Suicide and attempted suicide

18 World Health • 47th Year, No.2, Morch-Aprill994 Suicide and attempted suicide A. J. F. M. Kerkhof Prevention strategies need to focus on the reasons why so many people fail to cope with the pressures of everyday life. Stability in social relations, and healthy cultural attitudes towards emotional problems are essential. S uicidal behaviour is usually associated with the mental health status of individuals who cannot cope with their lives . But, when studying suicidal behaviour, we can observe social, economic and cultural influences linked to these individuals' decisions. Suicide refers to a de liberate act intended to end one's life in order to escape unbearable suffering. Dying is preferred to a prolongation of despair due to adverse conditions of li fe: the consciousness of pain, loneliness, guilt, loss, disease, depression, violence or poverty. Many people who commit suicide are depressed, a state of mind in which they depreciate the quality of their lives, and most have made the attempt before (60%). Attempted suicide refers to a deliberate but unsuccessful act intended to end one's life in order to escape unbearable suffering, or to help change the adverse conditions of living. The question whether an attempted suicide implies a deliberate but unsuccessful intention to die, or a deliberate intention not to die but to inflict harm upon oneself, is often difficult to answer. When asked why they took pills, or slashed their wrists, people often declare that they wanted to die and to find help as well: they wanted both . The essential qual ity of attempted suicide is that of ambivalence: expressing a wish to Difficulties in coping with life and loneliness may lead to severe depression die as well as a cry for help. Attempted suicide therefore has a strong social meaning: "please help me, I cannot cope by myself'. Many people who attempt suicide will repeat this behaviour in the near future (40%), and some will eventually die by suicide (I 0% ). There is always a reason Suicidal behaviour demonstrates that something is fundamentally wrong, either with an individual or with the situation in which the individual exists, or with both the situation and the individual. Suicidal behaviour does not show up without any reasons. Through information from re latives it has become clear that most people who committed suicide had long-lasting emotional problems such as depression, anxiety, unhappy relationships, alcohol- and drug-related problems, joblessness, fee lings of loneliness and guilt, problems with relatives, and so on. Many had received help in the form of outpatient or inpatient psychiatric treatment or psychotherapy. All this testifies to the fact that the precipitating factors of suicide generally are of a long- lasting nature. In order to understand them we have to take into consideration the individual's character traits, coping abilities, social support and life events. We also need to understand the social origins of individual emotional problems. In the early World Health • 47th Yeor, No.2, Morch-Aprill994 childhood of people who committed suicide we quite often find broken homes, separation and divorce, loss of one or both parents, rape and sexual abuse, incest, domestic violence, alcohol abuse by parents, and other adverse life events. In later periods of life occur such adverse events as sexual abuse, forced marriages, problems with in- laws and dowry, wife battering, war, torture and concentration camps. There is evidence that suicide victims have experienced more of these traumatic events than normal control groups. Studies of attempted suicide, such as the current WHO/EURO Multicentre Study on Parasuicide, show that this behaviour is more prevalent among young women, people with low education levels, the unemployed, the disabled, and the divorced and separated. The picture that emerges is of powerless groups or those with little chances to improve themselves, facing troubles in finding a place in society, and having many emotional and relationship problems as well. The conclusion has to be that suicidal behaviour is the result of both social conditions and individual maladaptation. suicides than Protestant regions. The rising trends in suicide rates in some European countries in the 1970s were most likely related to secularization (the decline of religious belief). Immigrants tend to show suicide rates similar to those in their countries of origin, so the cultural factors impinging on suicide rates can only be expected to change over several generations. Countries with high divorce rates show 19 comparatively high suicide rates. There are clear national differences in the general social , economic and cultural stability that are related to suicide. Examples of this can be found in India, Sri Lanka and China. In India and Sri Lanka, the suicide rates are exceptionally high among young females, which has to do with the dowry system and materialistic demands from the family of the bride, forced International differences General practitioners need to be alert for possible psychiatric problems. The impact of social influences on suicide is obvious when we look at the striking differences in suicide rates and attempted suicide rates between nations. Hungary shows the highest suicide rates, followed by Finland, Sri Lanka, Austria, Denmark and Belgium. As for attempted suicide rates, Finland, Denmark, Sweden, the United Kingdom and Hungary rank highest. There has always been a remarkable stability in the ranking order of suicide rates, suggesting that strong cultural forces are operating. One such factor is religion: suicide rates in Islamic countries are considerably lower, while the rates in Protestant northern Europe and in North America are higher than in Roman Catholic southern Europe or in Latin America. Even within countries, such as the Netherlands, USA and Canada, predominantly Roman Catholic regions produce fewer Firm social support is essential for everybody's mental balance. 20 marriages, and the subordinate position of females. In China, especially in the rural areas, high suicide rates among females are also being reported. Although not fully documented, it seems that the transition from a traditional agricultural society into a more modern, educated society is frustrated by traditional attitudes towards the subordinate position of women. A further social factor that needs to be considered is the availability of means to commit suicide. In the USA many suicides involve firearms while in some other countries no suicides whatsoever involve guns. Pesticides, barbiturates, car emissions and so on are favoured methods in different countries, depending upon their availability. Prevention A number of measures to prevent suicide are possible. It is most important to prevent people who have attempted suicide for the first time from becoming repeaters. This necessitates good management of suicide attempters in general hospitals and by general practitioners, and good aftercare in outpatient or inpatient mental health care. Unfortunately, the development of such management and aftercare programmes is still neglected, even in the industrialized countries. The next important preventive measure is to provide potential suicide candidates with easy access to affordable mental health care. Samaritan volunteers and telephone help services can be very useful. The expertise of general practitioners in dealing with psychological conditions is equally important. Basic to this is the attitude of society towards emotional problems and mental health. In cultures where emotional problems are regarded as weaknesses or signs of abnormality, the prevention of suicide is likely to be underdeveloped. Informal care within local villages and communities is crucial in preventing persons at risk from getting isolated and depressed. Attitudes towards emotional problems and mental illness need to be influenced by educating the general public towards a more permissive and informed opinion. Education targeted at emotional problems in general and to the short- term and long-term emotional effects of physical trauma (from sexual violence and war, for example) should be much better known to the general public. The success of suicide prevention efforts depends to a great extent upon whether the authorities can promote healthy attitudes towards mental health. The stigma associated with being mentally ill, which causes fear, misunderstanding and discrimination, has to be attacked. More attention should be World Health • 47th Year, No.2, March-Aprill994 paid to minor, acute or temporarily disabling psychological conditions and to the treatability of the more seriously affected. Prevention strategies first of all need to focus on the reasons why so many people fail to cope with the pressures of everyday life. Fundamental changes in suicide mortality cannot be expected from improvements in health care facilities alone. Stability in social relations and healthy cultural attitudes towards emotional problems are needed as well. • Or A.).F.M.Kerkhof is Associate Professor in Clinical, Health, and Personality Psychology at Leiden University, Wassenaarseweg 52, 2333AKLeiden, Netherlands, and also Editor· in·Chief of CRISIS, the iournal of Crisis Intervention and Suicide Prevention. The most vulnerable groups in any society feel the need for support from relatives and friends.