Suicide is considered one of the major causes of death across the globe. The rate of suicide has increased in the recent past and has become a serious problem globally, with nearly one million people committing suicide every year which represents a global standardised rate of 11.4 per 100,000 population i.e., 15 for males and 8 for females.1 From 2000 to 2016, the age-adjusted suicide rate has grown by 30%. Individuals generally have history of mental trauma and distress before attempting suicide. Rate of suicidal ideation is more than that of committing suicide. It is evident that the topic of suicide needs to have a global priority. As clinicians and researchers, it is pivotal responsibility of mental health professionals to establish prevention and intervention programmes to reduce the risk of suicides.
Keywords: Suicide, Suicidal risk, Psychology, Intervention, Treatment.
Suicide is an act of intentionally taking one’s own life. Suicidal ideation is more common among adolescents and younger adults. It is often considered the precursor of suicide which can be treated through various interventions.2 Suicide is a complex phenomenon. The contributing factors which lead to suicide attempt can be neurobiology, personal and familial history, socio-cultural environment and stressful events. 3 Suicide is one of the major causes of death in the world. According to a 2019 World Health Organisation (WHO) report, millions of people commit suicide every year; one every 40 seconds. 4 The numbers do not include unreported suicides, suicide attempts and those who think of committing suicide. For every completed suicide, on average there are 20 attempts and 100 suicidal ideations. 4
It is usually difficult to identify a person with suicidal ideation. 4 For example, almost half of the people with a lifetime history of suicide attempts reported that their goal was not to die, but was a cry for help. 5 The current narrative review was planned to focus on suicide, suicide attempts, and suicidal ideation. The review examined even studies exploring self-harm rather than suicide attempts if the majority of cases were either suicide-related or were cases with unknown intent.
With the passage of time, there has been a drastic increase in suicide rates. In Pakistan, it has become one of the major health issues. According to a 2012 WHO report, there were 13,377 cases of suicide in various regions of Pakistan. These numbers did not include individuals who thought of committing suicide. The rate of individuals with suicidal thoughts is 20 times higher than those committing suicide. 4 In Pakistan, on average 7000-8000 people commit suicide and 70,000-150,000 people try to commit suicide and many of them return home after getting treatment from some private hospital, with such cases going un-reported. Among those with suicidal ideation, 15.6% make an attempt within 12 months, while 31.8% progress to an attempt at some point in life. 6 According to different studies, only one-third of those with suicidal ideation ever attempt suicide. About 60% of them attempt suicide during the first year of onset of suicidal ideation. 6 It is important for mental health professionals to develop an intervention and prevention plan to reduce the rate of suicide attempts. Almost 31.9% has the risk of committing suicide within 12 months of onset, and it is 54.4% over the lifetime. 6
The key factor which leads a person to commit suicide is unbearable mental pain. In order to escape mental trauma, committing suicide becomes the only solution. 7 Studies have emphasised the concept of ‘psychache’ which is considered the main contributor towards suicide. 8 Suicide is a behaviour to escape from unbearable psychological pain; psychache. 7 Other factors also contribute towards committing suicide, such as personality dispositions, emotional characteristics and dis-regulation. 8
In a study, some cultural factors also contributed towards committing suicide.8 Another study reported that individuals committing suicide have certain cultural influences. 9 Interpersonal theory by Joiner proposes two interpersonal structures; perceived burdensome and thwarted belongingness which may lead to suicidal ideation and eventually suicide. 10 Studies have shown that about 45% of individuals who commit suicide tend to visit hospital once within a month of death without telling anyone about their plan of committing suicide. 10 Findings shows that communication gap and difficulties are also one of the factors behind suicide. When a person feels that he has no outlet and someone to speak with, it results in exaggeration of negative thoughts and, resultantly, suicide. 11 Poor self-disclosure along with various other factors have also proven to be more deadly towards suicidal behaviour. 12
There are various reasons for people who attempt suicide, with 80% having psychiatric illness. Actual risk and formulation of plan depends upon particular disorder. 13 Depression is the best predictor of suicidal ideation. For example, disorders characterised by extreme anxiety, like post-traumatic stress disorder (PTSD), and poor impulse control, like conduct or substance abuse, can be predictors of suicidal ideation, as about 87% of those who commit suicide are known to have met the criteria of some psychiatric disorder. 12,14
Studies show that about 16% individuals, among those who commit suicide, make their second attempt within a year. 15 A study in Australia show that the median time for middle-aged adults who committed suicide was 243 days, and for older adults it was 173 days. 16 Also 2% die in the subsequent year, 5% within 9 years and 13% after 37 years of the onset of suicidal ideation. 15
Other important risk factors for suicide could be poor childhood experiences, like family violence, physical abuse, sexual abuse, bullying, sleep disorder, chronic pain, or any other severe medical condition. Those with a family history of suicide, especially paternal, carry an additional risk factor. Among males, low income level, type of occupation, and being unemployed are often associated with suicides. 17
Among older adults, social isolation, spousal bereavement, neuroticism, physical illness and functional impairments contribute towards committing suicide. Studies have indicated that suicidal ideation is less common in people with severely ill adults who don’t have any clinically significant mood disturbances. 18
One study identified bullying among siblings as being associated with bullying in school, depression and, resultantly, suicidal ideation. In contrast, father-secure attachment contributed as moderator between school bullying and depression and suicidal ideation. 19
Another study reported that adolescents living in areas where there is no or poor socialisation have a higher tendency to experience hopelessness irrespective of socioeconomic status or depression etc. 20
A study examined the role of self-criticism and dependency as potential mediator between childhood maltreatment and committing suicide among university students. 21 Psychological abuse and lack of care among university students were significantly associated with suicidal risk and was partially mediated by self-criticism. 20
In a longitudinal study comprising former prisoners of war in Israel, PTSD symptoms and loneliness were considered the most significant factors towards developing suicidal ideation and eventually leading to suicide. 22
In a study, role of emotional intelligence (EI) as a protective factor against suicide was examined among students and the general population. Findings indicated that EI may act as a protective factor against suicidal ideation and behaviour. Individuals with higher EI have the ability to reduce the stress and they may cope well with suicidal thoughts and acts. 23
Intervention and treatment approaches
In clinical settings, psychotherapy and psychopharmacology are the two ways of intervention. In order to develop the intervention and treatment plan, immediate importance should be given to general mental health conditions, such as depression, anxiety, PTSD, mood disorders and so on. Studies have shown that individuals who seek medical care of depression tend to have lower risk of suicide in several countries. 24 Meta-analysis or randomised trials of anti-depressants have shown no impact on suicidal ideation or attempt. 24 Anti-depressants appear to reduce the risk of suicidal ideation and attempts among older adults, but a few studies have also shown the negative impact of anti-depressants among teens and adults aged 18-29 years taking anti-depressants, especially with major depressive disorders. 24
In a study covering 21 developed countries, findings showed that national policies were directly linked with lower risk of suicide, particularly among the males. The suicide rate dropped by 1.4 per 100,000, years after implementation of national policies. In England, regional health trusts were also associated with reduced number of suicidal attempts. 25
Healthcare providers have an important role in identifying those who need help owing to their history of suicide attempts. A person who self-harms when provided with proper and timely care, can come out of the psychological trauma. Social care professionals and primary or secondary social support mechanisms should be aligned, not working independently, to reduce the risks.
Spirituality, meaning one’s faith, also affects the mental wellbeing of an individual positively. It also improves physical health and brings happiness. Developing meaning in one’s life, change in beliefs and and the concept of life after death are elements of spirituality. Bonding with one’s religion also serves as a protective factor against suicides. It creates support and gives sense of security and peace to people. It also improves the body’s immune system and prevents people from various kinds of psychological, physical and emotional turmoil. 26
Different studies have explored the role of religion and psychological and physiological health. Findings indicate that religion act as a protective factor against hopelessness and committing suicide, which results in better psychological and physiological health, such as happiness, compassion and optimism. Religious beliefs also help a person to cope with stress in a better way. Spirituality and religiosity are needed for personal growth, personal striving and for reducing the intensity of negative emotions, such as fear, hopelessness and anxiety, and provides optimism and faith. 27
It is a national priority to protect individuals against the tendency to commit suicide. Care by primary care professionals plays a pivotal role in identifying and treating individuals with suicidal ideation. It is, however, difficult to identify the individuals who are at the risk of committing suicide as they tend to hide their true feelings and a few don’t even have serious intentions to commit suicide. 27
Basically, suicide is a complex issue with biological, psychological and social aetiological issues. Depression is considered the main issue which leads an individual towards committing suicide. There is drastic rise in suicide in the last decade and the situation has got worse in Asian countries. As countries, like Pakistan, with a weak health system and with meagre health resources, there is shocking increase in suicidal behaviour. There is a dire need to address the issue by adopting holistic approach by accounting for biological, social and psychological factors in account. 2
Suicide is a serious but preventable health problem. It arises from interaction involving individual mental health and emotional risk factors as well as family, social and community factors. Societal attitudes and conditions have profound effect on suicide and suicide prevention. Individuals with mental health concerns are to be accepted and supported without stigmatisation and discrimination. Suicide prevention is the responsibility of the entire community. Knowing when to seek help saves lives. Promoting hope and resiliency need to be at the centre of suicide-prevention strategies.
Suicide is one of the major causes of death across the globe, but it is preventable and treatable. By providing social support, clinicians and mental health workers can treat individuals with suicidal ideation. There is a dire need to address the issue. Communication is the key to reducing suicidal ideation and suicidal attempts.
Conflict of Interest: None.
Source of Funding: None.
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