(Image from iStock: melitas)
Content warning: This blog post contains discussion of suicide.
Author: Madison Hong
Editor: Riyaa Sri Ramanathan
Introduction
Choice. Perhaps one of the cruelest decisions lies within one that plagued an alarmingly large population of 49,449 in 2022: whether or not life is worth living anymore (“Provisional Suicide Deaths,” 2023). Suicide is directly defined as an act that one inflicts on oneself to perish, and as a result, they pass away (“Frequently Asked Questions,” 2023). In reality, such a term carries social, moral, and scientific meaning, acting as a liquid form that simultaneously implies overwhelming terror, unalleviated anger, and solemn joy. On a surface level, suicidal thoughts can be judged as a choice that an individual has to end their life or to attempt to carry on within their seemingly worthless life; it is a deliberate act of volition taken based on psychological factors. Despite this stereotype, suicide can often coincide with physiological symptoms of mental illness rather than being a mere feeling or a conscious decision. Though the psychological indications for suicide are more widely studied and displayed in media, the invisible effects of physiology are additionally relevant to the discussion of suicidality.
Physiologic Indications for Suicide
When deliberating suicide, most jump to the conclusion that depression, personality disorders, or traumatic events will cause one to contemplate taking one's life. However, suicide encompasses a wide melting pot of causes, including genetic and biological causes. A significant component of the physiology behind suicide involves specific genes that regulate the expression of the neurotransmitter serotonin. Serotonin regulates mood and behavior, thus regulating elements of suicidality, as studied within post-mortem patients who end their own lives. In addition to serotonin, physiologic stress can impact one’s risk for suicide, relating to the hypothalamic-pituitary axis, which regulates the fight or flight system. The brain itself has also been studied concerning neuroinflammation and suicidal actions.
Neurons control life, every action you might take, and every thought that pops into your head. In the same sentiment, neurons control our subconscious and feelings, influencing how people view the world and choose to deal with the sinister faces of the world. Unfortunately, suicide is the answer for some. Receptors on the ends of such neurons, specifically neurons responsible for transporting serotonin, can have increased or decreased activity, indirectly causing genetic and psychological indications for suicide. The most substantial evidence behind the relationship between serotonin receptors and suicidality lies in the 5-HT2A receptor, which is mainly located in the cerebral cortex, entorhinal cortex (which regulates information transferred to the hippocampus), piriform cortex (which processes olfactory information), limbic system, basal ganglia (for motor control), and dorsal horn of the spinal cord (Chattopadhyay, 2007). When studying platelet samples from suicidal individuals, researchers found “... that the B-max of 5-HT2A receptors was significantly higher in depressed patients…”. They consistently increased suicide victims when compared to regular patients (Pandey, 2013). An increase in these receptors will indicate the increased activity of said receptors, manifesting specific symptoms depending on where the receptors are located. The dorsal horn of the spinal cord, piriform cortex, cerebral cortex, and limbic system can process sensory information. When receptors are increased in those areas, it can result in the aggravation of depression symptoms, specifically hopelessness (Carballo et al., 2008). 5-HA2A binding has been positively associated with dysfunctional attitudes, which can increase one’s risk for suicide.
The hypothalamic-pituitary axis, which primarily regulates stress with the hormone cortisol, is typically associated with the fight or flight response in times of danger. However, it can also accompany variations of stress and mental disorders, such as when considering suicide patients. The HPA axis comprises three systems: one which releases corticotropin-releasing factor, which then causes the release of adrenocorticotropic hormone, ending with glucocorticoids (Smith & Vale, 2022). Cortisol is a form of a glucocorticoid released on a large scale in times of stress. When studying suicidal and depressed people, it was found that in the frontal cortex, the amount of CRF receptor binding sites was decreased, increasing the amount of unbound CRF (Pandey, 2013). Though not explicitly studied, the unbound CRF could play a part in correctly regulating the negative feedback loop of the HPA axis.
Inflammation is the body’s first immune response against irritants or foreign bodies. Similarly, psychological stressors can be likened to an external pathogen, causing the inflammation of the central nervous system, which can be expected to some degree. Outside of typical neuroinflammation occurring, when it is continually present, chronic damage to the central nervous system can be inflicted, leading to suicidal ideation and symptoms (Bengoechea-Fortes et al., 2023). The basis of inflammation begins with cytokines and interleukins, elements of the immune system that spur an inflammatory cascade when released. When observing the cerebrospinal fluid of suicide victims, an increase of pro-inflammatory cytokines was found, entering through the blood-brain barrier (Bengoechea-Fortes et al., 2023). Given that the blood-brain barrier has a specific permeability that does not allow certain components into the brain, it was found that suicide patients also had increased permeability into the brain, allowing more cytokines to influence inflammation in the brain. In addition to increased cytokines, increased interleukins could be found in suicide patients, each interleukin variation about a different suicidal trait. Interleukin-6 was positively associated with impulsivity, aggressiveness, lethal methods of suicide, short attention span, and childhood physical abuse, all of which are pertinent risk factors in a completed suicide attempt (Bengoechea-Fortes et al., 2023).
The Psychology Behind Suicide
Suicide is often compounded with depression, the stereotype being that external factors such as bullying and finances can cause depression, and when combined with a lack of will to live, suicide can be a result. While those factors can be the case for many cases of suicide, the more specific psychological indications for suicide include severe, unyielding psychological pain, cognitive difficulties, interpersonal relationships, and communicative abilities (Levi-Belz, 2019).
Psychache, or unbearable psychological pain, lies at the center of suicidal behavior, encompassing emotions such as angst, guilt, shame, fear, and dread (Verrochio et al., 2016). Mood disorders are commonly associated with psychache; mood disorders can mediate the amount of psychache that one endures. In depressed patients with suicidal ideation, experiencing psychache would expose them to suicide, leaving them vulnerable to the possibility of suicide. Along the same thought process, a study was enacted that measured heart rate variability and electroencephalogram delta powers (which indicate sleep duration and intensity), revealing decreased variability and delta powers (Long, 2021; Verrochio et al., 2016). These results indicated that those who experienced a more intense psychache obsessively dwelled over it and were not able to adequately compensate and treat the consequences of the psychache (Verrochio et al., 2016).
Though psychological pain can predict whether someone is at risk for suicide, other traits, such as interpersonal relationships and the inability to communicate, predict the potency of the suicidal ideation and the lethality of the method of suicide (Verrochio et al., 2016). Communication can allow a person experiencing suicidal ideation an outlet for the psychache and the opportunity for intervention on the single condition that the individual is willing to disclose information. For those who experience difficulty articulating emotions or discussing personal information with others, an “impossible” situation will spawn (Levi et al., 2008). This “impossible” model involves the hypothetical flow chart of actions that lead to either a medically not serious suicide attempt, a medically serious suicide attempt, or a completed suicide (Levi et al., 2008). Should a suicidal individual attempt suicide with a non-lethal injury or reach out to others about their suicidal ideation, the process of suicide is interrupted. However, suppose the method of suicide is deadly, such as firearms, hanging, or drowning. In that case, the suicide is categorized as a medically serious attempt and, thus, has much more drastic drawbacks than a medically not serious attempt (“Lethality of Suicide,” 2017).
Consequently, with the discussion of communication comes interpersonal relationships; if the individual is surrounded by peers or family that promote suicidal risk factors, the individual is more likely to attempt suicide. The interpersonal theory encapsulates three consistently observed motivators of suicidal behavior: thwarted belongingness, perceived burdensomeness, and acquired capability of suicide (Van Orden et al., 2010). Thwarted belongingness is depicted as having two main influences: loneliness and absence of reciprocal care, which can be demonstrated by living alone, having scant social support, family conflict, personal loss, any form of abuse, being socially withdrawn, and many other factors (Van Orden et al., 2010). Perceived burdensomeness focuses on self-hatred and thoughts of worthlessness or expendability; the individual feeling this will believe that they are expendable because of the opposing viewpoint from which they view themselves. This portion is divided into liability and self-hatred, exhibited by low self-esteem, self-blame, distress from life conditions, being “unwanted,” and believing that the individual is a burden on their family (Van Orden et al., 2010). However, the prior two factors detailed suicidal desire and acquired capability of suicide relatability. With exposure to suicide, impulsivity, combat exposure, and childhood maltreatment, elevated pain tolerance and lowered fear of death can result in increasing risk for suicidal behavior (Van Orden et al., 2010). Despite these factors, through the interpersonal theory, even if an individual inherits all three traits, suicide is not guaranteed.
Cognitively, deficits are observed in risks for suicidal behavior, including in “...executive function, motor speed function, and global neuropsychological function…” which specifically contribute to suicidal ideation (Pu et al., 2017). Though suicidal ideation does not always lead to suicidal behaviors, it can be an alarming risk factor for the act of suicide. In patients with major depressive disorder, executive function deficits have been observed, as well as in patients who have a history of suicide attempts (Pu et al., 2017). However, suicidal ideation itself can also indicate an executive function deficit related to memory, flexibility, and self-control (“Executive Function,” 2020). Faulty executive function, ineffective decision-making, inability to inhibit sensory stimuli, and inadequate expression of behavior can occur, all of which are in line with suicidal ideation. With defects in motor speed comes a disturbance in the limbic system, which is where emotional and physical actions are made. Often, motor speed is decreased in patients who have attempted suicide with suicidal ideations, as compared to those who have attempted without suicidal ideation (Pu et al., 2017). In line with executive dysfunction, decreased motor speed can cause psychomotor retardation, a common symptom seen in depressive patients (Buyukdura et al., 2010). Combining these two deficits can demonstrate some tell-tale signs of depression: slow thinking and moving, being tested by the BACS composite score for global neuropsychological function.
Suicide Isn’t Just Death
As mentioned previously, suicide does not just connotate the death of an individual; it instead details the pain, contemplation, and suffering that the individual went through before deciding to end their own life. Thus, suicide is not a death that just involves the victim; it requires anyone and everyone around them. Grief is felt tenfold, accompanied by perpetual confusion, anger, and guilt (“Grief After Suicide”, 2001). Most feel as though they could have done more for the deceased and tried harder to show affection or help in some way when in reality, this problem is a complex web of psychological, social, and physiological strings. This guilt coincides with an intense desire to understand why the individual decided to take their life, leading them through an obsessive cycle of deliberating and questioning whether or not they are at fault for the death. Parents often replay moments in which they believe they were inadequate, wondering whether or not things would have been different if they “... ‘had not lost [their] temper’ or ‘if only [they] had been around more’...” (Young et al., 2012). Abandonment and betrayal are typical responses to such reflections, believing that the victim had chosen to give up on life without regard for others purposefully; why was the relationship between the survivor and the victim not enough to sustain life? (Young et al., 2012). Among those who become antagonistic towards suicide victims are most likely socially connected to the victim: friends, family, and spouses, because they have intimate ties to each other, which were abruptly severed by suicide. These fervent emotions likely do not have an outlet, given the stigma of suicide and how people who die by suicide are regarded as selfish, and depressed, and that suicide can be easily solved after one bout of suicidal tendencies (“Breaking the Stigma”, N.D.). People often shun the topic of suicide, avoiding discussing the incident due to the uncomfortable circumstances, whether it be from casting a negative light on the victim or the survivor. Thus, suicide can cause a cascade of adverse effects which impact the victim and those around them.
What Can Be Done, By You and By Healthcare Workers?
In some cases, suicide occurs in a split second. One moment, a loved one was alive, and another, for seemingly no apparent reason, they perished. Unfortunately, this abrupt nature of suicide causes a plethora of issues following it, which highlights the importance of communication and being able to intervene early. However, as mentioned previously, some individuals cannot exhibit such vulnerabilities, meaning that suicide seems like the only answer to their problems. Though noticing the warning signs of a suicidal person looks mentally strenuous and abysmal, it is imperative to be able to recognize symptoms of suicidal intentions in the case that the victim has communicative difficulties. Verbally, these people can express thoughts of “wanting to die, great guilt or shame, and being a burden to others”, which, in today’s twisted culture, can often be joked about or made a simple remark instead of a heavy statement with intention behind it (“Warning Signs of”, N.D.) Proclamations of craving death, threats of self-harm, and the “I wish I could be depressed so I could be different from everyone else” culture has become integrated into adolescent life, so much so that the topic is densitized for most teenagers and young adults. This normalizing of depression and suicidal ideation can cause doubt in one’s feelings, self-scrutiny as to why the individual is not reaching out about this issue, and fear that their opinions will not be treated as a legitimate condition, further subduing the victim into staying silent about their suffering. Suppose the suicidal ideation becomes intensified and evolves into the person actively planning their death. In that case, the intervention window is minimized even further, leading to the observation of behaviors to indicate a future suicide attempt. They may begin to gather supplies for their suicide, such as rope, collecting pills, razors, and other lethal objects (“Warning Signs of,” N.D.). To separate themselves from the world and numb themselves from the psychache, drug and alcohol use might increase, along with risk taking (“Warning Signs of '', N.D.). Cliche as it might be, suicide notes, making farewells, resolving past social complications, or giving away prized possessions can indicate suicide, the victim wanting to leave a piece of themselves behind as an apology (“Warning Signs of”, N.D.). Noticing these physical and verbal signs is imperative to potentially preventing suicide from occurring.
The mental health field, arguably, does not effectively prevent suicide. In 2015, “...31.0% to 51.7%...” suicides occurring in hospitals “... [involved] psychiatric inpatients” (“Incidence and Method,” N.D.). Given that the hospital is a place of recovery and treatment, the percentage of suicides in psychiatric patients should, theoretically, not reach that high. Since they, unfortunately, are of that caliber, healthcare workers should aim to treat psychiatric patients with the care they need instead of offering up their daily 8:00 PM antidepressants. Though restraints can forcefully control patients and prevent any future harm, they can be “... traumatic to the patient…” exacerbating the intimidating atmosphere of the hospital setting (Betz & Boudreaux, 2015). Instead, healthcare workers can use “... [verbal] [de-escalation]...”, which humanizes the patient and removes a sense of power and powerlessness between the worker and the patient (Betz & Boudreaux, 2015). Physical restraints can and should be used as a resort, especially if the patient is aggressive or suicidal, but incorporating the patient’s humanity and dignity should play a part as well. Additionally, though assessments and suicide risk assessments are routinely done due to protocol, further evaluation should be enacted on the patient; mental health is a diverse field, and no set of symptoms will fit another person’s, something which still applies in the case of suicidal patients. A “...comprehensive risk assessment…” done by a “...mental health [consultant]...” should be done for all suicide risk patients, with no exceptions (Betz & Boudreaux, 2015). Considering the normalization of suicide threats and jokes around suicide in the current adolescent culture, it can be challenging to differentiate between genuine suicidal ideation and a mere jest; even so, on the possibility that it might be true, leaning on the safe side and regarding each confession of suicidal ideation to be serious can prevent a potential suicide. However, the most effective intervention to suicide is empathy and creating a safe environment for the victim to express their feelings and thoughts truthfully. Keeping a non-judgemental yet caring disposition can aid in building a rapport with the patient, which can help in future emergencies (Betz & Boudreaux, 2015).
Conclusion
Some regard suicide as the ultimate act of selfishness, a random outburst of depression, or a mysterious event of deceit. Speaking from personal experience, suicidal ideation of none and all of those ideas at the same time. It is an uneven mix of physiologic, psychologic, and even random factors, all of which combine to create a brew of psychache, interpersonal struggles, and communication deficits, along with neuroinflammation and neurological changes in serotonin and the HPA axis. Though these many definitions exist, little is known about suicide and how to assess the warning signs effectively. Some are easy to spot, and some exist only within the depths of the victim’s mind, making it not only arduous but mentally depleting to try and save someone from their brain. Despite this, you should remain determined to lighten the future for mental health. Not only to potentially prevent the sudden death of one of your loved ones but also to aid those who have gone through suicidal ideation and those who have grieved the loss of a suicidal patient. However uncomfortable or gruesome the topic may be, discuss it with those around you, operate with the intention of preventing suicidal tendencies in others, and most importantly, prevent yourself from falling into the inescapable cesspool of suicidal ideation and mental illness. If you are to take anything from this article, have it be that no matter what, a life saved is a life saved, and though it can be convoluted, agonizing, and gut-wrenchingly depressing, power on. Take it from someone who lived.
References
Bengoechea-Fortes, S. P., Ramírez-Expósito, M. J., & Martínez-Martos, J. M. (2023). Suicide, neuroinflammation and other physiological alterations. European archives of psychiatry and clinical neuroscience, 1–13. Advance online publication. https://doi.org/10.1007/s00406-023-01584-z
Buyukdura, J. S., McClintock, S. M., & Croarkin, P. E. (2011). Psychomotor retardation in depression: biological underpinnings, measurement, and treatment. Progress in neuro-psychopharmacology & biological psychiatry, 35(2), 395–409. https://doi.org/10.1016/j.pnpbp.2010.10.019
Carballo, J. J., Akamnonu, C. P., & Oquendo, M. A. (2008). Neurobiology of suicidal behavior. An integration of biological and clinical findings. Archives of suicide research : official journal of the International Academy for Suicide Research, 12(2), 93–110. https://doi.org/10.1080/13811110701857004
Centers for Disease Control and Prevention. (2023, August 10). Provisional suicide deaths in the United States, 2022. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2023/s0810-US-Suicide-Deaths-2022.html
Chattopadhyay, A., & Chattopadhyay, A. (2007). Serotonin 2A (5-HT2A) Receptor Function: Ligand-Dependent Mechanisms and Pathways. In Serotonin receptors in neurobiology. essay, Taylor and Francis.
Department of Health & Human Services. (2001, August 14). Suicide - family and friends. Better Health Channel. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/suicide-family-and-friends
Executive Function & Self-regulation. Center on the Developing Child at Harvard University. (2020, March 24). https://developingchild.harvard.edu/science/key-concepts/executive-function/
Incidence and method of suicide in hospitals in the United States. (n.d.). https://www.jointcommissionjournal.com/article/S1553-7250(18)30253-8/fulltext
Lethality of Suicide Methods. Means Matter. (2017, January 6). https://www.hsph.harvard.edu/means-matter/means-matter/case-fatality/
Levi, Y., Horesh, N., Fischel, T., Treves, I., Or, E., & Apter, A. (2008). Mental pain and its communication in medically serious suicide attempts: An “impossible situation.” Journal of Affective Disorders, 111(2–3), 244–250. https://doi.org/10.1016/j.jad.2008.02.022
Levi-Belz, Y., Gvion, Y., & Apter, A. (2019). Editorial: The Psychology of Suicide: From Research Understandings to Intervention and Treatment. Frontiers in psychiatry, 10, 214. https://doi.org/10.3389/fpsyt.2019.00214
Long, S., Ding, R., Wang, J., Yu, Y., Lu, J., & Yao, D. (2021). Sleep Quality and Electroencephalogram Delta Power. Frontiers in neuroscience, 15, 803507. https://doi.org/10.3389/fnins.2021.803507
Pandey G. N. (2013). Biological basis of suicide and suicidal behavior. Bipolar disorders, 15(5), 524–541. https://doi.org/10.1111/bdi.12089
Pu, S., Setoyama, S., & Noda, T. (2017). Association between cognitive deficits and suicidal ideation in patients with major depressive disorder. Scientific reports, 7(1), 11637. https://doi.org/10.1038/s41598-017-12142-8
Seattle University. (n.d.). Wellness and health promotion. https://www.seattleu.edu/wellness/mental/stigma/
Smith, S. M., & Vale, W. W. (2006). The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress. Dialogues in clinical neuroscience, 8(4), 383–395. https://doi.org/10.31887/DCNS.2006.8.4/ssmith
Tal Young I, Iglewicz A, Glorioso D, Lanouette N, Seay K, Ilapakurti M, Zisook S. Suicide bereavement and complicated grief. Dialogues Clin Neurosci. 2012 Jun;14(2):177-86. doi: 10.31887/DCNS.2012.14.2/iyoung. PMID: 22754290; PMCID: PMC3384446.
U.S. Department of Health and Human Services. (2023, August 10). Frequently asked questions about suicide. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/suicide-faq
U.S. Department of Health and Human Services. (n.d.). Warning signs of suicide. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/warning-signs-of-suicide
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E., Jr (2010). The interpersonal theory of suicide. Psychological review, 117(2), 575–600. https://doi.org/10.1037/a0018697
Verrocchio, M. C., Carrozzino, D., Marchetti, D., Andreasson, K., Fulcheri, M., & Bech, P. (2016). Mental Pain and Suicide: A Systematic Review of the Literature. Frontiers in psychiatry, 7, 108. https://doi.org/10.3389/fpsyt.2016.00108