The topic was so important to the World Health Organisation that it decided, for the first time since inception, to publish a 100-page report on the topic: around one million people die each year at their own hand, and another ten to twenty million make an effort to get to the end of this path of supposedly last resort.
Except for the fact that nine out of ten suicide perpetrators suffer from a psychiatric disorder, surprisingly little is known – despite the high numbers of casualties – about what drives people to suicide. It’s true that the number of suicides has indeed roughly halved since the ’80s of the last century. However, while the number of traffic fatalities from year to year has been steadily declining, the suicide rate has for about six years been heading back up. A glance through prestigious psychiatry journals shows that research on causes is far underdeveloped: JAMA and JAMA Psychiatry devote about six times as many articles to schizophrenia – which has only around one third of the frequency of cases when compared to suicide.
Even in the public media suicide is a taboo subject. Journalists are encouraged to deal very carefully with it. There is clear evidence for the Werther Effect: detailed reporting on the motives, circumstances and execution of such a deed can inspire imitators to realise their own secret plans. The “path of last resort” – taken perhaps by a celebrity with supreme ease – could act as a model for the depressed person to carry out an idea which they for a long time have been carrying around with them. Therefore newspapers usually dispense with overly intensive suicide-reports, a restraint that actually contributes, according to investigations and experience in Austria, to a decline in follow-up suicides.
Fear of the nuthouse
Yet doctors often feel uninformed when it comes to dealing with those vulnerable to suicide. The fear of doing something wrong, and perhaps then reinforcing the patient in his or her intention, is great. Conversely though, many sufferers do not dare to talk to their doctor about their situation. Georg Fiedler from the treatment centre for the suicidal at the University Hospital Hamburg Eppendorf (Germany) made this finding after more than 90 participants came forward when he campaigned by newspaper advertisement for a discussion on this topic. Most “are afraid that the doctor will turn away from them, they could be stamped as mentally ill and their autonomy would be restricted by compulsory treatment or even admission to a closed psychiatric ward”. Thus the German Society for Suicide Prevention has since its inception some 40 years ago offered relevant seminars for doctors, carers and nurses, so as to build trust on both sides.
Every eleventh pupil makes an attempt to kill him or herself
If we look for the triggers for suicidal thoughts, with their end aim ultimately being execution, a large spread of factors presents themselves. One part is due to genetic background. Cases of suicide in the family increase the risk for the children. However upbringing also influences depressive thoughts for those reaching adulthood. Little affection, little control and having few rules increase the risk, an authoritarian parenting style in contrast however hardly does at all. For girls the risk is greater; smoking, alcohol, migration background or separation between parents increases it even more. Particularly with youth the numbers are alarmingly high: around nine per cent of 15-year-olds have already tried to kill themselves, four out of ten have at least thought about suicide before. Whoever loses a classmate even without friendship ties to that person is vulnerable to suicide. This finding in a recent Canadian study, so write Sonja Swanson from Harvard and Ian Colman from the University of Ottawa in their article, should be taken up as part of preventative measures, rather than only involving those in the social environment most close to the victim.
No animal model
Whoever as a neurologist grapples with the issue of suicide works out that it has to do with deficits in the regions regulating emotions, but also fear. Those in danger of suicide have difficulties with the assessment of their mood, have reduced impulse control and often higher levels of aggression. If an unexpected event such as separation from a partner or the loss of a job occurs, they often lack the ability to compensate and suicidal thoughts arise. Stress thus leads to above-average activity in the cingulate and prefrontal cortex.
Thoughts of suicide and carrying it out are also reflected in the genome. One study in the American Journal of Psychiatry suggest that around 360 promoter regions in the genome are regulated differently and compared to those of normal mentally stable subjects are either over or under-active. Researchers at Munich’s Max Planck Institute of Psychiatry a few years ago discovered a “suicide allele”, an expression of a gene for the BNDF receptor (NTRK2) which occurs in affected individuals especially frequently. Interestingly, the particular variants do not match the general picture of depression, but occur primarily with people who have already attempted suicide. Another candidate gene is SAT1, which is active mainly under high stress and when damage occurs in the cell. However, whether this gene is only a marker or actually engaged in the workings of the psyche of a potential suicider is not an answer given by the respective research results produced by Alexander Niculescu from Indianapolis and Gustavo Turecki from Montreal. What the researchers have been missing so far is an instructive animal model. However, suicide in the animal kingdom is basically unknown.
Old and young particularly vulnerable
Most scientific findings in this area are still offered by epidemiology. But even here the registering of deliberate self-injury, such as occurs in Ireland, is the exception. Eastern European countries such as Kazakhstan and Lithuania in particular are at the top positions, whereas the south of Europe, such as Spain and Italy, has a relatively low rate. Women over the age of 70 contribute the most to the figures, but not far behind is the age group15-29 years. Among this group in Western nations, reaching for poison, for a noose or a firearm is the most common cause of death. Across all age groups, however, women are scared away more than men from such a final and irreversible conclusive decision.
While suicide – whether accomplished or attempted – is not even to be found in the general directory of mental disorders DSM-5, targeted large studies on it are – as expected – also rare. And the initiatives which seek to knock down the numbers are also thin on the ground. In Nature a few weeks ago Dutchmen André Aleman and Damien Denys presented the formulation of a four-step plan that seeks firstly to provide a precise definition of suicide and suicide-attempt symptoms. Secondly it says that we should try to learn more about the mechanisms that drive a person to do so. Finally, targeted research programs with reasonable budgets should via the fourth step lead to effective prevention measures which drive the numbers down significantly.
A prevention program in Germany has meanwhile now brought it to international fame and is frequently quoted: the Nuremberg Alliance Against Depression is based on four pillars, taking in information and training for doctors, matching PR campaigns to reach the general public, and training given to multipliers such as priests, social workers, geriatric nurses and teachers. The program aims by way of information and offers to ultimately also reach people who have a suicide attempt in their past, as well as their family members and support groups. Under the leadership of Ulrich Hegerl from the German Foundation of Depression Help, the number of suicides and suicide attempts in the Nuremberg-Erlangen area fell by around 24 percent. The successful program has now grown into being a European Initiative (OSPI) and been firmly established in several countries.
Suicide must not remain a taboo subject. Ulrich Hegerl and his team have also had success in bringing this erratic path of thinking to the public and to make it the topic of conversation. The member states of WHO have undertaken to reduce their suicide rate by at least ten percent by 2020. There needs to be another path for people who see no alternative to suicide. Participating in these efforts is the task of politicians, doctors and of the whole society.