Depression and Suicide _ ______________________________________________________________________
instead becomes a welcome prospect of permanent relief from suffering and anguish [442]. Individuals with physical pain are substantially more likely than those without pain to report lifetime death wish; to have current and lifetime suicidal ide- ation, plans, and attempts; and to die from suicide. Chronic uncontrolled pain is a consistent risk factor for suicidality, even after controlling for demographics and psychiatric and substance use disorders [443; 444]. The perception of being a burden significantly predicts wishing to die, active suicide ideation, presence of a suicide plan, his- tory of suicide attempts, and preference for death over disability in patients with chronic pain [445]. Chronic uncontrolled pain elevates the risk of suicide to escape unbearable suffering, in part by promoting (or becoming amplified by) depression and hopelessness. This intensifies a desire to escape that erodes the natural fear of dying, promoting the development of fearless- ness about death—a key risk factor for suicide [446]. Psychologic Pain Suicide is viewed as behavior motivated by the desire to escape from unbearable pain, and suicide risk research implicates two related constructs: psychache and pain tolerance, defined as the greatest duration or intensity of painful stimuli one can withstand before pain is intolerable and unbearable [447; 448]. Psychache is a crucial link between suicidal risk and behavior and mediates the relationship between depression or other psychologic conditions and suicidality [447; 448; 449; 450; 451]. As discussed, numerous studies indicate that psychache highly predicts suicidality and distinguishes attempters from ideators. Changes in suicide preparation and intent over three years significantly correlates with changes in psychache but not depression or hopelessness [452]. Evidence links pain tolerance to self-injurious behaviors and suicide risk. Psychache and physical pain are linked to other predictors of suicide, including impaired reward processing, hopelessness, and depression [448]. Mental pain is a uniquely intolerable experience that exceeds the sum of negative emotions, thoughts, and sensations. Beliefs can develop that change or improvement is not possible and self-destruction is the only resolution [447; 453]. Unbearable, persistent psychologic pain is also thought to reduce awareness of the body and its signals, making it more likely to perceive the body as an object and an easier target to attack [454]. Among patients in residential treatment with serious psycho- pathology, history of suicide ideation or attempts is associated with proportionally greater psychic pain and fewer reasons for living. Treatment of such patients should include both an understanding of the sources of psychic pain and promotion of individual discovery of reasons for living [455]. Psychiatric Disorders Traditional suicide risk factors include mood (e.g., bipolar disorder, MDD), anxiety, impulse control, personality, psy- chotic, and alcohol/substance use disorders [368]. There is little evidence that trait impulsivity increases risk of attempts in
ideators, although suicidal behavior can occur during transient impulsive states [456]. In patients with MDD, the condition most associated with suicide, the lifetime suicide prevalence is 4% for hospitalized individuals, 2.2% in mixed inpatient/ outpatient populations, and 8.6% if hospitalized for suicidality [66]. However, it is important to remember that MDD alone does predict acute risk of suicide, and depression and most psychiatric disorders alone do not predict transition from
ideation to suicidal plans or attempts. Acute Anxious Agitated Distress
While symptomatic panic disorder, PTSD, and generalized anxiety disorder influence suicide behavior more than any other psychiatric disorders, it is the acute state of anxious agitated distress (not an anxiety disorder diagnosis) that greatly increases risk of ideators moving to suicide attempts [368; 457]. Among inpatient suicides, 79% met diagnostic criteria for severe or extreme anxiety and/or agitation. Anxious agitated distress is characterized by intense/severe anxiety, agitation, or panic and mental anguish and unrest with restless or repetitive behaviors, heightened arousal, expressions of emotional turmoil, irritability, anger outbursts, insomnia, and nightmares [351; 368; 409; 458; 459]. It is commonly observed immediately before suicide and is a documented precursor of near-fatal attempts. Clinicians should inquire regarding perceived anxious agitated distress and may ask patients if they feel like “jumping out of their skin” or “going to explode” or if feel they must “take action” or “do something” from overwhelming inner restlessness. Bipolar Depression An estimated 5 to 10 million Americans currently suffer from bipolar disorder. Bipolar depression is the depressive phase of bipolar disorder, when suicidal behavior is most frequent but least responsive to standard treatment. On average, patients with bipolar disorder spend three times longer in the depressive phase than in the manic phase. It is a highly disabling disorder, causing marked occupational and social impairment. Patients with bipolar depression have a 25% to 56% lifetime prevalence of suicide attempts, and 10% to 19% die by suicide [460]. Alcohol and Substance Use Disorders More than 33% of suicides occur during alcohol use, typically at high levels of ingestion, and controlled trials confirm that acute alcohol use is a potent suicidal risk factor [461; 462; 463; 464]. Alcohol intoxication significantly increases suicide risk and may heighten psychologic distress and aggression, encour- age suicide attempts, and inhibit adaptive coping strategies [465]. During intoxication, disinhibition facilitates movement from ideation to impulsive action, and alcohol intoxication predicts use of lethal means in suicide [465; 466]. However, substance use disorder and suicidality can be temporarily linked, as patients are likely to deny suicidality after intoxica- tion has resolved [467; 468].
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