FOREWORD: Causes and Treatment for Suicide
In this foreword to observation articles by Arendas, Barbour, Burri, Roberts, Piekarski, and Wheless, Sofia Chaoui explores how emergency departments handle the epidemic of suicide amongst minors.
According to the CDC, suicide is the second leading cause of death for ages 10-24 (CDC WISQARS, 2016). Even worse, four out of every five teenagers who attempt suicide show clear warning signs such as withdrawing socially, displaying extreme mood swings, or talking about feeling trapped (2016). A 2015 study found that suicide rates for African-American children between the ages of 5 and 11 doubled between the years of 1993 and 2013 (Sherman, 2016, para. 2). A lot of new conventions and tactics have been invented and discovered to try to help people struggling with depression, anxiety, and other life-altering events. But even with all of these new forms of self-help for teenagers and children to access online or in person, many of the adolescents and children who display these symptoms wind up in the emergency room—some more than once for the same reason: attempted suicide. And in recent years, suicide rates in the United States have increased by a shocking 30% (Pompilli, 2018).
A lot of environmental and medical changes have occurred in the past ten to twenty years that could be and are a part of the reason why suicide rates have increased. A common misconception is that suicide is only the direct result of a psychiatric illness or mood disorder— that and nothing else. While many patients who suffer from a mental illness are prone to suicide, 54% of people who commit suicide were actually never diagnosed with a mental illness (2018, para. 1). Environmental factors include but are not limited to: immediate environmental factors, evolutionary environment, prenatal environment, early formative years, temporal environment, portable environment origins and destinations, biometeorological factors, bioclimatic factors, socioeconomical environmental factors, and biopsychosocial factors. Environmental effects that we may not necessarily feel but know exist, such as global warming and pollution, have direct physical effects on our neurotransmitter systems. For example, the ash from a volcanic eruption may contain toxic particles that elicit neuroimmune responses in the brain, putting the body in stress mode (Postolache & Merrick, 2010, pg 4). Stress is a huge factor contributing to the occurrence of suicide. Immediate environmental factors, such as the availability of tools and methods for an individual to kill him or herself, are also important to think about. Data from multiple decades for both the United States and Mexico reveals a 0.7% rise in suicidal rates in US counties per one degree Celsius increase and a 2.1% rise in suicidal rates in Mexican municipalities per one degree Celsius increase (Burke et. al, 2018).
Prenatal environments are where the brain develops in utero. Unknown environmental factors could infect the mother, embryo, or fetus while in utero, damaging the fetus’s developing brain and causing abnormalities which remain dormant until manifesting as mental illness years later (2010, pg. 2).
In today’s man-made society, we are surrounded by new technologies such as smartphones, laptops, artificial light, artificial cooling systems, heating systems, and a new fast-paced, stressful lifestyle with little exposure or connection to the natural world. From an evolutionary perspective, this lifestyle and these technologies are still relatively new to our species, and it is likely that our neurocircuits, neuroendocrine connections, and other regulatory processes are more adapted to our ancestors’ environment than our own current one (2010, pg. 2).
Of course, the effects of childhood trauma, cultural expectations, mental illness, and social order are not to be discounted. Early exposure to trauma is a consistent indicator of suicidal behavior in many research papers published in the attempt to break down the causes of suicide in different populations such as black children, who are more likely to experience such traumatic events at a young age (2016, para. 4).
So what is being done to reduce the occurrence of suicide and suicidal ideology? Mostly used in the past, safety contracts, also known as “no-suicide contracts or no-harm contracts” (Shana, 2017, para. 16), were used to try and convince patients that they had a responsibility to not kill themselves since they have signed this contract. This tactic failed because the safety contract was not legally-binding, and even if it was, it would be pointless because the patient would not be able to face any legal consequences to their actions because they would be deceased.
In the medical field, and especially in the emergency department, a traditional risk assessment is often used to identify acute, chronic, and protective risk factors. Acute risk factors are current and/ or new risk factors that a patient is dealing with, such as: current psychiatric illness, recent stressors (unemployment, lack of social support, etc.), current suicidal thoughts, and current access to lethal means (Shana, 2017, para. 15). Chronic risk factors include past psychotic history, chronic substance abuse, history or trauma, previous history of suicide attempts, demographics, and family history of suicide attempts. Physicians also hone in on possible protective factors that could prevent a patient from committing suicide, such as: positive coping and problem solving skills, family responsibility, children at home, religious beliefs, or are married. Physicians then evaluate the criteria and decide on whether to discharge the patient or keep them in the emergency department. (2017, para. 16). Assessment of suicidal thoughts and behaviors is something that is necessary for all physicians to know how to do (2017, para. 22) because mental illness tends to creep into all aspects of the patient’s life. These tests and questions that they ask their patients are a way to help guide the physician to getting the information they need to provide treatment. This tactic, and other similar tactics like the Basic Suicide Assessment Five-Step Evaluation, are what is currently used in medical settings in the case of a suicidal or possibly suicidal patient. There are no definitive results in predicting suicide through research into risk factors, so the method of risk assessment is mostly used to develop an informed intervention that is “uniquely specified for the patient’s needs” (Shana, 2017, para. 18).
In managing high risk patients, the Health Insurance Portability and Accountability Act of 1996 allows for some leeway in confidentiality. Physicians can now contact family members, friends, or outpatient treatment providers in order to gain collateral information even without the patient’s permission (2017, para. 19). This can be a problem in effectively saving lives because some people will not report their suicidal thoughts in the fear of losing their privacy/confidentiality.
Actively suicidal patients are kept under strict one-to-one observation to ensure a safe environment (2017, para. 20). They are checked for items that could be used for self-harm, such as bell cords, sheets, bandages, restraint belts, plastic bags, elastic tubing, and oxygen tubing to help protect them from themselves. But even with close supervision, lethal means are easily accessible in hospitals, and suicide still occurs in the emergency department.
Medication is also a treatment that has been used to help patients suffering from mental disorders that impact their daily lives like social anxiety and suicidal thoughts. These antidepressants, mood stabilizers, and antipsychotics are tricky for providers to prescribe because prescribing too high of a dose can result in distressing symptoms that increase suicide risk, such as anxiety, panic, agitation, pain, and insomnia (2017, para. 23). Over the years, and especially after the introduction of antidepressant prescription drugs have been introduced, suicide rates have dropped significantly. But something strange happened afterwards—- the suicide rates lowered then became stable and started to rise again. This means that either the people who antidepressants used to work for have developed some type of resistance to the drug, less people are accessing this drug, more people are getting depression, or new, different types of mental disorders that lead to higher risk of suicide are arising and these drugs are not effective against them. These medications also take about two weeks before showing maximum improvement in the patient’s emotional and mental wellbeing (2017, para. 23).
According to a study done in 2015, which asked that very question to both patients and physicians, “incomprehension” was a common answer on both sides. This means a lack of understanding from either side but especially the physician. Physicians who have learned about this topic from a textbook in their quest to reach their career goals do not often have a full comprehension of the many ways it can manifest itself, and do not tend to see their patients as “complex” but are trained to look for one thing to cure, i.e. they are sad because of this they feel hopeful because of that. The possibility of their patient lying to them, which is especially likely from a minor who has their parent in the room, is not usually taken into consideration.
From a physician’s point of view, it is important to look out for signs of malingering. Although the majority of patients who come in with their main complaint being suicide are being completely honest, there are some folks who may not be entirely honest and exaggerate their symptoms in order to be hospitalized. Whatever their motive may be, such as avoiding arrest or legal charges, gaining shelter, or accessing controlled substances, these types of patients take up space that could be used by patients who are in more dire need.
There has been a lot of new processes, medications, and education training to improve the hospitalization experience in emergency rooms and reduce suicide. While some techniques have been more successful than others, we as a country and as a world still have a lot of room for improvement. In the next few articles by Barbour, Burri, Arendas, Roberts, Piekarski, and Wheless, a few things that could use some improvement in the emergency room are discussed and the following articlel further delves into these issues.
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