INTRODUCTION:

Suicide, from Latin suicidium,is defined as the act of internationally causing one’s own death. Suicide resulted in 828,000 global deaths in 2015.an increase from 71200 deaths in 1990.¹ every year close to 800 000 people take their own life and there are many more people who attempt suicide. Every suicide is a tragedy that affects families, communities and entire countries and has long-lasting effects on the people left behind. Suicide occurs throughout the lifespan and was the second leading cause of death among 15-29 year-olds globally in 2016.Suicide does not just occur in high-income countries, but is a global phenomenon in all regions of the world. In fact, over 79% of global suicides occurred in low- and middle-income countries in 2016.²

It is estimated that approximately 1.5% of all deaths worldwide are by suicide in the year 2020. The suicide mortality rate in 2015 was 12% in 100,000, which means about one death every 20 s. Rates of completed suicides are generally higher among men than among women, ranging from 1.5 times as much in the developing world to 3.5 times in the developed world. Suicide is generally most common among those over the age of 70; however, in certain countries, those aged between 15 and 30 are at the highest risk. Europe had the highest rates of suicide by region in 2015. There are an estimated 10 to 20 million non-fatal attempted suicides every year. Non-fatal suicide attempts may lead to injury and long-term disabilities. In the Western world, attempts are more common among young people and among females. These suicide figures are probably still an underestimation of the real cases. Registering a suicide is a complicated process, often involving judicial authorities. Suicide deaths may not be recognized or may be misclassified as an accident or another cause of death. Sometimes suicide is not acknowledged or reported, due to its sensitive nature and the taboo that still surrounds it. Suicide attempts, i.e. non-fatal suicidal behavior, are much more frequent, and are estimated to be about 10–20 times more frequent than actual suicide. The estimated global annual prevalence of self-reported suicide attempts is approximately 3 per 1,000 adults. About 2.5% of the population makes at least one suicide attempt during their lifetime.³

Etiology:

An understanding of the theoretical perspectives on suicide is helpful.

Social theories:

In an attempt to explain statistical patterns of suicide Emile Durkheim, a French sociologist, divided the social theories into three categories: the egoistic, the altruistic and the anomic

Egoistic:

This refers to those people who are not strongly integrated into any social group. The lack of family integration explains why the unmarried are more vulnerable to suicide than the married. It also explains why couples with children are the best-protected group of all other groups that were studied. Durkheim also believes that rural communities have more social integration than urban areas, hence the low suicide rate. Another example is that of Protestants versus Catholics. He believes that Protestantism is a less cohesive religion than Catholicism, and consequently the Protestants have higher suicide rates among their members.

Altruistic:

Durkheim believes that individuals who are philanthropic are prone to suicide because of their excessive integration into a group. Suicide is viewed as an outgrowth of that integration.

Anomic:

This refers to social instability, with a breakdown in social standards and values. It is believed that this group’s integration into society is disturbed. Individuals in this group are thus deprived of customary norms of behaviour. This explains why those who experience negative changes in their economic fortunes are more vulnerable to suicide.

Psychological theories:

The first important psychological insight into suicide was reported by Freud. According to him suicide represents aggression turned inward against an “introjected” object. This retroflexed murder is either turned inward or used as an excuse for punishment, or self-directed death instincts, which he refers to as Thanatos. Freud identified three components of hostility suicide: a wish to kill, a wish to be killed, and a wish to die. Freud also described suicide as an aggression turned inward against an introjected ambivalently cathected loved object and he doubted that there could be a suicide without any earlier repressed desire to kill someone else.

Other psychological theories:

Contemporary sociologists believe that much can be learned about the psychodynamic issues of suicidal patients from their fantasies about what will happen and what the consequences will be if they commit suicide. Their fantasies are revenge, escape, rescue, rebirth, and reunion with the dead, new life, sacrifice, control, power, restitution and atonement. People who have suffered the loss of a loved object or have a narcissistic injury experience overwhelming effects like rage and guilt. They are the ones most likely to act out suicidal fantasies. Suicide patients use preoccupation with suicide as a way of fighting off intolerable depression. A sense of hopelessness is an indicator of long-term suicidal risk. The suicide attempt can cause long-standing depression to disappear, especially if it fulfills the patient’s need for punishment. Depressed persons may also attempt suicide just as they appear to be recovering from their depression.⁴

Biological factors:

The following are biological factors predisposing to suicide.

Genetics:

Twin studies, done as a landmark study in 1991, show monozygotic concordance of 11.3 and dizygotic concordance of 1.8. Suicide risk is eight times greater for first-degree relatives of psychiatry patients than controls and four times greater among first-degree relatives of psychiatry patients who had committed suicide. In families with a heavy genetic loading for mood disorders the suicide rate was higher. The genetic factor for suicide may be independent or in addition to the genetic transmission of mental disorders^.

Neurochemistry:

A decrease in serotonin levels leads to a decrease in 5-hydroxyindolacetic acid (5HIAA) in the cerebrospinal fluid (CSF). This was found in depressed patients who attempted suicide. Studies have shown that there is an association between serotonin decrease in the central serotonin system and poor impulse control. Those who view suicide as an impulsive behaviour use this as an explanation.⁴

Risk factors:

Suicide under the age of 5 is hard to find. Most literature (including this mini review) on youth suicide refers to school-age children (7–12 years) and adolescents (13–20 years). These young people are by nature vulnerable to mental health problems, especially during the years of adolescence. This period in life is characterized by movement, changes and transitions from one state into another, in several domains at the same time. Young people have to make decisions about important concrete directions in life, for example school, living situation, peer group etc. They must also address new challenges with regard to building their own identity, developing self-esteem, acquiring increasing independence and responsibility, building new intimate relationships, etc. In the mean time they are subject to ongoing, changing psychological and physical processes themselves. And besides that they are often confronted with high expectations, sometimes too high, from significant relatives and peers. Such situations inevitably provoke a certain degree of helplessness, insecurity, stress and a sense of losing control. To address these challenges and successfully cope with these emotions, young people must have access to significant supporting resources such as a stable living situation, intimate friendships, a structural framework and economic resources. Risk factors can be seen as factors that undermine this support or hinder access to these resources, while protective factors strengthen and protect these resources, or serve as a buffer against risk factors.³

There are several factors associated with an increased risk for suicide. Among them is gender, age, religion, marital status, and employment or nature of profession.

Demographic factors:

Gender more males commit suicide than females, whereas more females tend to attempt suicide than males.

Age: The risk for suicide increases with age: The risks in men peaks at age 45 and in women at age 55.1 Suicide rates among young people, especially in the 15–24 age brackets, are on the increase. Suicide among males aged 25–34 years has increased by almost 30% over the past decade. In the USA suicide is the leading cause of death in the age group 15–24 years old, followed by motor vehicle accidents and homicide. In South Africa suicide accounts for 1, 3% of deaths of people in the age group 15–24^.4

Sexual orientation:

Gay and bisexual male adolescents have higher rates of suicidal thoughts and attempts than heterosexual male adolescents because of the increased risk of parental rejection, peer rejection, social stigma, and victimisation. These are considered environmental factors associated with suicidal behaviour among adolescents.

Family stress and conflict:

(Academic failure, death of a loved person, military deployment of one of the parents, parental divorce, physical abuse, relationship breakup, sexual abuse): these may cause the adolescents to act impulsively or become overwhelmed, contribute to feelings of despair or hopelessness, or make adolescents feel more vulnerable.

Information and communication technologies (Internet, mass media):

The Internet can provide adolescents with information about how to commit suicide, media coverage of a suicide may lead to suicide clusters.⁵

Low self-concept, low self-esteem, low social self-concept, and poor social skills:

These may make the adolescents (particularly female adolescents) feel isolated or rejected, the role of self-esteem in suicide attempt; overweight among the causes of suicidal thoughts in adolescents.

Marital status :

Marriage acts as a protective factor against suicide. Reported rates of suicide among the various categories revealed that among married people the suicide rate is 11/100 000. Marriage appears to be reinforced by having children and the marriage has to be stable. Rates of suicide were highest among divorced men (69/100 000) and those who are widowed (40/100 000).

Race:

In the past, suicide rates were higher among whites than blacks in the USA.

Occupation Social status:

Predisposes to a greater risk of suicide. Gainful employment generally protects against suicide. Suicide is higher among the unemployed. The suicide rate increases during economic recessions and times of high unemployment, and decreases during times of high employment. Physicians are traditionally at a greater risk of committing suicide than non-physicians and the general population. Physicians who commit suicide are said to have a history of mental illness, in addition to their professional, personal and family difficulties. Specialties with high suicide risk are musicians, dentists, nurses, social workers, artists, mathematicians, scientists and police officers. Other sources cite that psychiatrists, ophthalmologists and anesthetists also have high risk of suicide.

Psychiatric diagnosis and psychiatric symptoms: About 90% of people who commit suicide have a diagnosable mental disorder. Depression is most commonly associated with suicide. An estimated 400 per 100 000 depressed male patients and 180 per 100 000 depressed female patients commit suicide. Past and current suicidality past suicidal behaviours are a significant factor for suicide. About 50% of those who died of suicide had made at least one previous attempt. The presence of current suicidal ideation plans and attempt are associated with a high risk of suicide. The risk is higher if there are multiple attempts, if planned, with a low possibility of rescue, use of a lethal method, high intent of dying or causing serious medical complications.

Individual history:

This includes medical conditions like malignancies, heart disease, HIV/AIDS, chronic obstructive lung disease, etc. other factors include psychosocial stressors, family history of suicide and mental illness.

Personality strength and weakness:

This relates to lack of coping skills, lack of problem-solving skills, pessimism, hopelessness, perfectionism, rigid/polarised thinking.

Figure:- Risk Factor and Warning Signs

You can’t see what a person is feeling on the inside, so it isn’t always easy to identify when someone is having suicidal thoughts. However, some outward warning signs that a person may be contemplating suicide include:

· Talking about feeling hopeless, trapped, or alone

· Saying they have no reason to go on living

· Making a will or giving away personal possessions

· Searching for a means of doing personal harm, such as buying a gun

· Sleeping too much or too little

· Eating too little or eating too much, resulting in significant weight gain or loss

· Engaging in reckless behaviors, including excessive alcohol or drug consumption

· Avoiding social interactions with others

· Expressing rage or intentions to seek revenge

· Showing signs of extreme anxiousness or agitation

· Having dramatic mood swings

· Talking about suicide as a way out

It can feel scary, but taking action and getting someone the help they need may help prevent a suicide attempt or death.

How to talk to someone who is feeling suicidal:

If you suspect that a family member or friend may be considering suicide, talk to them about your concerns. You can begin the conversation by asking questions in a non-judgmental and non-confrontational way. Talk openly and don’t be afraid to ask direct questions, such as “Are you thinking about suicide?” During the conversation, make sure you:

· Stay calm and speak in a reassuring tone

· Acknowledge that their feelings are legitimate

· Offer support and encouragement

· Tell them that help is available and that they can feel better with treatment

· Make sure not to minimize their problems or attempts at shaming them into changing their mind. Listening and showing your support is the best way to help them. You can also encourage them to seek help from a professional.

· Offer to help them find a healthcare provider, make a phone call, or go with them to their first appointment. It can be frightening when someone you care about shows suicidal signs. But it’s critical to take action if you’re in a position to help. Starting a conversation to try to help save a life is a risk worth taking.

· If you’re concerned and don’t know what to do, you can get help from a crisis or suicide prevention hotline. If you live in the United States, try the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255). They have trained counselors available 24/7. Stop a Suicide Today is another helpful resource.

If you think someone is at immediate risk of self-harm:

· Call 911 or your local emergency number.

· Stay with the person until help arrives.

· Remove any guns, knives, medications, or other things that may cause harm.

· Listen, but don’t judge, argue, threaten, or yell.

What increases the risk of suicide?

There’s usually no single reason someone decides to take their own life. Several factors can increase the risk of suicide, such as having a mental health disorder. But more than half Trusted Source of all people who die by suicide don’t have a known mental illness at the time of their death. Depression is the top mental health risk factor, but others include bipolar disorder, schizophrenia, anxiety disorders, and personality disorders.

Aside from mental health conditions, other factors that increase the risk of suicide include:

· Incarceration

· Poor job security or low levels of job satisfaction

· History of being abused or witnessing continuous abuse

· Being diagnosed with a serious medical condition, such as cancer or HIV

· Being socially isolated or a victim of bullying or harassment

· Substance use disorder

· Childhood abuse or trauma

· Family history of suicide

· Previous suicide attempts

· Having a chronic disease

· Social loss, such as the loss of a significant relationship

· Loss of a job

· Access to lethal means, including firearms and drugs

· Being exposed to suicide

· Difficulty seeking help or support

· Lack of access to mental health or substance use treatment

Those who have been shown to be at a higher risk for suicide are:

· Men

· People over age 45

· Caucasians, American Indians, or Alaskan Natives

Assessing people who are at risk for suicide:

A healthcare provider may be able to determine whether someone is at high risk for suicide based on their symptoms, personal history, and family history. They will want to know when symptoms started and how often the person experiences them. They’ll also ask about any past or current medical problems and about certain conditions that may run in the family. This can help them determine possible explanations for symptoms and which tests or other professionals might be needed to make a diagnosis. They will likely make assessments of the person’s:

· Mental health: In many cases, thoughts of suicide are caused by an underlying mental health disorder, such as depression, schizophrenia, or bipolar disorder. If a mental health issue is suspected, the person will likely be referred to a mental health professional.

· Substance use: Misusing alcohol or drugs often contributes to suicidal thoughts and behavior. If substance use is an underlying problem, an alcohol or drug addiction rehabilitation program may be the first step.

· Medications: The use of certain prescription drugs — including antidepressants — may also increase the risk of suicide. A healthcare provider can review any medications the person is currently taking to see if they could be contributing factors.

Treatment for people who are at risk for suicide:

Treatment will depend on the underlying cause of someone’s suicidal thoughts and behavior. In many cases, though, treatment consists of talk therapy and medication.

Talk therapy:

Talk therapy, also known as psychotherapy, is one possible treatment method for lowering your risk of attempting suicide. Cognitive behavioral therapy (CBT) is a form of talk therapy that’s often used for people who are having thoughts of suicide. Its purpose is to teach you how to work through stressful life events and emotions that may be contributing to your suicidal thoughts and behavior. CBT can also help you replace negative beliefs with positive ones and regain a sense of satisfaction and control in your life. A similar technique, called dialectical behavioral therapy (DBT), may also be used.

Medication:

If talk therapy isn’t enough to successfully lower risk, medication may be prescribed to ease symptoms, such as depression and anxiety. Treating these symptoms can help reduce or eliminate suicidal thoughts. One or more of the following types of medication could be prescribed: antidepressants, antipsychotic medications and anti-anxiety medications.

Lifestyle changes:

In addition to talk therapy and medication, suicide risk can sometimes be reduced by simply adopting certain healthy habits. These include:

· Avoiding alcohol and drugs: Staying away from alcohol and drugs is critical, as these substances can lower inhibitions and may increase the risk for suicide.

· Exercising regularly: Exercising at least three times per week, especially outdoors and in moderate sunlight, can also help. Physical activity stimulates the production of certain brain chemicals that make you feel happier and more relaxed.

· Sleeping well: it’s also important to get enough quality sleep. Poor sleep can make many mental health symptoms much worse. Talk to your healthcare provider if you’re having trouble sleeping.

How to prevent suicidal thoughts:

If you’ve had suicidal thoughts or feelings, don’t be ashamed and don’t keep it to yourself. While some people have suicidal thoughts without any intention of ever acting on them, it’s still important to take some action. To help prevent these thoughts from recurring, there are several things you can do.

Take medications as directed:

You should never change your dosage or stop taking your medications unless your healthcare provider tells you to do so. Suicidal feelings may recur and you may experience withdrawal symptoms if you suddenly stop taking your medications. If you’re having unwanted side effects from the medication you’re currently taking, speak with your provider about switching to another one.

Never skip an appointment:

It’s important to keep all your therapy sessions and other appointments. Sticking with your treatment plan is the best way to deal with suicidal thoughts and behavior.

Pay attention to warning signs:

Work with your healthcare provider or therapist to learn about the possible triggers for your suicidal feelings. This will help you recognize the signs of danger early on and decide what steps to take ahead of time. It can also help to tell family members and friends about the warning signs so they can know when you may need help.

Eliminate access to lethal methods of suicide:

Get rid of any firearms, knives, or serious medications if you worry that you might act on suicidal thoughts.⁶

Who is at risk?

While the link between suicide and mental disorders (in particular, depression and alcohol use disorders) is well established in high-income countries, many suicides happen impulsively in moments of crisis with a breakdown in the ability to deal with life stresses, such as financial problems, relationship break-up or chronic pain and illness. In addition, experiencing conflict, disaster, violence, abuse, or loss and a sense of isolation are strongly associated with suicidal behaviour. Suicide rates are also high amongst vulnerable groups who experience discrimination, such as refugees and migrants; indigenous peoples; lesbian, gay, bisexual, transgender, intersex (LGBTI) persons; and prisoners. By far the strongest risk factor for suicide is a previous suicide attempt.⁷

Prevention and control:

Suicides are preventable. There are a number of measures that can be taken at population, sub-population and individual levels to prevent suicide and suicide attempts. These include:

· Reducing access to the means of suicide (e.g. pesticides, firearms, certain medications);

· Reporting by media in a responsible way;

· School-based interventions;

· Introducing alcohol policies to reduce the harmful use of alcohol;

· Early identification, treatment and care of people with mental and substance use disorders, chronic pain and acute emotional distress;

· Training of non-specialized health workers in the assessment and management of suicidal behaviour;

· Follow-up care for people who attempted suicide and provision of community support.⁸

CONCLUSION:

It is clear that suicide is a serious problem among the youth. Suicide ideation represents the earliest stage of suicide risk. Therefore, it is crucial that preventative programs and interventions tap into this issue. Also, it has been illustrated in the literature that adolescent boys and girls have different coping strategies, which can be divided into positive and negative coping. It is hypothesized that negative coping is related to high levels of suicide ideation, thus it is crucial to look at coping strategies as well as suicide ideation in terms of a suicide prevention program.

CONFLICT ON INTEREST:

Nil.

REFERENCE:

1. Suicide prevention wikipedia Available online at-https://en.wikipedia.org/wiki/suicide

2. WHO preventing suicide Aglobal imperative. Geneva: World Health Organization (2021) Available online at- https://www.who.int/news-room/fact-sheets/detail/suicide

3. Blisen J. Suicide and Youth: Risk Factors Front Psychiatry. 2018; 9: 540.

4. Masango SM Rataemane ST, Motojesi AA, Suicide and suicide risk factors: A Literature Review 2008; 50(6):25-28

5. Runcan R, Suicide in Adolescence: A Review of Literature 2020(3):109-120

6. Tiomothy J. suicide ans suicidal behavior Healthline; Dec. 2019; Available online at- https://www.healthline.com/health/suicide-and-suicidalbehavior#suicidal-signs

7. Dendup T, Zhao Y, Dorji T, Phuntsho T. Risk factors associated with suicidal ideation and suicide attempts in Bhutan: An analysis of the 2014 Bhutan STEPS Survey data; Journal of Plos One, Jan 30, 2020. Available from-(journals.plos.org/plosone/article?id=10.1371/journal.)

8. Niken AL, Paraswati MD, Windarwati HD. What are the risk factors and protective factors of suicidal behavior in adolescents? A systematic review, Journal of Child and Aduloscent in Psychiatric Nursing; Feb 2021:34(1); 7-18.

Received on 15.03.2021 Modified on 08.04.2021

Asian J. Nursing Education and Research. 2021; 11(3):441-446.

DOI: 10.52711/2349-2996.2021.00107

Pay attention to warning signs:

Eliminate access to lethal methods of suicide:

Get rid of any firearms, knives, or serious medications if you worry that you might act on suicidal thoughts.6

Who is at risk?

Get rid of any firearms, knives, or serious medications if you worry that you might act on suicidal thoughts.⁶