It is a wonderful life – preventing suicide

It is Christmas Eve, a happy time for many, but for George Bailey, the future is gloomy. Previously a successful and respected businessman, he, through no fault of his own, is facing financial ruin and arrest. The only way out, he sees, is to jump into the river and commit suicide. This is a scenario from Frank Capra’s film, It’s a Wonderful Life first screened in 1946. Initially, a box office failure, it later became one of the favourite English movies of all time.

September 10 was World Suicide Prevention Day. Nearly a million persons die by suicide each year worldwide. In Sri Lanka, 3000 individuals commit suicide while around another 60,000 attempt self-harm. Of all the animal species, only humans commit suicide. Those knowledgeable of trivia might ask, “Isn’t there a species of rodents called lemmings that commit ritual suicide each year by jumping into the sea?” Actually, this is untrue. This urban legend perpetuated by a 1958 Walt Disney film White Wilderness showed lemmings supposedly committing mass suicide by leaping into the ocean. But the scene was faked. Disney captured the lemmings from another place and threw them into a river for the film, a most unethical act of filmmaking which would not be allowed nowadays.

Why do humans commit suicide in contrast to other species? Ironically, our species name Homo sapiens means in Latin ‘wise man’. Suffice to say that our developed frontal lobes, the decision-making part of the brain, enables us to override the natural built-in self-protection mechanisms and suicide. The sociologist Emile Durkheim named two broad classes of suicide distinguished by their motivation: altruistic and egoistic.

In this article, I will address the causes of egoistic suicide, the more common type where persons commit suicide because they are convinced that there is no point in living. Merely having thoughts of ending your life is not abnormal. In fact, it is normal. All human beings, at some point or the other, have experienced them.

As psychiatrists, when we assess a person who has such thoughts, we use certain guidelines to decide whether such thoughts are benign or dangerous. Usually, such thinking starts as normal thoughts and escalates. Initially, persons undergoing stresses may feel that it would be nice to die in their sleep and never wake up, next, they may think it is better to die from an accident or other natural causes, in the third stage persons may contemplate ending their own life but have no clear idea on how to do it. In the fourth stage, they will consider different ideas for suicide and in the final stage they will take action to initiate the plan by collecting pills and lethal weapons and deciding a suitable time. They may also do last acts, such as writing a last will or giving away their possessions. This final stage is the most dangerous and, if not recognised in time, will lead to the ultimate act of suicide.

Identifying such states accurately is an important task for the mental health worker. This is difficult. Patients inwardly yearn for help but outwardly, perhaps because of social stigma and embarrassment, actively hide such feelings.

The commonest psychiatric disorder that may lead to suicide is depressive disorder where a person’s mood is persistently low and he or she feels worthless and hopeless. A person after a bereavement or loss may have a mood state resembling depression, but there is an important difference as pointed out by Sigmund Freud a century ago in his classic paper Mourning and Melancholia. Persons with depression experience profound loss of self-esteem, but in persons in mourning, their self-regard is preserved. An important task of a professional helping a person contemplating suicide is to deal with this loss of self-esteem and show the person that however bad the situation might seem, that he or she has value as a human being.

Other psychiatric and related problems also increase the risk of suicide. The most common are personality disorder, alcohol or substance dependence and psychotic illnesses like schizophrenia. The primary task of managing persons who may have these conditions and are contemplating suicide would be to ensure safety and then treat the underlying condition. The first step is important as treatment takes time to be effective.

When evaluating a person for potential suicide, we also look for other factors that studies have shown to increase the risk. These factors in alphabetical order are: access to poisons or dangerous weapons, age (older persons have a higher risk), depression, family history, gender (males are three to four times at more risk), hopelessness, impulsivity, living alone, panic or severe anxiety, personality disorder, physical illness, prior suicide attempt, race (some races have a higher risk), recent personal loss, recent suicide of friend or relative, substance use, and being unemployed. We can change some of these factors (at least in theory) but some we cannot.

After identifying the risk factors in a particular patient, we try our best to reduce the former. For example, when managing an elderly man with ideas of suicide living alone, with no occupation, who is depressed, we will not only treat the depression but try to improve his social connections and get him occupied. There is nothing we can do about his age or gender.

Researchers have also identified the factors that protect against suicide. They are: good family support, having children at home, being pregnant, religion, and belonging to a culture that proscribes suicide.

Read through the above lists and see for yourself where you stand. But don’t worry, even if you have several risk factors but lead a reasonably contented life with no significant plans for ending your life, then there is no danger. But if you are aware of any persons who have several of these factors and also talk frequently about ending their lives, please ensure that they talk to a mental health professional and get evaluated.

In the film It’s a Wonderful Life George Bailey did not jump into the river. There was a conference in heaven and a guardian angel is sent to intervene. The angel shows him in real time what life would have been like for Bailey’s family and his town if Bailey never existed. Without George Bailey, his brother Harry drowns as a child. An unscrupulous businessman takes over his town and turns it into a gambling den. His wife Mary never marries. He now realises the enormous good he has done in his life. His self-esteem restored, he returns home with newfound optimism to face the challenges of life.

Other psychiatric and related problems also increase the risk of suicide. The most common are personality disorder, alcohol or substance dependence and psychotic illnesses like schizophrenia.