A 26 - year - old factory worker was brought into Outpatient Department of a General Hospital by a colleague from the same factory one afternoon. The history from him revealed that he had two children and a wife but he was heavily indebted since the past one year. One of the statements he made during the consultation was“ I feel like ending it all”. The Doctor observed that depression was written all over him. Suicidal ideation was suspected.

He was admitted but he insisted on going home to tell his wife and prepare for admission which he documented. On getting out of the hospital with his colleague holding him, he jumped in front of a fast moving lorry.

Within three minutes of leaving the consulting room, his crushed body was brought back to the doctor who certified him dead. His colleague was shaking, sweating and looking in disbelief. escaped death.

Key facts

Close to 800 000 people die due to suicide every year. 

For every suicide there are many more people who attempt suicide every year. A prior suicide attempt is the single most important risk factor for suicide in the general population. 

Suicide is the second leading cause of death among 15-29 year-olds. Ingestion of pesticide, hanging and firearms are among the most common methods of suicide globally.

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. 

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.

Suicide is a serious public health problem; however, suicides are preventable with timely, evidence-based and often low-cost interventions. For national responses to be effective, a comprehensive multisectoral suicide prevention strategy is needed. Methods of suicide

It is estimated that around 20% of global suicides are due to pesticide self-poisoning, most of which occur in rural agricultural areas in low- and middle-income countries. Other common methods of suicide are hanging and firearms.

Knowledge of the most commonly used suicide methods is important to devise prevention strategies which have shown to be effective, such as restriction of access to means of suicide.

Suicidal ideation, also known as suicidal thoughts, is thinking about or having an unusual preoccupation with suicide. The range of suicidal ideation varies greatly from fleeting thoughts, to extensive thoughts, to detailed planning, role playing (e.g., standing on a chair with a noose), and incomplete attempts, which may be deliberately constructed to not complete or to be discovered, or may be fully intended to result in death, but the individual survives (e.g., in the case of a hanging in which the cord breaks). 

Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered a risk factor. 

Suicidal ideation is generally associated with depression and other mood disorders; however, it seems to have associations with many other mental disorders, life events, and family events, all of which may increase the risk of suicidal ideation. For example, many individuals with borderline personality disorder exhibit recurrent suicidal behavior and suicidal thoughts. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts 

Signs and symptoms

Suicidal ideation has a straight forward definition—suicidal thoughts—but there are some other related signs and symptoms. Some symptoms or co-morbid conditions may include unintentional weight loss, feeling helpless, feeling alone, excessive fatigue, low self-esteem, presence of consistent mania, excessively talkative, intent on previously dormant goals, feel like one's mind is racing. The onset of symptoms like these with an inability to get rid of or cope with their effects, a possible form of psychological inflexibility, is one possible trait associated with suicidal ideation. They may also cause psychological distress, which is another symptom associated with suicidal ideation. 

Other possible symptoms and warning signs include: hopelessness, Insomnia or oversleeping, loss of appetite or overeating, depression, severe anxiety, impaired concentration and loneliness.

Risk factors

There are numerous indicators that one can look for when trying to detect suicidal ideation. There are also situations in which the risk for suicidal ideation may be heightened. The risk factors for suicidal ideation can be divided into three categories: Psychiatric disorders, life events, and family history. 

Psychiatric disorders

There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation. The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. The disorders in which risk is increased the greatest include: anxiety disorders, major depressive disorder, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD). 

Others are personality disorders, psychosis (detachment from reality), paranoia, schizophrenia and substance use disorders.

Prescription drug side effects

Some prescription drugs, such as selective serotonin re-uptake inhibitors (SSRIs), can have suicidal ideation as a side effect. Moreover, these drugs' intended effects, can themselves have unintended consequence of an increased individual risk and collective rate of suicidal behavior:  

Life events

Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previous listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk the greatest are: alcohol abuse (studies have shown that individuals who binge drink, rather than drink socially tend to have higher rates of suicidal ideation), unemployment, chronic illness or pain, death of family members or friends, end of a relationship, tobacco use and unplanned pregnancy.

Others are previous suicide attempts (having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts), military experience, community violence, undesired changes in body weight (women: increased BMI increases chance of suicidal ideation, Men: severe decrease in BMI increases chance of suicidal ideation. 

In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight). Exposure and attention to suicide related images or words are other factors.

Family history. Family history of depression, abuse (physical, emotional and sexual abuse), family violence and family disruption are risk factors for suicidal ideation.

 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 behavior. 

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

Suicide is a complex issue and therefore suicide prevention efforts require coordination and collaboration among multiple sectors of society, including the health sector and other sectors such as education, labour, agriculture, business, justice, law, defense, politics, and the media. These efforts must be comprehensive and integrated as no single approach alone can make an impact on an issue as complex as suicide.

Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts. In a study of individuals who did commit suicide, 91% of them likely suffered from one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness. This emphasizes the importance of early detection.

Treatment

Treatment of suicidal ideation can be problematic due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include: therapy, hospitalization, outpatient treatment, and medication or other modalities. 

Therapy

In psychotherapy a person explores the issues that make them feel suicidal and learns skills to help manage emotions more effectively. 

Hospitalization

Hospitalization allows the patient to be in a secure, supervised environment to prevent the suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalized involuntarily. These circumstances are: If an individual poses danger to self or others and if an individual is unable to care for oneself.

Hospitalization may also be treatment option if an individual: Has access to lethal means (e.g., a firearm or a stockpile of pills), does not have social support or people to supervise them, has a suicide plan and has symptoms of a psychiatric disorder (e.g., psychosis, mania, etc.)

Outpatient treatment

Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patient's level of social support, impulse control and quality of judgment.

Medication

Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients' energy levels before lifting their mood. This puts them at greater risk of following through with attempting suicide. Additionally, if a person has a comorbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation. 

Antidepressants may be effective.

Antidepressants have been shown to be a very effective means of treating suicidal ideation. Although research is largely in favor of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation.