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How Can We Prevent a Potential Suicide?

Christoph Anatol HERDA, Acting Chair of the Department of Mental Health, Psychiatrist

On suicide and feeling suicidal. Psychiatric doctors and psychotherapeutic counselors have slightly different, but complementing views on this phenomenon. In this article, Dr. Christoph Herda,psychiatrist, will offer his thoughts on this subject.

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Whenever a celebrity commits suicide, as both Kate Spade and Anthony Bourdain did last week, it becomes a hot topic of conversation. Some of us might even think that a friend or family member might be somehow suicidal as well. How can we approach them, help them, and prevent them from a potential tragedy?

How common are suicides? In China, about 120,000 people end their own lives each year. These big numbers can be a bit abstract, so to put it into perspective,237 people died in 2014 on Malaysia Airlines flight 370, but in China alone, there are 330 suicides per day. This is a tragic waste of life, especially because most of those lives can be saved with proper help.

Having suicidal thoughts is a symptom and not an illness by itself. In Western culture,s this symptom, in the vast majority of cases, is part of a psychiatric disorder, usually depression. Other disorders, such as alcohol use disorder or psychosis, increases the risk of having suicidal thoughts. In China, most suicides are not part of an existing mental disorder, but are short term reactions to insults, hurt feelings, and situations of losing face, where the time between the intention to end their life and the action is often only minutes.

In both cases, whether it’s the sudden hopelessness after losing face or having strong depressive suicidal thoughts, the main issue is to “buy time.”

With depression, there is often a development and worsening of suicidal ideation over time. Feeling suicidal can mean different things on a continuum of despair on one end and a strong urge to act on the other.

  • Wish for quietness (without the intent to die): Typical thought: “I want to sleep and only wake up when all this [the actual problem] is over.”
  • Wish to be dead (without the urge to act): Typical thought: “It would be better if I were dead. Nobody would miss me anyway. Maybe they are better off without me.”
  • Suicidal ideas (with a more or less concrete thought of a possible way to act): Often a sign of ambivalence, but without the urge to act, still rather passive. Typical actions: thinking of possible ways and means, doing internet research on possible ways to end one’s life.
  • Suicide intent: Suicidal ideas with concrete planning, with intent possibly put into words towards others, and a certain urge to act upon it. Typical thoughts: “It won’t get any better. There is no solution. I can’t stand it anymore.”
  • Suicide attempt: Suicidal action that has been survived. Clear intention to die and the conviction to reach that aim with that method.
  • Suicide: Suicidal action that resulted in death.
  • Para suicidal action: Looks like a suicide attempt, but the intention was not necessarily to die, although this possibility was taken into consideration. Often has instrumental or appellative character. The message: “something has to change.” Others might feel manipulated by para suicidal actions, but they are a cry for help and places the person at a higher risk for a suicide attempt.

Today I would like to focus more on feeling suicidal within depression. Suicidal thoughts are common in severe depression. When you have an infection, you often get fever – when you have severe depression, you often have some form of suicidal thoughts. They are part of a depressive episode. Often patients are reluctant to talk about these thoughts themselves, maybe because they think that having these thoughts is crazy, or out of fear that they might be placed into a mental health institution against their will.

If somebody has acute suicidal thoughts with the urge to act, we have to relieve the emotional pressure leading to this despair as quickly as possible, in order to “buy time” to address the underlying depression with medication (anti-depressants) and psychotherapy. In this context, “buying time” is to prioritize safety and survival.

In practice, the psychiatrist, ideally together with the patient and a friend or next of kin, decide the short term treatment plan. If the decision is in favor of inpatient treatment for a few days, we will help to make contact with the Shanghai Mental Health Center. United Family Hospital and other international hospitals in Shanghai are currently not allowed to treat psychiatric patients as inpatients, unless there is another medical condition of another specialty, ie. very high blood pressure or a wound, that also requires inpatient treatment, but even in these cases, transfer to a mental health institution is required after three days. The Shanghai Mental Health Center provides single rooms on its VIP floor and psychiatric treatment according to international standards and guidelines. For expats, sometimes an evacuation to the patient’s home country is considered.

If a decision is made to treat a patient with milder forms of suicidal thoughts as an outpatient, I normally prescribe a sedative and an anxiolytic drug, such as Lorazepam, to take off much of the emotional pressure and give other medications, such as antidepressants, and other treatment approaches, like psychotherapy, time to work.

For mental health professionals, deciding which form of treatment – inpatient or outpatient – for each case is often challening. If every person with the slightest suicidal thoughts were placed into a mental health institution under 24/7 surveillance, a very high percentage would survive, but some will experience this as an unnecessary traumatic experience in itself. Being put into treatment against one’s will is not the best precondition for healing, but sometimes it is necessary, if safety cannot be established otherwise.