What Are the Implications of Mental Illness on Suicide Risk and Prevention?

Personal Statement
My name is Jarrai Gassama and I recently completed my Nursing Program at LWTech and I currently work as a psychiatric nurse. This work was an assignment I did from my English 102 class. I chose this topic because, recently we have seen an increase in the rate of suicide in our communities among mentally ill people. Therefore, the goal of writing this paper is to educate people about suicide warning signs in order to help prevent suicide.

Abstract

Before I started working as a psychiatric nurse, it never occurred to me that I can work in a mental health or behavioral facility. Individuals with mental illness are commonly perceived as aggressive and assaultive. These presumptions initially influenced my decision for not going into mental health nursing. However, when I finally decided to work at a mental health institution, my entire paradigm and thinking about mental health illness changed. Contrary to the popular opinion, mentally ill individuals are not generally aggressive or assaultive but are vulnerable individuals experiencing various challenges related to their illnesses. Mental illness put individuals at risk for several unpleasant circumstances such as drug addiction, dysfunctional family, hopelessness and of course suicide. This paper discusses the relationship between mental illness and suicide, risk factors for suicide and strategies to prevent suicide.

What are the Implication of Mental Illness on Suicide Risk and Prevention?

There has always been debate over the issue of whether individuals with mental illness are at greater risk for suicide compared to the general population. The controversy is ongoing, and more research is needed to explore the mechanisms of how mental illness puts people at risk. But whatever position one holds, the fact of the matter is that there is a strong relationship between mental illness and suicide, and many people who attempt or complete suicide have some challenges related to some kind of mental disorders. According to Brådvik (2018), a recent psychological autopsy (a psychological profile to determine the mental state of someone who is already deceased, usually by suicide) revealed that about 90% of individuals who committed suicide have one or more mental disorders and the risk of suicide increases by 5-8% if they have mental disorders such as depression, alcoholism and schizophrenia. There is no doubt mental illness increases suicidal risk. Thus, understanding and recognizing the risk factors can help prevent suicide.

The term “suicide” is complex to understand, and its meaning can be interpreted differently by different people. However, understanding the word “suicidal ideation” or “suicide attempt” can help us to understand the word “suicide” better. Suicidal ideation means having thought of ending one’s life while suicide attempt is doing an act with the intension of dying but surviving from the act. Therefore, suicide is an act of self-harm that results in ending an individual’s life. According to Center for Disease Control and Prevention (CDC) suicidal ideation refers to “thoughts of engaging in suicide-related behavior” while “Suicide attempts refer to non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior” that may or may not result in injury and Suicide refers to “death caused by self-directed injurious behavior with any intent to die as a result of the behavior” ((as cited in Sachs-Ericsson et al., 2016). Like suicide, the definition of mental illnesses can be complex and broad, but for the purposes of this paper, focus will be on mental illnesses that have greater relations with suicide such as depression and schizophrenia.

Depression is a lifetime battle that puts individuals going through it at a great danger including suicide. Individuals with depression experience isolation, low energy and negative thoughts that put them at risk for suicide. According to Meyer et al. (2017) an individual going through depression “will usually experience a mood disruption that affects his or her thoughts, feelings, behavior and overall wellbeing” (p. 149). Untreated depression has the potential to wreak havoc and ruin an individual’s life if help is not sought promptly. Research by the American Association of Suicidology (AAS) reports that “in individuals with untreated depression, the life risk of suicide ranges from 2.2% to 15%.” ((as cited in Meyer et al, 2017). A recent interview of Megan Markle (wife of Prince Harry, a member of the British royal family) by Oprah Winfrey supports this claim. When people feel depressed, stressed and overwhelmed, not seeking for help can trigger thoughts of suicide. Markle stated, “I was really ashamed to say it at the time and ashamed to have admit it to Harry…. But I knew that if I didn’t say it, then I would do it. I just don’t want to be alive anymore” (CBC, 2021). These statements by Megan were profound and disturbing and one can conclude that stress and depression dealing with the challenges she faced caused her to consider suicide.

Depression is one of the major risks of suicide among individuals with mental illness. As reported by American Association of Suicidology (AAS) “Individuals with clinical depression are at a 25 times greater risk for suicide than the overall population” (as cited in Meyer et al, 2017). Depression not only increases the risk of suicide but also leads the individuals to engage in acts that further increase their risk for suicide such as alcoholism, drug abuse and self-injurious behaviors such as cutting. Substance use disorder such as alcohol and drug misuse negatively impact mental health, but alcohol misuse among individuals with depression has the strongest association with suicide. (Østergaard et al., 2017). Most of the antidepressants have almost the same adverse effects as alcohol. When taken in large amount, they can lead to respiratory depression. Thus, in most cases, when people with depression attempt or commit suicide, they overdose with alcohol in combination with antidepressant medications and other illicit drugs such as heroin.  (Just last week, one of my patients was admitted for overdoing on alcohol, 10 pills of 5mg of Ativan and heroin.) Like depression, other mental illnesses such schizophrenia also increase suicide risk.

Psychotic behaviors as seen in individuals with schizophrenia increase suicidal thoughts and attempts. Individuals with schizophrenia often experience mental crises that affect their emotions and their ability to think or act right. As reported by Meyer el at. (2017), “twenty to forty percent of people diagnosed with schizophrenia have attempted suicide and 4% to 10% complete the act of suicide” (p. 158). The inability to make the right decisions often puts these individuals at risk for suicide and other self-injurious behaviors. According to Meyer el al. (2017), “fear of mental disintegration and drug misuse increase the risk of suicide among people with schizophrenia.” (p. 159). Just like depression, alcoholism and drug abuse in individuals with schizophrenia can potentiate suicide risk. As one of my patients with schizophrenia remarked, “The only thing that makes me feel good is drinking alcohol and sniffing my meth. This place sucks and I need to be discharged to do what I know how to do best: get some drugs. I don’t care if I die.”

Also, worsening of symptoms due to noncompliance with treatment increases suicide risk among individuals with schizophrenia. While medications are prescribed for these individuals to maintain a balance and to help relieve the symptoms associated with schizophrenia such as disorganized thinking, delusion and hallucination, “poor adherence to treatment” aggravates these symptoms and increases their risk for self-harm, including thoughts of attempting suicide (Meyer et al., 2017).  The inability to cope with their illness and the stress associated with hearing voices commanding them to commit suicide often leads to death by suicide.

While the majority of experts hold the view that mental illnesses increase suicide risk, there are others with varying viewpoints who question the role of mental illness in precipitating suicidal behavior.  According to Hjelmeland et al, “suicide is about far more than mental illness, and may be about something quite different (as cited in Bantjes, 2017). They argue that socio-cultural and economic issues like poverty, family conflict and lack of access to quality health care services increase risk for suicide (Bantjes, 2017). Also, Brådvik (2018), acknowledges that “depression is strongly related to both suicidal ideation and attempt, but it lacks specificity as a predictor, and little is known about the characteristics that increase the risk of suicide among people with depression” (p. 2). He argued that the risk for suicide should not be determined merely by a psychiatric illness. In his view, “ethnicity and immigrant status” can also significantly influence peoples’ decision to commit suicide. According to Brådvik (2018) risk factors such as “language barriers, worrying about family back home, the lack of information on the health care system, loss of status, and loss of social network, often leading to hopelessness, depression, and anxiety” trigger suicidal ideation among immigrants (p. 2).

While it is true that that sociocultural and economic factors like poverty and immigrant status can increase risk of suicide, having mental illness causes far greater risk for suicide compared to experiencing poverty or changes in immigrant status.  This is because in addition to their mental health issues, individuals with mental illnesses face other life stressors such as financial problems, domestic violence or legal issues.  All these factors contribute to their increased risk for suicide.

But as Meyer et al (2017) mentioned, understanding the motivation for suicide among mentally ill individuals could be challenging if we do not understand how mental illness interacts with other risk factors (p. 148). According to Meyer et al (2017), “impulsivity, hopelessness, physical or sexual abusive in childhood, previous suicide attempt, drug and alcohol abuse and social isolation” trigger thoughts of suicide among people with mental illnesses.  Mental illness can aggravate these factors as well. For example, when individuals have a mental breakdown, they tend to stop working, to become isolative and withdrawn, or to do drugs.

Recently we have noticed an increased in suicidal ideation due to the Covid-19 pandemic. With COVID-19 pandemic, concerns about mental health and substance use have grown, including concerns about suicidal ideation. The rate of suicide can definitely go up in individuals with mental illnesses due to coronavirus-related stress (isolation, financial problems, domestic violence etc). Czeisler et al. (2020) stated that “the rate of suicidal ideation increases from 4.3% in 2018 to 10.7% since the COVID-19 pandemic began in early 2020.”

Recently, I have interacted with many people going through mental health crises who reported increased suicidal thoughts and attempts due to the pandemic. For example, one of my patients when asked what makes him attempt suicide replied, “I cannot stand this covid! I don’t know when the covid will end. I don’t know whether I will have it. It’s just stressful and frustrating. I don’t want to deal with it or worry about it anymore.” The pandemic is very stressful for many patients, but for some others, the fear of catching the disease gives them extreme anxiety and depression.

In addition to the above risk factors, individuals with mental illnesses are likely to commit suicide after being exposed to someone who committed suicide. As Jordan (2017) explained, “exposure to the suicide of another person, particularly of a close intimate, elevates the risk of suicidal behavior and completion in the person exposed” (p. 616). Thus, witnessing someone who committed suicide is not only depressing and heartbreaking but increases an individual’s risk for suicide.

After discussing various ways individuals with mental illnesses are at risk for suicide, it is important to now consider strategies to implement in order to help prevent suicide. Therefore, establishing suicide prevention strategies such as offering suicide prevention training in mental institution, addressing the issues related to poverty and to provide counseling for those exposed to suicide can prevent suicide.

Training healthcare workers in assessing patients for suicidal risk is crucial for the treatment of mental illness and suicide prevention. According to Bantjes (2017), establishing suicide prevention guidelines such as “clinician training” and providing post-suicide debriefing can reduce suicide rates (p. 2). One of the most important things I have learned as a psychiatric nurse is that 50% of people who die by suicide saw a medical provider in the month prior to their death. This is very alarming due to the fact that the onset of depression is often times detected during a primary care visit. The inability to conduct a thorough and complete screening for depression may lead to the high rate of suicide among individuals with a prior doctor’s visit before committing suicide. However, with the initiation of PHQ-2, PHQ-9 and the Columbia suicide rating scale, in 2003, 1999 and 2008 respectively, primary care providers and other healthcare workers can quickly assess individuals for depression and suicide in order to prevent suicide.

As Bandjes (2017) argued, “focusing on psychiatric risk factors and promoting access to psychiatric care for at-risk individual without considering other factors can hinder the effort to prevent suicide” (p. 617). He believes that suicide prevention strategies should also include addressing the sociocultural and economic needs of people such as proving accessible and quality mental health services and providing job opportunities for mentally ill people (p. 617). This is important for suicide prevention because addressing poverty and other financial problems can reduce stress and depression related to financial problems, in turn preventing suicide.

Finally, suicide prevention strategies should include providing counseling and emotional support to individuals at risk for suicide. According to Meyer el at., 2017, suicide prevention strategies should include addressing risk factors that are “most efficacious such as creating programs that are geared to help individuals battling drugs and alcohol, encouraging and motivating patients to complete treatment regimen and providing emotional support for individuals experiencing “hopelessness and social isolation” (p. 167).

While the issues of mental illness and suicide will always remain a topic for debate, the purpose of the paper is to enable people to understand and recognize suicide warning signs in order to prevent suicide. Oftentimes people avoid talking about suicide due to the fear of eliciting the act of suicide in individual who are at high risk for suicide. However, with the increase rate of suicide globally, it is important to begin the conversation about suicide in our schools, at hospitals, and in the community so as to prevent it. Screening and assessing individuals for suicide allows healthcare providers to determine the individual’s risk for suicide in order to provide safety and a collaborative treatment plan to a suicidal patient. As a nurse, one of my roles is to educate and help communities and individuals to identify the risk factors for suicide. Most individuals who die of suicide experience major depressive disorder. Thus, it is important to educate communities about the warning signs of depression and identify resources to help with positive coping strategies. It is also important to immediately refer high-risk individuals with active suicidal ideation to a behavioral therapist for further help. Also, another way to successfully educate individuals about suicide prevention is to use therapeutic communication. Effective nurse-patient relationships create a trusting environment where individuals will be more comfortable to discuss their thoughts freely without being judged. When patients open up about their suicidal ideas, it provides an opportunity to gather more personal information and provide effective nursing intervention that promotes the safety of the patients. While healthcare workers may spend more time with patients, it is everyone’s job to prevent suicide.

References

Bantjes, J. (2017). ‘Don’t push me aside, Doctor’: Suicide attempters talk about their support needs, service delivery and suicide prevention in South Africa. Health Psychology Open. https://doi.org/10.1177/2055102917726202

Brådvik L. (2018). Suicide Risk and Mental Disorders. International Journal of Environmental Research and Public Health, 15(9), 2028. https://doi.org/10.3390/ijerph15092028

CBC NEWS. (2021, March 7). Meghan and Harry’s Oprah interview [Video]. Youtube. https://www.youtube.com/watch?v=4Kj8UPnZfPc

Czeisler, M. É., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., …Rajaratnam, S. M. W. (2020). Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(32), 1049–1057. https://doi.org/10.15585/mmwr.mm6932a1

Jordan, J. (2017). Postvention is prevention-The case for suicide postvention. Death Studies, 41(10), 614–621. https://doi.org/10.1080/07481187.2017.1335544

Meyer, C. L., Irani, T., Hermes, K. A., & Yung, B. (2017). Explaining suicide: Patterns, motivations, and what notes reveal. ProQuest EbookCentral https://ebookcentral.proquest.com

Sachs-Ericsson, N. J., Rushing, N. C., Stanley, I. H., & Sheffler, J. (2016). In my end is my beginning: developmental trajectories of adverse childhood experiences to late-life suicide. Aging & Mental Health, 20(2), 139–165. https://doi-org.vwlmcproxy01.lwtech.edu/10.1080/13607863.2015.1063107

Østergaard, M. L. D., Nordentoft, M., & Hjorthøj, C. (2017). Associations between substance use disorders and suicide or suicide attempts in people with mental illness: a Danish nation‐wide, prospective, register‐based study of patients diagnosed with schizophrenia, bipolar disorder, unipolar depression or personality disorder. Addiction, 112(7), 1250–1259. https://doi.org/10.1111/add.13788