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Mental health

On the brink

More care and a few phone calls cut new suicide attempts by a factor of ten

HÉLIO DE ALMEIDAA counseling session plus follow-up phone calls every few weeks for a year and a half was all it took to cut by a factor of ten the rate of suicide among people who had already tried to end their lives earlier. This result is striking because it shows that a simple and virtually cost free strategy can save lives, by creating bonds between a healthcare professional willing to listen, on one end of the line, and someone who needs to talk about such intense psychological suffering that he sees no alternative but to put an end to his life, on the other.

“After the initial contact, conducted while the person is still in hospital, all that was required was a psychologist and a phone line”, tells us psychiatrist Neury Botega, a professor at the State University of Campinas (Unicamp). Botega coordinated a group that tested the effectiveness of this intervention strategy in Brazil, as part of a World Health Organization (WHO) initiative aimed at reducing suicide mortality, particularly in poorer countries, which account for 85% of the cases of self-inflicted death.

From January 2000 to April 2004, mental health experts from five countries gathered data about 1,867 people who had attempted suicide and who had been seen to in eight hospitals in Brazil, India, Iran, China and Sri Lanka. After their suicide wounds had been treated, each person had an interview with a mental health professional (psychiatrist, psychologist or psychiatric nurse) and was invited to take part in the study.

Those who agreed joined one of two groups. The 945 members of the first group were assessed and sent to an appropriate healthcare network service. The second group, in addition to this, was informed about the psychological and social factors that drive someone to suicide and about those that protect people from this. These would-be suicides also learnt about the suicide rates among the population and about the likelihood of those who have already tried to kill themselves having a go at it again. The second group was also given guidance about the availability of mental health public services.

One week after leaving hospital, each of the 922 patients in the second group got the first call from a member of the team that had seen to him. When there was no phone, the researchers visited the people in their homes. In Vietnam, for instance, they had to cycle to the participants’ houses. The contacts, to a total of nine, were increasingly spaced out, and worked somewhat like the work of the CVV Centro de Valorização da Vida center, a philanthropic organization established in São Paulo in 1962, in which volunteers listen to people that call a specific phone number, though one of the differences is that the CVV team provides no counseling. In each conversation, the WHO researcher inquired how the person was feeling and tried to encourage him to get medical care and to find the strength to overcome adversities.

Eighteen months after the hospital stay, the researchers sought out the people that they had seen to. Of the 826 members of the first group that they managed to locate, 18 (2.2%) had died from suicide, whereas only 2 of the 872 people in the second group (0.2%) had killed themselves, stated the researchers in an article published in late 2008 in the Bulletin of the World Health Organization. “Regular contact showed patients that somebody was concerned about them”, explains Botega. “The action mechanism of this strategy is similar to that of psychosocial counseling: it works like an emergency emotional support network, for those who lack an efficient support network”, wrote the researchers in the article which detailed their work.

The impressive results of this initiative, known as Supre-Miss (short for Suicide Prevention – Multi-site Intervention Study on Suicidal Behaviors), makes it clear that with very little structure and technical training one can avoid the death of those who do not really want to die. Even before completing the Brazilian stage of the work, in which some 120 would-be suicides in the city of Campinas (the second largest in São Paulo State) were monitored, Botega had been showing to the public healthcare network that this strategy, with some adjustments, was feasible.

In 2003, at the invitation of the São Paulo City Council, Botega and his team trained, for 6 months, 90 healthcare professionals who worked in the Sé district (downtown São Paulo), where 416 thousand people live. Training was also conducted in the Jabaquara district, in the southern part of the city, with a population of 210 thousand inhabitants. “Those who were seen to at the hospitals of the two districts already left with an appointment to come back and the name of the staff member that was going to talk to them”, tells us Botega. The psychologists would call the home of those who did not turn up and, if they did not find them, asked for an agent from the Family Healthcare Program to visit the person at home.

Months after the training, the Unicamp psychiatrist, who for almost two decades has been researching what drives people to try to do away with themselves, was surprised to learn that a group he had trained continued meeting to monitor potential suicides. He is now waiting for the Ministry of Health to release funds to start a project approved in 2008: to train 700 healthcare professionals from different towns to disseminate knowledge on how to deal with suicidal people.

In this course, information is provided on suicide rates and on groups considered to be high-risk. It also teaches techniques for dealing with people who feel so devoid of support that they want to kill themselves, as well as paying attention to their warning signs. “The may provide fairly direct indications and say ‘I don’t want to live anymore’, ‘One day I’ll just disappear’, or ‘You’re going to miss me’. Alternatively, they may provide indirect clues, such as changing their habits, starting to distribute personal objects, or visiting friends and relatives that they haven’t seen in a long time”, states psychologist Blanca Guevara Werlang, from the Pontifical Catholic University of the State of Rio Grande do Sul (PUC-RS), who, along with Botega, is part of the Ministry of Health group that is working on a national suicide prevention strategy.

One of the challenges the Unicamp psychiatrist faces is getting rid of the prejudice and incorrect ideas of many healthcare staff about suicide. He states is it is common to imagine that those who threaten to attempt suicide do not do it or that talking about the subject with those who are deeply devoid of hope and support can induce self-extermination. Perhaps this belief derives from a historical case: a stream of suicides that took place in Europe in the eighteenth century after the publication, in 1774, of the novel The Sorrows of Young Werther, by the German writer Johann von Goethe, in which the main character kills himself as a result of unrequited love. For Botega, however, talking about suicide plans can help the patient to look for ways out of his suffering.

“Therefore, we work toward changing how healthcare staff sees the problem, so that they lose their fear of approaching those who are at risk”, tells us Botega. “The more openly a person talks about loss, isolation and loss of value, the less confused his emotions are. The person then becomes reflective, which is crucial, because nobody, other than the individual himself, can revoke the decision to die”, explains the Unicamp researcher, who helped the Ministry of Health develop the National Suicide Prevention Strategy, launched in 2006, and a manual on the subject for mental health professionals.

HÉLIO DE ALMEIDAThough they are not impossible, only rare suicide cases are the fruit of a rational decision or of political, ideological or moral conviction – as is the case of suicide attackers, Buddhist monks, or those who commit hara-kiri or seppuku (voluntarily tearing the abdomen with a sword), like the samurais from feudal Japan, as a means of recovering honor. “Rational or philosophical suicide, the result of a free and planned act and without any strong influence of mental unbalance is rare”, says Botega.

Tolerated by some societies and condemned by others, suicide is regarded as a world mental health problem that accounts for the death of almost one million individuals a year. Today, 17 people kill themselves out of every group of 100 thousand, according to WHO data. From 1950 to date, the suicide rate among men escalated by 49%, reaching almost 30 cases per 100 thousand people, while among women it increased by 33%, to 7 out of every 100 thousand. During this time, the profile of the suicidal population also changed. The number of aged people dropped while the number of young people increased. Up to the mid-twentieth century, 60% of those who committed suicide were over 45. Today, 55% are under this age.

For reasons not entirely understood, Brazil and most Latin American countries have suicide rates regarded as low. But one should not rest on this. In just one decade, the rate of Brazilians who kill themselves rose by an average of 15%: from 3.9 cases per 100 inhabitants in 1994 to 4.5 cases per 100 thousand inhabitants in 2004. Men usually resort to more violent forms, such as hanging and firearms, whereas women intoxicate themselves. Here too, this attitude is becoming more common among younger people, especially in the 20 to 40 age group. They generally take drugs and medication when attempting suicide.

The Brazilian rates trail far behind those of Eastern European countries, such as Lithuania (38.6 per 100 thou), Russia (32.2 per 100 thou), or Hungary (26 per 100 thou), or even of countries with moderate rates, such as the United States and Canada, where 11 out of every 100 thousand people kill themselves. However, the size of our population puts Brazil among the ten top countries in terms of the number of suicides. According to the Ministry of Health, 8,550 people killed themselves in the country in 2005 – one per hour.

However, these are only the known cases. For each person who dies, many others try and fail – or do not even try, but have already seriously thought about the matter. In 2003, Botega’s team interviewed 515 Campinas inhabitants older than 14, who had been picked randomly so as to represent the city’s inhabitants. They discovered that, out of every 100 people, 17 had at some point thought about killing themselves, 5 had devised a plan, and 3 had actually tried. According to an article published in 2005 in Revista Brasileira de Psiquiatria, out of every 3 people who put their plan into action, one ends up in an emergency room.

Although suicide attempts are less common among adolescents, there are signs that a lot of them have already thought about it. Some five years ago, Blanca Werlang and the psychologist Viviane Roxo Borges interviewed 730 teenagers aged 13 to 19 in Porto Alegre, capital of the State of Rio Grande do Sul, and in Erechim, a mid-size town in the north of that state. They discovered that 35% of the interviewees (mainly girls) had already thought about suicide and many of them showed signs of depression.

Oddly enough, Brazil’s southern states have the highest suicide rates, particularly the State of Rio Grande do Sul: 11 suicides per 100 thousand inhabitants, two and a half times the national average. In pursuit of the reason underlying such high figures, the physician Stela Meneghel, from the University of Vale do Rio dos Sinos (Unisinos), in the town of São Leopoldo, assessed the suicide rates in Rio Grande do Sul from 1980 to 1999 and found that in these 20 years it rose by 50% among men, reaching 20 per every 100 thousand. This is double the suicide rate on record for the state, which also grew, describes Stela in a study published in 2004 in Revista de Saúde Pública [Public Health Journal]. In absolute figures, the cases of provoked death – generally by hanging – shot up from 642 to 1,093 a year.

At first, Stela ascribed the higher incidence of suicides in Rio Grande do Sul to the country’s economic crisis which, from the early 1980’s to the mid-1990’s, resulted in rising unemployment rates and, in Rio Grande do Sul, essentially an agricultural state, in small farmers losing their land to indebtedness and social disaggregation, when the parents and children split up, normally migrating to larger cities in pursuit of survival. “Rio Grande do Sul became poorer”, comments Stela, who worked with researchers from the Federal University of Rio Grande do Sul, the Federal University of Pelotas and Anvisa, the National Sanitary Surveillance Agency.

Conducting more in-depth analyses in the quest for better explanations, however, the team found that it was not in the poorer regions that the most despairing inhabitants were to be found, to the point of lassoing around their neck the very rope that they had previously used in their work. The suicides turned out to be concentrated in areas of small properties, to the state’s south, east and north, occupied by the descendents of Germans with especially morally demanding religions. Wherever there were more Protestants, in particular Lutherans and Adventists, such as in Santa Cruz, Três Passos, Gramado, Canela, Lageado and Estrela, the suicide rates were almost twice as high as in the towns whose inhabitants were mostly Roman Catholic, Spiritualists or had Afro-Brazilian religions.

In a classic study dating back to 1897, French sociologist Émile Durkheim had already verified that the suicide rate was far higher in Protestant countries than in Catholic ones. Several studies confirmed this idea, finding a low rate of suicides also among Muslims and Jews, although others, conducted mainly in the United States, did not regard Catholicism as a suicide protection factor. Based on a 1999 WHO survey, religious tradition apparently helps to check suicidal inclinations. The suicide rate is close to zero in Muslim countries such as Kuwait, since Islam forbids suicide, but is higher in Catholic countries, such as Italy (11.2 suicides per 100 thousand inhabitants) or in Buddhist countries, such as Japan (17.9 suicides per 100 thousand inhabitants). And it is far higher in countries whose population comprises mainly atheists, such as Russia.

To a protestant education, underscored by the extreme importance ascribed to individual effort and to work, Stela’s group added the strictness of German culture. Then it became clear that impoverishment might trigger the idea of suicide, but this decision was also heavily influenced by religion and ethnicity. “For a Brazilian of any other origin, losing everything is not the end of the world”, says Stela, whose conclusions had the support of the Federation of Lutheran Parishes. “But the Germans or their descendents can’t bear it, because they have a rather rigid moral code. For them, finding oneself unemployed or mortgaging the land to pay one’s debts is extremely painful.”

Experts do not doubt that social, cultural and even economic factors influence suicide rates. But they know that such factors do not fully explain them. “Suicide is a problem with several complex causes”, says Botega.

Recently, there has been growing evidence that there is almost always a mental health problem – often untreated – underlying suicide. Some years ago, Brazilian psychiatrist José Manoel Bertolote, from the WHO Mental Health Department, analyzed data about 15,629 suicides in different areas, especially in Europe and in the United States. In 97% of the cases in which full data was available, suicide involved a psychiatric condition. “Psychiatric illnesses are a major risk factor that increase the likelihood of suicide”, explains Botega.

The most common of such illnesses is depression, underscored by deep sadness most of the time. It is associated with loss of interest in previously pleasurable activities. During the course of their lives, 5 to 12 percent of men and 10 to 25 percent of women develop depression and, among the severely depressed, 15% kill themselves. The second most frequent problem is drug and alcohol abuse. In almost 23% of the cases, the person who committed suicide was drunk or under the effect of other substances. Two other common problems suicides are schizophrenia, which affects 1% of the population and causes serious symptoms such as delusions and hallucinations, and bipolar disorder, in which episodes of euphoria alternate with episodes of depression. In a study published in 2003 in the British Journal of Psychiatry, Bertolote calculated that, even though medication does not work for all cases, if these psychiatric conditions were properly treated, 165 thousand deaths by suicide could be avoided a year.

Besides psychiatric problems, another factor that raises the likelihood of someone giving up the struggle is their personality characteristics. While working on her doctorate at Unicamp under Neury Botega, Blanca Werlang outlined the psychological profile of suicides, using a strategy called psychological autopsy. Developed in the 1950’s by US psychologist Edwin Schneidman, it consists of what is just about detective work: reconstructing the deceased’s personality based on the clues left behind and information gathered from friends and family members.

From 1999 to 2001, Blanca identified 100 suicide cases in the coroner’s office in the city of Porto Alegre and contacted the police precinct where they had been reported. By monitoring the investigations established to assess the deaths, she managed to contact the family members and friends of 21 suicides. After reading their letters and notes, as well as talking to the relatives and people close to the suicides, Blanca concluded that the immediate fact that had driven them to take their lives varied widely – from job loss to family quarrels. Behind this, however, there was a history of psychiatric problems (including alcohol abuse) and of complicated relationships among the family members, which fueled the development of a personality which found it difficult to face life’s common problems. “These people generally absorb the family’s characteristics and have a narrow psychology that keeps them from seeing the way out of certain problems”, says Blanca. “Feeling incapable of reacting, they chose death as a way of getting rid of their intolerable suffering.”

Those who commit suicide are generally more aggressive and prone to acting unthinkingly, on impulse. “The decision to say ‘enough’ is taken more easily by impulsive people”, says Brazilian psychiatrist Gustavo Turecki. Coordinator of a multidisciplinary group studying suicide at McGill University in Canada, Turecki believes that the development of this personality trait depends on childhood conditions.

After analyzing some 200 papers on suicide, Turecki and Alexander McGirr suggest, in a study from 2007 in Current Psychiatry Reports, that parents’ rejection and physical or sexual abuse during childhood fuel the development of an impulsive personality. “Though personality may only be consolidated after adolescence, intervention during sensitive development periods may have long-lasting effects and diminish vulnerability to suicide”, they comment in their article.

By keeping track of a group of 4,488 Canadian children from childhood to the end of adolescence, Turecki’s team was able to verify that impulsive behavior is associated with a higher suicide risk, regardless of whether psychiatric conditions appear. Comparing the level of  gene activity  in the brain of suicides with those of people who died in accidents, the McGill University researchers identified certain biochemical paths in the brain that might be altered, diminishing the activity of the frontal region, responsible for control of impulsiveness. Some of the people who committed suicide had an altered version of a gene that is fundamental for the activity of the astrocytes, the brain cells in charge of nourishing neurons, according to an article published in January in General Psychiatry Archives. The most recent result, announced in the March issue of Nature Neuroscience, reinforces the notion that propensity to suicide is determined during development, by showing that among suicides who were child abuse victims the activity of the system that regulates response to stress was weaker.

While teams are working worldwide to understand what leads certain people to give up on life, the one possible solution is to train professionals from the healthcare field and other areas to identify people at risk and provide them with guidance in their search for help. Among other things, Blanca advocates that the discussion of suicide be opened to the population. “Talking about death is difficult, especially when it is self-inflicted”, she states. “But, if one doesn’t talk about it, how are people to know where to get help?”

The Project
1. Multicentric study of the World Health Organization on intervening in suicidal behavior (SUPRE-MISS) (nº 02/08288-9); Type Regular Research Awards; Coordinator Neury José Botega – Unicamp; Investment R$ 44,260.55 (FAPESP)
2. Suicidal behavior prevention plan (nº 03/07173-6); Type Public Polices Program – 1; Coordinator Neury José Botega – Unicamp; Investment R$ 16,038.82 (FAPESP)

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