The rippling effects of suicide.

• Author: Pahl, Jorg J.

VERY FEW ACTIONS generate as much emotion in family members and friends as suicidal behavior. Only the person engaging in suicide suffers greater emotional turbulence. What often is perceived as being the severest form of auto-aggression--death by suicide--is in reality an attempt to escape psychic pain. Suicide appears to be the only option left for people who, after trying to solve life's crises, find themselves in an untenable situation.

Anyone can become suicidal when the situation producing the emotional pain is believed to be inescapable, never ending, and unbearable. Individuals respond to such situations with behaviors that can vary from suicidal ideation (suicidal thoughts), a common occurrence affecting 20% of Americans in their lifetimes, to completed suicide, a rare event affecting approximately 12.5 per 100,000 annually.

Psychiatrists are in the uneviable professional and legal position of having to determine who will go beyond purely suicidal ideation to attempting or ultimately completing the suicidal act. The current understanding of the nature of suicide contains elements of ambiguity. Psychiatrists' ability to predict and prevent this tragic event is limited. The future appears bright, however. Recent advances in brain chemistry have brought with them new hope that many of these deaths can be prevented. In the meantime, psychiatrists and other health care professionals continue to treat these emotionally distraught patients based mainly on information gathered during the clinical interview.

When examining the issue if suicidal tendencies, it is important to define what constitutes suicidal behavior, determine its prevalence, and identify psychological and biological factors that predispose one to suicide and precipitate the actual attempt. Only through use of rigorous scientific methods can it be possible to improve the ability to predict such behavior and protect the 30,000 who die annually by their own hands.

Suicidal behaviors are much more complex and common than the general public would think. They cover a spectrum of thoughts, communications, and acts, ranging from the least common, completed suicide; to the more frequently occurring, attempted suicide and suicidal communications; to the most common, suicidal ideation and verbalizations.

Research indicates that thinking about suicide occurs at least once in the lifetimes of 40% of Americans. General population surveys have found that 20% of Americans have experienced an episode of moderately severe suicidal ideation (defined as lasting at least two weeks, forming a plan, and identifying two weeks, forming a plan,l and identifying the means) at some point in their lives. Another 20% report at least one episode of suicidal ideation that did not involve formation of a plan. In contrast, completed suicide occurs in less than 0.1% of the population. These demographic data are important. They show that thinking about suicide rarely results in a completed act. Such data carry with them obvious treatment implications.

It is important to articulate the psychological and biological factors that predispose one to suicide and precipitate the actual attempt. It is extremely discouraging to note at the outset that current suicide prediction and prevention practices are an inexact science at best. While there are many...