SUICIDE

INTRODUCTION

Suicide is an irrational desire to die. We use the term "irrational" here because no matter how
bad a person's life is, suicide is a permanent solution to what is nearly always a temporary
problem. Suicide is a symptom and sign of serious depression. Depression is a treatable disorder,
but often the treatment takes time, energy and effort on the part of the person who's feeling
depressed. Sometimes, as a person who is depressed feels the energizing effects of an
antidepressant medication, they will still feel depressed, but have more energy. It is during this
time in treatment that many people turn to suicide and suicidal acts.

Suicide's effects are tragic and felt long after the individual has taken their own life. It is usually
the second or third leading cause of death amongst teenagers, and remains one of the top ten
leading causes of death well into middle-age. A person who dies by suicide leaves behind them a
tangled confusion of family members and friends who try to make sense of a senseless and
purposeless act.

Most people who think about suicide, however, never make a "serious" attempt at it (every
attempt, though, is viewed as "serious" by the person making it). For every attempted suicide,
there is thought to be one or more people where the thought of suicide has never translated into
an actual attempt. With over a half a million people making a suicidal attempt each year, this
translates into a huge problem that society largely ignores or tries to sweep under the rug.
Prevention efforts largely target teenagers, but few professionals feel comfortable dealing with
people who are actively suicidal. In most communities, the health care system is also not well-
equipped to deal with the magnitude of the problem or the specific needs of a person who is
suicidal.

Suicidal behavior is complex. Some risk factors vary with age, gender and ethnic group and may
even change over time. The risk factors for suicide frequently occur in combination. Research
has shown that 90 percent of people who kill themselves have depression or another diagnosable
mental or substance abuse disorder.

Adverse life events in combination with other strong risk factors, such as depression, may lead to
suicide. Suicide and suicidal behavior, however, are not normal responses to the stresses
experienced by most people. Most people who experience one or more risk factors do not
become suicidal. Other risk factors include:

 Prior suicide attempt

 Family history of mental or substance abuse disorder
 Family history of suicide
 Family violence, including physical or sexual abuse
 Firearms in the home
 Incarceration
 Exposure to the suicidal behavior of others, including family members, peers and/or via the
media in news or fiction stories.
DISCUSSION

A Growing Issue

In fewer than two decades, the rate of suicide has increased by more than 30 percent in half of
America’s states. Additionally, the National Institute of Mental Health has shared that, in 2016,
suicide was the 10th leading cause of death in this country.

According to the Anxiety and Depression Association of America, more than 18.6 percent of
Americans suffer from anxiety and 6.7 percent live with depression. Considering the stigma that
surrounds mental illness, it’s reasonable to assume that these numbers are actually higher.

Further, a recent study looked at the lives of more than 20,000 American adults. The results were
heartbreaking. Among other revelations, it found that 46 percent of respondents felt alone either
sometimes or always and that 43 percent felt that their relationships were meaningless. Even
more devastating — 27% rarely or never felt as though there are people who really understand
them.

Behavioral scientist Deborah Stone, explains, “Suicide in this country really is a problem that is
impacted by so many factors. It's not just a mental health concern. There are many different
circumstances and factors that contribute to suicide. And so that's one of the things that this study
really shows us. It points to the need for a comprehensive approach to prevention."

Reflect on Your Role

If you’re watching all of this unfold around you and are feeling helpless, you’re not alone. Many
can relate. As this continues to become more common, don’t allow yourself to become
complacent. In this age when we are overloaded with information on our phones all day every
day, it’s easy to move on to the next story — but we have to do more.

Reflect on your own attitude about suicide and mental illness. In my role as a social sciences and
psychology professor, I regularly encounter students who are shocked by the disparity between
real facts and their own preconceived ideas about depression and anxiety. So often, they realize
that their unintentional actions and unconscious beliefs contribute to a culture that minimizes the
suffering of others. When we confront our own biases, we can help create change.

Think about how you respond to people in emotional crisis. Are you listening to understand? Are
you putting yourself in their shoes? Are your opinions about their situation clouding your ability
to provide support? When I worked answering phones for a suicide prevention hotline, almost
every caller described feeling unheard and misunderstood. Many said they felt like a burden or
an annoyance to those around them. As a collective, we need to do better.
We Can Fight This Together

No one should ever feel alone. We have to unite as allies to fight this darkness together. We can
change the narrative by creating a culture of compassion. We don’t have to understand the
specifics of someone’s journey to show empathy and love.

Here’s how you can become the warrior we need in this battle right now:

 Get the Facts - No matter what you think you know, you can always learn more. Read current
articles and dig through websites such as the National Alliance on Mental Illness. Keep up
with new research and current initiatives. We need you!
 Know the Warning Signs - Maybe you’ve got a friend who has been withdrawn lately or a
sister who always seems nervous. Instead of brushing it off as moodiness or a quirk, get
familiar with the warning signs associated with mental illness. They may not even be aware
of their own behavior. By being informed and sharing what you know, you could save
someone’s life!
 Active Listening - If someone is in distress and says they are feeling overwhelmed, depressed
or suicidal, take them seriously. Put down your phone, look them in the eye and let them
know you are paying attention. Allow them to speak without interrupting, nod and offer
reassurance. Treat them as you’d want to be treated.
 Enlist Help - Someone who is suffering may be unable to get help for themselves. A person
who is drowning may be so far underwater that they can’t call out to anyone. In those
situations, the responsibility falls on you. Take them to a hospital, call a hotline or reach out
to a loved one. Just don’t leave them alone in distress.
 Volunteer - Crisis centers across the country are understaffed and struggling to meet the
demand of a growing number of people living with mental illness. Many people cannot even
afford to seek the help they need. Volunteering not only helps support the agencies that
provide free mental healthcare but you will also gain valuable skills, insight and perspective.
 Raise Awareness - We have to shine a light on this life-threatening issue. In order to do this,
we have to create a dialogue and have the tough conversations. We have to educate
ourselves and others about the facts and myths surrounding mental illness. Invite a speaker to
come to your workplace or school, participate in community events and donate to
organizations committed to raising awareness. Do your part.

The mantle of mental illness is heavy but, if we all work together to carry it, we can lighten the
load. In order to be truly supportive, we have to challenge our own biases and beliefs, but it is
absolutely worth the effort.

Our friends, family, coworkers and members of our community are dying. They are not weak —
they are in need. We cannot stand by and let this continue. We cannot scroll past another tragic
story and then move on with our day like nothing has happened.
Anthony Bourdain’s life mattered. Kate Spade’s life mattered. My neighbor’s life mattered. My
friend’s brother-in-law mattered. My life matters — and so does yours. Will you stand up with
me? Can we work together to save lives?

ADVANTAGES

Suicide is one of the best ways to set free. It is the key to open the gates to our ultimate destiny.
In my view suicide has more advantages than disadvantages. Lets say i were to kill myself now.
This would make my family devastated while making my friends and relatives sad. But it would
be a good thing for me. I would be free from this misery called life and finally be in peace. It
would also result in reduction of mouth to feed thus those who want to live can live. Suicide, in
general provides environmental relief of human load and for the person who killed
himself/herself, it frees them from the pain and sorrow which made them feel that there is no
meaning to life or for someone like me who sees no meaning to life whatsoever and finds life
nothing but a meaningless and pointless cycle of ‘just one more day and it’ll be over’. So it
completely depends on the person who commits suicide. For me its advantage is that I will be
free finally but for you it could be something else.

But whatever your mindset be, just remember that one day you’ll die eventually so end it when
you can with minimal pain and sorrow rather than waiting for the slow and painful death on your
deathbed after maybe few decades.

DIS-ADVANTAGES

 Heavy impact on the lives of your family members.

 Your father and mother, if alive at their old age, will have to spend their last phase of their
life in sorrow. Your wife and children have to struggle to make the ends meet.
 Loss of chance in living and fulfilling your dreams by utilizing your brain’s thinking ability
and your hands and legs which other animals on earth didn’t possess and can’t achieve.
 A future old 'you', who will be like a library of thoughts that can guide the future generation
with his experiences of life, will be missed.

ALTERNATIVE

Wanting to die is a pretty reasonable reaction to lots of terrible life circumstances. Been there,
done it all, still alive.

So the real question is why and how do some of us keep going when we frequently want to die.
The answer lies in a mix of motivations and solutions that we practice. Here are a few of the
“alternatives to suicide” that I have used over the 40-plus years since I first wanted to die:
Escape strategies: Binge watching television, binge reading fiction, writing revenge-themed
novels, staring at the ocean, staring out the window.

Exhaustion strategies: Logging long hours at the gym, on a trail, up a mountain, on the bike, in a
kayak.

Engagement strategies: Using some creative skill; petting the cat or dog; arranging wildflowers
into a bouquet, spending an hour shopping for $5 worth of giftwrap and ribbon.

Encouragement strategies: Marking every little step forward. Creating a to-do list so detailed that
you count it progress when you finish your shower… your breakfast… your commute.
Reminding yourself during times when you are without hope that the God in whom you believe
has promised “a hope and a future” to you (Jer. 29:11). Even if that comes far in the future, when
you finally arrive in the country where God wipes away every tear (Rev. 21:4).

Extension strategies: Extending yourself for others, even when you feel like nothing. Sheryl
Sandberg, in Option B, her book about surviving the grief she suffered after her husband’s death,
says one tool she learned was to log daily three ways she had influenced others for the good.
Offer kindness. Volunteer. Show a colleague a new skill.

Remembrance strategies: At one point, my best suicide preventive was recalling that I would
have killed myself if I’d tried the particular overdose I’d considered at age 19. Some years later,
I held to the memory of a voice (that I know as God) telling me “If you don’t have a reason to
live ’til spring, plant bulbs.” I still plant bulbs, lots of them, every year.

Ritual strategies: Daily routines that never change can keep you going. For me, these include
alarm at 6. Coffee. Oat cereal with milk and berries. The print newspaper. The chair where the
Bible and journal and planner wait. The routines resume in the late evening, when 9 p.m. brings
on hot tea, the buzzing electric toothbrush, jammies and a book by the bed.

Safety strategies: At the worst, we keep ourselves safe. We call the friend who is willing to come
over, so we’re not alone. We text the person who will remind us that we don’t always feel this
terrible. We check in with a suicide hotline or the crisis text service when we need to say things
that even the best friend shouldn’t hear. (And by the way, the hotline care strategy is to listen
first, then help the caller identify any circle of belonging and even one thing the caller will do in
the next 24 hours other than kill herself. That is to say: name notwithstanding, “suicide
prevention” hotlines are designed not to prevent suicide, but to help us find alternatives to
suicide. And the evidence is that they work.)
METHODOLOGY

Methodology for approaching suicide as a complex phenomenon

Socio-anthropological study

We conducted two distinct but complementary studies; the first anthropological study will not be
described in detail here in terms of its methodology, since it has already been published in book
form 19. In this investigation, Minayo reconstituted the history of workers at the CVRD mining
company, marked by the historical development of the largest iron ore exporting company in the
world over the course of the last 60 years. Given that 90% of Itabira's economy hinges on
mining, the study analyzes the characteristics of the entrepreneurial state at the local and national
levels and highlights the effects of privatization during the 1990s on workers' subjectivity and
the social and political costs of this change for the city. It was precisely this transition marked by
industrial restructuring introducing abrupt changes that lead to the central question in this
research: can an increase in suicide rates represent a crisis of socioeconomic and cultural
degradation in a given social space? This study contains a detailed analysis of relations between
the company and the town of Itabira and the economic, social, and political effects for its
population based on the current changes, clarifying numerous points in this investigation.

In the second socio-anthropological study, we link the first with epidemiological and
psychosocial approaches. The previously cited book 19 provided the tone and thrust for the latter
two, so that the fieldwork involved the technique of observing the local context and
systematically recording ethnographic information on the theme under study. We sought to
understand the weight of a closed culture on work and the family within the traditional pattern of
company towns 21; the cultural roots marking the construction of Itabira's identity (with peasant
and farming/livestock raising origins, a history of pan-mining during the gold-mining era, and
more recently iron ore mining); and further noting that the town offers educational and work
areas and cultural, recreational, and sports attractions beyond work itself and outside the home.
Considered jointly, these data help understand the social depression that took the town by
assault.

Epidemiological study of morbidity and mortality

We conducted an epidemiological study of the descriptive type. In two previous studies, Minayo
& Souza produced a temporal analysis of mortality from external causes 34 and mortality from
suicide 35 in Brazil in the 1980s and 90s. In a third study 36, we analyzed suicide among young
Brazilians ages 15-24 years in nine metropolitan areas from 1979 to 1998. The methodology in
the current study involved two distinct procedures: (1) an epidemiological analysis of overall
morbidity and mortality in Itabira and (2) an epidemiological analysis of suicides in Itabira.

• Epidemiological analysis of overall morbidity and mortality in Itabira

In order to identify the general causes of death and hospitalization, we studied the group of
"violence and accidents" and the subgroup "suicide" according to gender, age bracket, marital
status, and schooling; alleged causes of suicide and suicide attempts, and the means used. We
analyzed the period from 1990 to 2001 for mortality and the year 2000 for hospitalizations. We
obtained the data from the Mortality Information System (Sistema de Informações sobre
Mortalidade - SIM) of the Brazilian Ministry of Health, a national system created in 1975 which
covers nearly 100% of deaths in Brazil, and from the Hospital Information System of the Unified
National Health System (Sistema de Informações Hospitalares/Sistema Único de Saúde -
SIH/SUS) of the Ministry of Health (Ministério da Saúde - MoH), implemented in 1993 with the
purpose of reimbursement for hospitalization in public and outsourced hospitals. The latter
produces administrative data covering 80% of hospital care in Brazil.

We based our study of the data on the International Classification of Diseases (ICD-9 37 and
ICD-10 38). We calculated the mortality rates from violence and accidents during the period
1990 to 2001, according to the entire set of such causes and the specific subgroups (traffic
accidents, homicide, suicide, falls, etc.), based on the resident population as provided by the
webpage of the Information and Information Technology Department of the National Health
System (Departamento de Informação e Informática do SUS - DATASUS - www. datasus.
gov.br), a government source available on the Internet. To situate Itabira vis-à-vis other realities,
we analyzed it in comparison to the overall national Brazilian data and those for the State of
Minas Gerais and the State capital Belo Horizonte. We calculated the overall mortality rates
according to gender and age bracket.

• Epidemiological analysis of suicides in Itabira

We conducted a detailed and in-depth epidemiological study of the suicides in order to

contextualize the phenomenon. We calculated the proportional mortality and mortality rates for
the period from 1990 to 2001. We investigated the following variables: gender, age, schooling,
marital status, birthplace, and types of suicide for the first and last years in the temporal series.
We divided the population into the following age brackets: 0-14 years; 15-24; 25-39; 40-59; and
60 and over. We adopted the Brazilian Classification of Occupations of the Ministry of Labor
and Employment, version 1994 39. We defined gender, schooling, and marital status according
to the Procedures Manual of the MoH Mortality Information System (2001) 40.

In order to improve the information on suicide, which is known to be underreported, we

conducted an active data search in the local notary public's office and in the local Military Police
Battalion, with reports from 1996 to 2001, the period during which there were records available
by gender, age, month of occurrence, occupation, and means used in suicides and suicide
attempts. The notary public uses the same death certificate that generates information for the
Mortality Information System. As a second source, we used the police reports filed on suicides at
the Military Police Battalion. The criterion for including data was that they appear on both the
death certificates and police reports. We excluded deaths resulting from other causes or those in
which the cause was difficult to elucidate.

We gathered data on morbidity from Injuries and Poisonings from the "2001 Reduced Files"
database on Hospital Admissions Authorizations (Autorizações de Internação Hospitalar - AIH),
the CD-ROM on Hospital Morbidity in the SUS by place of residence, technical notes (2002) 41.
We defined primary diagnosis as the injury leading to hospitalization and the secondary
diagnosis as the external cause generating the injury and hospitalization. This was possible
because MoH Ruling 146 of November 13, 1997, makes it mandatory to specify the two types of
diagnosis 42. However, we observed insufficient training in adequately filling in these two
categories, and there were frequent cases of the two diagnoses being switched. The morbidity
study covered Itabira and also Belo Horizonte, Minas Gerais State, and Brazil for the year 2001.

We analyzed suicide attempts according to the variables gender, age, occupation, season, length
of hospital stay, and case fatality. We compared the data from the AIH with an active data search
in the Military Police Battalion and with the reports on completed suicides. We produced a large
volume of data allowing us to support and compare the other levels of socio-anthropological and
psychosocial analysis.

CONCLUSION

Improving care at the end of life will require many changes in attitudes, policies, and actions.
Such changes will involve a multitude of people and institutions that have a role in making and
implementing decisions about patient care or in structuring the environments in which such
decisions are reached and realized. Clearly, what patients and their families know, expect, and
desire is important. Health care professionals play critical roles in diagnosis, communication,
guidance and direction, treatment, negotiation, and advocacy for patients at many levels.
Decisions by health plan managers, institutional administrators, and governmental officials shape
and often impede the ability of patients, families, and clinicians to construct a care plan that
serves the dying person well.

In general, changes in systems of care—not just individual beliefs and actions—are necessary if
real gains are to be made in helping people live well despite fatal illness. Such widespread
changes depend in part on a stronger social consensus on what constitutes appropriate and
supportive care for those approaching death. Widely publicized—albeit not necessarily typical—
instances of patient and family powerlessness to stop what they see as futile and painful
treatments reflect a lack of such consensus. Paradoxically, this lack of consensus also is evident
when patients or families demand treatments that practitioners see as useless, counterproductive,
or even inhumane. It similarly reveals itself in a health care delivery and financing system that
still rewards life-prolonging interventions (even when they will be ineffectual) and slights
palliative and supportive services for those for whom life-extending treatment is neither helpful
nor desired.

Freud may have been right that "our unconscious does not believe in its own death; it behaves as
if immortal" (Freud, 1915, in Freud, 1959, p. 304). The committee was optimistic, nonetheless,
that this society would cultivate the conscious intelligence and spirit to recognize the reality of
death and the likelihood that it will bring distress. It likewise was optimistic that people would
work together to create humane systems of care that assure the consistent use of existing
knowledge to prevent and relieve suffering and that support efforts to provide people the right
care at the right time in the right way. The analyses, conclusions, and recommendations
presented here are offered with optimism that we can, individually and together, "approach"
death constructively and create humane care systems that people can trust to serve them well as
they die.