There are a large number of factors that contribute to the risk related to attempting and completing suicide. Commonly discussed risk factors for suicide include: psychiatric illness, a sense of hopelessness and isolation, treatment side effects, and stresses related to one’s identity e.g., loss of a significant other, loss of position, etc. These factors do not explain all of the risks associated with suicide, but most risk factors can be modified or identified and understood as one of these risk factors.
There are a variety of psychiatric disorders that are commonly associated with suicide. Rates as high at 20% for people suffering from Depression, Schizophrenia and Bipolar Disorder are reported. Personality Disorders, Anxiety Disorders and Eating Disorders also have high rates. In youth, suicide is the #3 killer behind accidents and homicide. However, more young people 15-24 years of age die as a result of suicide than all other medical causes combined.
The early identification and successful treatment of these conditions are very important. Much like other organs, it appears that the longer someone is psychiatrically ill, the harder the illness is to treat. Long delays in identification of serious mental illnesses results in unnecessary suffering, as do additional delays resulting from failed treatment trials also contribute to this phenomena.
At the present time, clinicians have little to guide them in regards to which medication or other psychotherapy to chose for a given person. The Child and Adolescent Psychiatry and Behavior Medicine division at CHW is engaged in a number of studies that may potentially inform clinicians which treatments to use. It will likely be years before most of these studies’ results are readily available with applicable information to most clinicians.
Unfortunately, adverse drug reactions can also play a role in suicidality. People who do not feel well as a result of their treatments often stop them. This is frequently without consultation with their doctor. While it is not possible to guarantee no side effects with any treatment, there are often alternative treatments that might work better for any given person.
Akathisia is a neuromotor syndrome frequently described as ‘motor restlessness’ People suffering from this condition frequently describe an extremely uncomfortable feeling where they continually need to be moving accompanied by a serious psychic distress. This feeling can be so severe that it is described as torture and people may resort to suicide to escape this. Antipsychotic medications and the selective serotonin reuptake inhibitors (SSRI’s) are commonly associated with akathisia. In recent years akathisia has been identified as a significant and modifiable risk factor for suicide. Switching medications and/or treating with another medication frequently can decrease this excruciating symptom. Unfortunately, not enough clinicians consider this potential side effect and do not warn patients of its existence often enough.
While it is unlikely we can prevent significant stresses from affecting our children, we can and need to better understand these events as risk factors for suicide. Closely monitoring someone who has recently suffered a loss can be a great way to decrease suicide. Hopelessness and isolation contribute to someone taking their own life, and should be addressed and minimized if possible.
Bipolar Disorder can serve as an example of the above difficulties. Identification of Bipolar Disorder frequently takes years, due to symptom overlap with other common psychiatric disorders and behavioral disturbances of childhood. In psychiatric clinics and primary care settings, people with Bipolar Disorder are often misdiagnosed as having Depression. Unfortunately, antidepressants can make mania worse and cause akathisia. It is common for a decade to pass before Bipolar Disorder is accurately diagnosed and effectively treated. This misdiagnosis often results because patients only complain of the depressive symptoms and rarely seek medical help on their own for mania.
The most common treatments for Bipolar Disorder are traditional mood stabilizers like lithium, divalproex, and carbamezapine or the newer antipsychotics. These medicines can frequently have unwanted side effects including akathisia.
The frustrations of the illness, the side effects of treatments and isolation from or lack of support systems can result in suicide. Mania is a medical emergency as a person suffering from mania can ruin their lives in short amounts of time due to irresponsible or risky behaviors. The depression associated with Bipolar Disorder is one of the most common factors associated with suicide. While less people suffer from Bipolar Disorder than Depression, its economic impact on society is higher, e.g. lost wages, caregiver time, medications, hospitalization costs, etc.
In summary, the early identification of psychiatric illness and related psychosocial stressors, combined with improved clinical application of research findings, are critical to decreasing the unnecessary loss due to suicide.
Russell E. Scheffer, M.D.
Chuck Aring Professor of Child and Adolescent Psychiatry
Director, Child and Adolescent Psychiatry and Behavioral Medicine
Medical College of Wisconsin
Children’s Hospital of Wisconsin.