Instructions: Spend 5-10 minutes reviewing the case below and considering the question and discussion that follows. Case Study 1 You are working in a free clinic dedicated to a largely immigrant population. Your patient, Juan, is a 45-year-old construction worker who recently arrived from Mexico for work opportunities. He left Mexico due to financial hardship, and initially secured financial stability with his local construction position. Juan came in today in hopes of refilling a prescription for his anti-hypertensive medications since he has not yet established care in your area, and he does not have health insurance. As you speak with Juan during his visit, he tells you that he is learning English, but for the most part, understands very little of the language and feels “lost” in his new surroundings so far. He has strong family and social bonds in Mexico but is alone here. He explains that he had been sending most of his salary back home and had taken great pride in his ability to provide for his family with this position. But, recently the housing market in the area has taken a steep downturn, with a significant decline in the number of new projects and Juan lost his job. Juan expresses dismay that he is having difficulty supporting not only himself in this new environment, but also that he is no longer able to support his family, and becomes tearful when discussing his situation. While Juan has no prior diagnosis of anxiety or depression, he admits to feelings of hopelessness since losing his job.
1. Although you have just met Juan, take a moment to consider his current risk factors for suicide.
Discussion: While Juan has a strong network of friends and family at his home, his isolation in this country as an immigrant increases his suicide risk. In addition, his age and his profession, construction, have been associated with suicide risk. His recent, sudden, job loss also adds to the risk Juan faces. The feelings of hopelessness are concerning symptoms that warrant further exploration.
Those who do not receive adequate support are at increased risk for continued psychological problems, thereby increasing their risk of suicide. Evidence-Based Practice: In 2018, the Australian Rural Mental Health Study investigated the relationship between depression and suicidal behavior. Out of 1051 participants, 364 reported depression in their lifetime. Of these, 48% reported lifetime suicidal ideation, and 16% reported a lifetime suicide attempt. The severity of depression was a significant correlate of suicidality in both men and women, but suicide attempts were significantly more common among females with a younger age of depression onset and with a higher number of psychiatric comorbidities. No additional factors were found for males, making prediction difficult for men. 17 Social Factors Social isolation can be a significant risk factor for suicide. 15 Social isolation can occur for certain groups in specific geographic regions. For instance, in a small rural community, the LGBTQIA+ population may be isolated or marginalized, placing these individuals at a greater risk for death by suicide. In another example, questioning youth who are not connected with their family have a significantly higher suicide attempt rate than peers who have a supportive family. 15 In a broader view, several social factors are associated with an increased risk of suicide: living alone, a high degree of introversion, traumatic events that had occurred in adulthood, and interpersonal stressors. Extreme hopelessness, helplessness, and worthlessness, which may or may not result from depressive disorders, have also been shown to contribute to increased risk.
Sexual Orientation Sexual orientation has been shown to affect suicide risk. In the 2015-2019 National Surveys on Drug Use and Health, lesbian, gay, and bisexual adults are three to six times more likely than heterosexual adults to have suicidal thoughts, plans, or attempts. This demonstrates the importance of suicide prevention services that address the specific needs of lesbian, gay, and bisexual adults. 28 Emotional Factors Bereavement or loss of a close friend or relative, or a loved one can cause a significant amount of emotional distress, which can, in turn, lead to hopelessness and loneliness. 29 Within bereavement groups, those that are bereaved by suicide contribute to the highest risk for suicide. 30
Sleep Disturbances For a long time, experts believed that sleep disturbances were risk factors for suicidal ideations and suicidal behaviors. 32 However, a recent study published in 2020 showed that while sleep disturbances (insomnia, poor sleep quality, nightmares) are statistically significant risk factors for suicidal ideation, attempts, and death, these effects only weakly predict suicide. This finding is consistent with a growing body of evidence demonstrating this same relationship. Traumatic Brain Injury Athletes and veterans who have sustained multiple traumatic brain injuries (TBI) are vulnerable to suicidal behaviors and suicidal ideations. Regardless of gender, age or comorbidities, studies show that those with TBIs have more suicide attempts, and the risk of attempted suicide increases with the severity of the TBI. 33 Stigma Surrounding Suicide Public stigma is a social phenomenon in which members of society have negative attitudes about people with devalued characteristics. Stigma is a term that usually contains three elements: problems of knowledge (i.e., “ignorance”), attitudes (i.e., “prejudice”), and behavior (i.e., “discrimination”). Characteristics associated with suicide include emotional weakness, attention-seeking, selfishness, malingering, and immorality. Those who attempt or die by suicide are perceived to be impious (i.e., “not praying enough”) or as betraying family and friends through a cowardly or selfish act. 34 The result of public stigma surrounding suicide can result in fewer observed help-seeking behaviors, and those that have survived suicide may internalize feelings of shame. 35
Physical Factors
Physical Health Conditions While it is established that mental health disorders are risk factors for suicide, the relationship between poor physical health and suicide risk is unclear. 31 It is known that there is a close relationship between physical and mental health. Individuals with multiple physical health conditions tend to have a lower quality of life and a higher likelihood of a mental health disorder. Numerous studies have suggested that the type and number of physical illnesses are associated with suicide. However, most of the studies are based on small, non-representative samples of the population (e.g., U.S. military veterans). A recent population-wide study of over one million people in Northern Ireland examined the relationship between physical health and suicide. 31 It showed that activity limitation is a significant factor for suicide risk, even after adjusting for chronic poor mental health. The effect of activity limitation was more pronounced for younger ages.
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