Suicide: Complexities and Treatment Challenges

Attempted and completed suicides both represent a major clinical and public health challenge. The CDC has ranked suicide as the 11th leading cause of death among persons over age 10 (33,289 suicide deaths were reported in the US in 2009).

In an article in Psychiatric Times, Drs Tondo and Baldessarini noted that 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder. Patients with major depression or bipolar depression have a 20- to 26-fold increase of mortality rate over the general population. It was also stated in this article that fewer than a third of persons who commit suicide are receiving psychiatric treatment at the time of their deaths. The authors further noted that there is only inconsistent evidence that antidepressants may help prevent suicides.

It was thought that the strong association between the rapidly expanding use of antidepressants and the moderately declining suicide rate in the US and in other countries were indirect evidence of effectiveness of antidepressants in reducing suicide.

Several studies have shown that mood disorders have been associated with increased suicidal behavior. This is especially true in patients with a mixed, manic-depressive, or dysphoric-agitated state, and perhaps also in those with anger, aggression, or impulsivity-all of which are particularly prevalent in bipolar disorder and may contribute to the unusually high suicide risk in persons with this disorder. In such patients  (especially those who are young), antidepressants may lack a beneficial effect or even increase suicide risk, at least early in treatment. Long-term treatment with mood stabilizers, particularly lithium, may be a more effective component of comprehensive clinical management aimed at suicide prevention.

From clinical experience we know that psychological conflict, psychological trauma, grieving, interpersonal conflict, and other psychological issues can all contribute to self-destructive behavior that  can result in suicidal behavior. Suicidal gestures that may have been initiated to get attention or manipulate others can inadvertently result in a completed suicide. There are special issues concerning suicidal behavior in the military where recent studies have shown more soldiers are killed by suicide than in combat. There are special issues concerning suicidal behavior in children and adolescents. Bullying behavior including cyberbullying has been shown to induce suicidal behavior in young people.

Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide prevention is a challenging issue, not only for mental health professionals but for leaders in the military, teachers, parents, and for us all. We need to recognize that there are many mental health issues that have to be faced in the aftermath of a suicide.

We shall try to discuss many of these issues in future blogs. I am also pleased to announce that suicide will be a major part of the theme of the May 16 to 18 meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (of which I am the current President). The meeting will be held in San Francisco (just before the meeting of the American Psychiatric Association in the same city). A very interesting and informative program with outstanding speakers is being developed and will be announced shortly. I will also provide further information about this program in future blogs and you can contact me if you have any questions at this time.

[Editor's Note: Dr Blumenfield orginally published a version of this piece, titled "Let's Talk About Suicide," in his blog, Psychiatry Talk].