Why Suicide?
by Cassie Kwok, Senior Writer and Editor
April 3, 2003

Many of us were saddened and shocked to hear of Leslie Cheung's death on April 1, 2003, of an apparent suicide. To take one's own life, one must feel so helpless to the point that he/she believes there is absolutely no solution to their problem, or that they cannot accept the reality of a situation. The only answer is to die. Everyone is probably asking, why? What was it that pushed him to the edge? Where were his friends when he needed them most? Were his motives so compelling that they were worth dying for? We may never know the real reasons, but some of us might feel that if we had even the slightest hint there was a potential for such an action, perhaps we could have helped to prevent it.

Suicide can be prevented. While some suicides occur without any outward warning, most do not. The most effective way to prevent suicide among loved ones is to learn how to recognize the signs of someone at risk, take those signs seriously and know how to respond to them. The emotional crises that usually precede suicide are most often both recognizable and treatable.

Reasons for Suicidal Tendencies
Suicide is a complex behavior, and has many medical, psychological and social factors. Research has shown that a chemical imbalance in the brain, specifically decreased levels of serotonin, and genetics are possible biological risk factors. Psychological disorders contributing to suicidal tendencies include major depression, schizophrenia or certain psychotic illnesses; alcohol or substance abuse; or exposure to suicide or suicidal behaviors within one's family/peer group or media reports of suicides.

Our society and individual cultural traditions place so much pressure on us to conform, perform, and be successful, that if we did not meet these expectations, we may feel inadequate and withdraw from society to escape from them. This, in turn, could set off a chain of emotional distress to the extent that one can no longer deal with them.

This doesn't mean that suicidal behavior is inevitable in anyone having these factors, but it does mean that they may be more vulnerable and should reduce the possible risk with a psychiatric evaluation and by seeking treatment at the first sign of mental illness.

Awareness, Intervention and Methodology

The U.S. Public Health Service has published a report entitled The Surgeon General's Call to Action To Prevent Suicide [1] (http://www.surgeongeneral.gov/library/calltoaction/calltoaction.htm) which introduces a national plan for addressing suicide - Awareness, Intervention and Methodology (AIM) - an approach developed by researchers, health and mental health clinicians, policy makers, suicide survivors, and community activists and leaders. They engaged in careful analysis of what information are known and unknown about suicide and its potential responsiveness to a public health model emphasizing suicide prevention. This plan addresses the issue at a very high level, recommending that government, health care organizations, the insurance industry and general community become more proactive in recognizing the warning signs and suicide prevention, however, these could also be applied at an individual level.

Awareness - Recognizing Some of the Possible Risk Factors
It's impossible to predict with certainty who will kill themselves, or try. People at the highest risk level for suicide were those recently hospitalized for attempted suicide. Those at lowest risk were individuals treated as outpatients. Other studies indicate that people with untreated depression have a higher suicide rate than people receiving treatment. In short, the more severe the depression, especially if untreated or inadequately treated, the greater the suicide risk.

Suicidal behaviors occur as a response to a situation that a person views as overwhelming. If you know that someone has any of the following symptoms or conditions, be more aware of any major or sudden changes in their behavior. This may be a cry for help, and just having a sympathetic nonjudgmental listener may be enough to help deter a potential attempt. However, keep in mind the following warning signs that may make someone vulnerable:

• Previous suicide attempt
• Mental disorders - particularly mood disorders such as depression and bipolar disorder
• Co-occurring mental and alcohol and substance abuse disorders
• Physical illness
• Family history of suicide
• Impulsive and/or aggressive tendencies
• Barriers to accessing mental health treatment
• Relational, social, work, or financial crisis or trauma, such as job loss, death of a loved one or divorce
• Easy access to lethal methods, especially guns
• Speech suggesting the individual is close to suicide, giving away possessions or preparing a will
• Deterioration in functioning at work or socially
• Feelings of desperation, isolation, abandonment, anxiety, guilt or hopelessness
• Self-destructive or risky behavior, loss of control, rage explosions.
• Unwillingness to seek help because of stigma attached to mental and substance abuse disorders and/or suicidal thoughts
• Influence of significant people - family members, celebrities, peers who have died by suicide - both through direct personal contact or inappropriate media representations
• Cultural and religious beliefs - for instance, the belief that suicide is a noble resolution of a personal dilemma
• Local epidemics of suicide that have a contagious influence

The best way to find out if a loved one is having suicidal thoughts or intentions is to ask. Don't worry that you'll plant the idea or push the person into something he or she had no intention of doing. What you will do is offer an opportunity to talk and, if your loved one is having suicidal thoughts, to discuss the pain and negativity fueling those thoughts. This can help decrease suicide risk.

Keep in mind that your task is not to become the therapist but rather to convey your concern and get your loved one appropriate medical care, if needed. When you talk about suicide, be direct. Here are some questions to ask:

• Are you thinking about dying?
• Are you thinking about hurting yourself?
• How and when would you do it?

In the face of possible suicide, be supportive, be empathetic and take preventive actions. Remove or secure guns, knives and anything else you can think of that could be used in a suicide attempt. You may also want to monitor use of all medications. In the face of an imminent threat, do whatever is necessary, even if it means calling the police - call 911 or emergency medical help - or getting the person professional help against his or her wishes.

In order to help those who may be at risk, the following support and services should be available in an on-going basis until they have been evaluated and treated appropriately.

• Effective and appropriate clinical care for mental, physical, and substance abuse disorders
• Easy access to a variety of clinical interventions and support for help seeking
• Restricted access to highly lethal methods of suicide
• Family and community support
• Support from ongoing medical and mental health care relationships
• Learned skills in problem solving, conflict resolution, and nonviolent handling of disputes
• Cultural and religious beliefs that discourage suicide and support self-preservation instincts

• Enhance research to understand risk and protective factors related to suicide, their interaction, and their effects on suicide and suicidal behaviors. Additionally, increase research on effective suicide prevention programs, clinical treatments for suicidal individuals, and culture-specific interventions.
• Develop additional scientific strategies for evaluating suicide prevention interventions and ensure that evaluation components are included in all suicide prevention programs.
• Establish mechanisms for federal, regional, and state interagency public health collaboration toward improving monitoring systems for suicide and suicidal behaviors and develop and promote standard terminology in these systems.
• Encourage the development and evaluation of new prevention technologies, including firearm safety measures, to reduce easy access to lethal means of suicide.

Coping With a Suicide [2]

Suicide Survivors: Those Left Behind
It's estimated that on average every suicide leaves at least six people deeply affected by the death. That amounts to nearly 200,000 people a year suffering one of the most painful forms of grief that exists. Family, friends and co-workers left in the aftermath of suicide are commonly referred to as suicide survivors.

When an individual commits suicide - or tries to - that person's family and close friends often are devastated and experience intense and persistent pain. Suicide survivors may suffer through repeated nightmares and flashbacks of the suicide scene, and they may avoid people and places that remind them of the suicide. Some survivors lose interest in activities they once enjoyed and grow emotionally numb - feeling incapable of caring. Beyond bereavement, suicide survivors may themselves become depressed or develop another mental illness due to severe stress.

Common Emotions
If you're a suicide survivor, you may have experienced one or more of the following reactions. These emotions usually subside with time, but the process can take weeks to months. The emotions may also recur from time to time, particularly during a special holiday, such as a birthday or an anniversary that reminds you of your loved one.

• Shock. Shock is typically your first reaction, along with emotional numbness. You can't believe what has happened. It may feel like you're watching someone else's nightmare.
• Confusion. Only about one-third of those who commit suicide leave behind notes. But even notes may provide only partial answers as to why your loved one felt the need to take his or her life. Realizing that you may never know the answer is part of the healing process.
• Grief. You may cry often and easily. Tears are an honest expression of how you feel about losing someone you love.
• Despair. Feelings of sadness and loss can erode your appetite, sleep, energy level and relationships. This can lead to depression.
• Anger. You might become furious at a doctor, a family member, a friend or yourself for not seeing the suicide coming. You may feel angry toward your loved one who committed suicide for hurting so many people. Feeling and expressing this anger also is part of the healing process.
• Guilt. The "if onlys" come back to haunt you. If only you had noticed the warning signs, contacted a doctor or insisted on your loved one getting help. In time you'll realize that it wasn't your fault.

Seek Help
It's fairly common for suicide survivors to develop a mental illness, especially depression. You may also experience intense reactions that are similar to post-traumatic stress disorder. This can produce terrifying nightmares, make you afraid of expressing tender emotions, and keep you away from people and places you once enjoyed because they remind you of your loved one.

If you're having trouble dealing with the loss, don't hesitate to seek help from your doctor or a mental health professional. Otherwise you may not improve, and other problems may develop. Counseling or psychotherapy can help you cope with the crisis you're facing. Support groups made up of other suicide survivors also can help you find your way through the maze of emotions and physical changes you may be experiencing. Counseling or support groups led by trained professionals are especially important if you don't have adequate support from family and friends.

Many suicide survivors refuse to seek help because they think it's a sign of weakness. But it's just the opposite. Seeking help when you need it is a sign of strength. It's a sign that you're taking charge of the problem because you want your life back.

Learning to Cope
You may never fully recover from the suicide of a loved one and may always feel the loss. With time and help from others, however, the pain of the loss will begin to diminish. To nurture the healing, consider these suggestions:

• On days when you're feeling blue or just need to get your feelings out, talk with a family member or a friend who's a good listener.
• Stay in touch with your family and friends. It's tempting to withdraw from those close to you, but you need to maintain your social connections. Friends and family also can help divert your attention to other things.
• On special occasions, such as birthdays and holidays that you celebrated with the person who committed suicide, let yourself grieve. Don't hold back your feelings. If it would help you to feel better, change some family traditions that you now find too painful.
• Finally, remember this important fact: It's OK to begin laughing and enjoying life again. You don't have to prove that you loved the person by lingering with your grief. Your sorrow and tears are one way of honoring your loved one. Picking up and carrying on with your life is another.

REFERENCES
[1] The Surgeon General's Call to Action To Prevent Suicide, U.S. Office of Public Health, Office of the Surgeon General, July 1999 (http://www.surgeongeneral.gov/library/calltoaction/calltoaction.htm)

[2] Excerpted from Suicide and Coping With Suicide, Mayo Foundation for Medical Education and Research (MFMER), November 16, 2001, (http://www.mayoclinic.com/invoke.cfm?id=MH00017)

NIMH Suicide Research Consortium, National Institute of Mental Health (http://www.nimh.nih.gov/research/suicide.cfm)

American Foundation for Suicide Prevention
(http://www.afsp.org)