Suicide - Underrated and misunderstood

Dr AA George, clinical psychologist at the Free State Psychiatric Complex and Senior Lecturer, Faculty of Health Sciences, University of the Free State

Thinking about ending one’s life (suicide ideation) on a frequent basis can lead to increased pre-occupation with suicidal thoughts, to the point where a detailed plan is put into action – also called a suicide attempt. Optimistically, we hope that the suicide attempt is effectively managed towards a complete recovery, with the necessary interventions. If loss of life has occurred due to the suicide attempt, the individual has completed suicide. Although the suicidal mindset focuses on eradicating the pain or stressor, the left-behinds (surviving family/friends) are often shocked or disillusioned by these acts, an aspect often less discussed.

A fleeting thought of suicide is not an uncommon experience for quite a number of people, especially during moments of stress or strife. Sadly, for some, their surrounding circumstances or confronting situations seem so insurmountable that these evoke feelings of despair, hopelessness, and constrict the individual reasoning abilities to a point where suicide seems to be the only reasonable solution to their problem. Thinking about ending one’s life (suicide ideation) on a frequent basis can lead to increased pre-occupation with suicidal thoughts, to the point where a detailed plan is put into action – also called a suicide attempt. Optimistically, we hope that the suicide attempt is effectively managed towards a complete recovery, with the necessary interventions. If loss of life has occurred due to the suicide attempt, the individual has completed suicide. Although the suicidal mindset focuses on eradicating the pain or stressor, the left-behinds (surviving family/friends) are often shocked or disillusioned by these acts, an aspect often less discussed...

A glance into suicidal thinking

“Take the saddest/most embarrassing moment in your life and multiply this by 1,000
Then subtract your libido, self-confidence, and appetite
Now add feelings of slipping deeper and deeper into a state of pain and non-resolution”
(Author unknown)

This suicidal experience is associated with thoughts such as:

“There is no point in going on”

“Nothing I do will be able to help me”

“I’m probably better off dead”

“Even though I try, I will make no difference”

Who are most at risk?

The global trend of suicide prevalence has changed over the past few decades. Initially, the adult and elderly population were at higher risk, which was in line with the age-related stressors (loss of employment, financial debt, divorce, illness, experiencing a growing number of losses, as well as the experience of loneliness) during these age groups. Currently, the suicide picture has significantly swung the pendulum to the point where the age group of 15-29 years is at the highest risk of suicide (WHO, 2021). Accordingly, one person complete suicide every 40 seconds, and for each suicide at least 20 or more persons will attempt suicide. Within the confines of South Africa, the South African Depression and Anxiety Group (SADAG) expressed much concern about the youth, given that 17.6% of teens considered attempting suicide, while more than 20% of 18-year-olds had one or more suicide attempt. These alarming figures cannot be viewed with complacency and need our urgent attention as community, professionals, and government.

Why our youth are at higher risk

Transitioning into adolescence and then into early adulthood is typically accompanied by a number of challenges and adjustments. Such challenges are varied, and depending on an individual’s resources and support, many social exposures (alcohol and other recreational substances, romantic relationship challenges, competitive educational environments, poor parent-child relationships, to name but a few) may be satisfactorily traversed. Unfortunately, many of these challenges transgress into stress factors which, if allowed to escalate, can negatively impact on the individual’s mental health.

In addition to these social pressures, South Africa is viewed as one of the more violent countries in the world, while its high unemployment rate and associated repercussions have placed inordinate stressors on family well-being (OSAC, 2020). Compounding this effect, is the presence of uncertainty in the socio-political arena. These economic uncertainties contribute to a strained societal environment in which the most vulnerable are often neglected in terms of adequate and efficient resource provision. The youth are more impulsive and less skilled in problem solving, thereby increasing their vulnerability to the above stressors.

Reading the warning signs

IS PATH WARM (APA, 2010)
I – Ideation: Talking/asking about suicide content
S – Substance use: Substances can disinhibit protective impulses and serve as a means to escape the unbearable/painful thoughts
P – Purposelessness: Questioning meaning in life, including your purpose
A – Anxiety: Agitated and emotionally difficult
T – Trapped: Feeling that this situation is inescapable
H – Hopelessness: Loss of purpose and meaning
W – Withdrawal: From family, friends, social and community activities, and previously engaged-in groups
A – Anger: Rage, uncontrollable anger, vengefulness
R – Recklessness: Don’t care attitude, inconsiderate and reckless actions seemingly without cause
M – Mood changes: Mood improves in a positive manner, happier, more agreeable, etc.

Tell-tale warning signs:

• Significant changes in academic marks or uncharacteristic absenteeism from classes/lectures
  
• Uncharacteristic sharing, to the point of giving away precious possessions

Risk factors for suicide

The presence of risk factors compounds the probability that suicide behaviour may occur (Turecki & Brent, 2016; WHO, 2021).

• Previous suicide attempt: Still the number one factor that predicts future attempts
  
• History of suicide: Family history or attempts by close friends increase risk
  
• Alcohol/substances: Decreases inhibitions and causes mind-altering changes
  
• Life situations: Marital separation, romantic break-up, difficulty adjusting to new circumstances
  
• Recent loss: Death of a person very close, physical amputation or loss of other physical functions
  
• Limited social resources: Poor support system by family, friends, etc.
  
• Psychiatric history: History of a mental illness or presence of psychotic conditions
  
• Various forms of trauma
  
• Stressful life experiences: Household violence, criminal violence, disaster situations, physical illness, chronic diseases, financial or legal difficulties

Responding to suicide

Suicidal thinking consists of constrictive thought patterns that seem polarised; however, research has indicated that reasoning is still possible and that a suicidal individual can change their mind (Yasgur, 2016). For the individual who is suicidal, the following ‘tips’ may prove useful (Malema, 2019; WHO, 2019).

• Take your mind off and rest by counting digits backward from 10 to 1.
  
• If you feel angry, avoid the situation, but face it again after 10 minutes.
  
• Accept help from colleagues and friends to deal with your worry.
  
• Participate in distraction activities, e.g., regular exercise, regular sleep, or good nutrition.
  
• Seek professional help, as this is key in helping you deal with your problems.

As a family member or friend, you may become aware that someone is suicidal.

• Do something now. Avoid delaying, ignoring, or denying.
  
• It is a shock to your system. Acknowledge it, BUT know that you are targeted for help.
  
• Support emotionally. Be there for them.
  
• If you can, enquire about possible methods being considered and, where possible, remove any dangerous items.
  
• Get extra help and accompany them. Make suggestions and listen to the person’s wishes regarding who they might talk to.
  
• Do not withdraw suddenly after the person has been stabilised.

Professional help is available and can make a big difference. Consult a GP or go to your local casualty department, where you should receive some help and be referred to a psychologist and/or psychiatrist, depending on the need. These professionals will be able to do a risk assessment and advise accordingly in terms of treatment and a psychotherapy plan to assist, support, and guide the person towards coping more effectively with life challenges.

Concluding

Covid-19 is the most recent global health challenge that has placed pressure on health facilities. Most notably, developing economies seem to have been under greater response pressure in managing the pandemic. Some evidence suggests that a short-term decrease in suicide rates following the immediate aftermath of the pandemic onset was noticeable. Disaster events seem to trigger what is called the ‘pulling together effect’, leading to an environment filled with social concerns, cohesiveness – including the presence of social and emotional support – which are also needs that buffer the effects of suicide behaviour (Gordon et al., 2011; Wilkinson & Pickett, 2020; Zortea et al., 2020). Unfortunately, as the levels of hope in managing the pandemic have become more palpable, the ‘pulling together effect’ tends to decrease in effect. As the presence of the pandemic extended over time, the measurable risk of depression and suicide screening numbers steadily increased, especially in females (Mayne et al., 2021).

Suicide has been a public health challenge for many centuries, and we have learnt a great deal about the personal, social, and interactional dynamics related to suicide behaviour. As mentioned earlier, effective management warrants responses from all levels of society, and South Africa is currently in urgent need of a national suicide prevention strategy policy. Unfortunately, the existing National Mental Health Policy Framework and Strategy Plan lacks detailed content and is not suicide prevention specific. According to the WHO (2021), the most effective response to suicide requires every nation to implement a comprehensive and multi-sectoral strategy approach plan.