia.

When psychological and/or physical pain combines with hopelessness, as can happen with many psychiatric disorders, suicide risk becomes especially high. That can happen with severe and unrelenting suffering, and result in a request for what is sometimes called physician-assisted suicide. As usual, successful treatment of psychiatric disorders will lessen suicide risk.

The main protective factor for suicide is connectivity. Most important is having someone to talk to who is trusted, including family, friends, and therapists. The challenge is being able to ask loved ones for verification of negative thoughts, even if that temporarily makes you feel ashamed for even doing so publicly.

When cutting off suicidality fails, sometimes paradoxically the person or patient seems better, but for no clear and convincing reason. That may mean they are relieved because they decided on suicide, putting them at the highest risk. Both clinicians and social connections should not be fooled by that.

My gratitude today is for only having one patient who died by suicide, way back at the start of my residency training.

Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times.

Reference

1. Svrluga S, Wan W. Yale to update policies after lawsuit over student mental health. The Washington Post. August 25, 2023. Accessed September 8, 2023. https://www.washingtonpost.com/education/2023/08/25/yale-settlement-mental-health-lawsuit/