Suicide as a public health issue

Abstract

Suicide is currently a serious public health issue worldwide. According to records from the World Health Organization(1), approximately 800,000 people commit suicide every year, which means one death every 35 seconds worldwide. Brazil ranks eighth in absolute number of suicides, with an average of 11 thousand cases a year, that is, 31 deaths per day, with the number of men being nearly four times higher than that of women(2,3). These figures may be even more alarming if we consider the underreporting of suicide deaths. The number of suicide cases is hidden between records of homicides, accidents and other causes of death. Despite that, official records available already allow us to confirm the seriousness of this phenomenon, which transcends the category of personal tragedy to become a serious public health problem, especially because of the intensity of pain, the years of potential life lost, and its epidemic character(4,5). Despite these data and the recognition of the depth and complexity of the phenomenon, suicide is an issue that is still a taboo. More specifically, it is defined as the human act of self-inflicted cessation of life. For its delimitation, the notion of the individual’s intention to die should be considered in suicide attempts(5). The classification of nonfatal suicidal behaviors ranges from suicidal ideation – the different levels of suicidal thoughts accompanied or not by planning – to suicide attempt, which is defined as a self-injurious behavior in which there is the intent to end one’s life(2). The line between suicidal ideation, attempted suicide and suicide itself is very thin. In general, anguish and suffering that underlie the idea or intent of suicide can reach an overwhelming level and boost the act. This thin line warns that self-inflicted death is almost always thought out, planned and preceded by attempts, thus increasing the chances of immediate and effective preventive interventions. This assertion does not rule out cases that do not go through planning and usually result from a desperate impulse(6). Thus, suicide is a complex human and universal phenomenon. It is a process whose cause must not be reduced to a specific event. Therefore, to understand it, it is essential to consider the individual’s life trajectory, his/her subjectivity, and variables related to the historical, economic and cultural context. Given that, suicide requires an analysis of the culmination of psychosocial factors and individual experiences. The complexity of suicide lies in the way in which these factors intertwine and, above all, become potent(7). The dynamics of various risk factors in a vulnerable individual causes the onset of a psychic pain that can reach intolerable intensity, preventing the individual from seeing a possibility of its interruption other than anticipating his/her own end. This set of factors is an essential issue when studying suicide and can be discussed in the rescue of life histories of people who have committed suicides(8). Knowing the factors that predispose a person to try to take his own life is the first step to create efficient and effective prevention programs and structure public policies. That is, it is important to carry out a survey of alternatives on what to do with this public health problem through instruments and establish a course of action(9). In the analysis of factors related to suicide, the identification of mental disorders is fundamental and can help the health professional to clinically consider the risk and analyze the strategies to reduce it. Among the mental disorders related to cases of suicide, there are mood disorders, especially depression; mental and behavioral disorders resulting from the use of psychoactive substances, such as alcoholism; personality disorders, especially borderline, narcissistic and antisocial disorders; schizophrenia; and anxiety disorders(10). Among the risk factors, there are those of a psychological nature, such as recent losses, poorly elaborated childhood bereavement following parental death, family conflicts, important dates, birthday reactions, impulsive personality, striking aggressiveness, and labile humor. Sociodemographic factors may also be influential. They include: male gender; age between 15 and 35 years and older adults over 75 years old; extreme economic strata; residence in urban areas; unemployment (mainly recent job losses); retirement; social isolation; being single or separated. Some clinical conditions are considered by the Ministry of Health as risk factors because they are sometimes incapacitating, such as: intense organic diseases, chronic pain, disfiguring lesions, epilepsy, spinal cord trauma, malignant neoplasms, and presence of HIV virus(4,5). It is also necessary to put effort into suicide postvention, namely, the development of preventive actions aimed at mitigating the damage to the survivors. The anguish of those who live with the memory of a suicide must be seen with attention by health professionals because it represents a significant risk factor for the occurrence of other events of the same nature. This care is even more necessary in the absence of support networks and relationships for the bereaved person(11). In addition, suicide can have an impact on at least six people close to the deceased. These people commonly begin to have their lives deeply emotionally, socially and economically affected(12,13). Thus, it is understood that efforts to promote health and the prevention of suicidal behavior at all levels of severity go beyond health knowledge. As it is a complex and multi-determinate phenomenon, these actions must be based on risk and protective factors, as well as on the knowledge produced by professionals from different fields of knowledge. The knowledge generated by these professionals can contribute to the reduction of the rates of suicide and suicide attempt in Brazil and in the world. Health professionals and social workers from all fields of knowledge and levels of performance must be trained to assess the risk of suicide(1,3). Therefore, the Brazilian Journal in Health Promotion (Revista Brasileira em Promoção da Saúde – RBPS) seeks to collaborate significantly with the challenge of highlighting an emerging and multidimensional problem. By focusing on this theme, it aims to increase knowledge about factors and raise awareness among health professionals, Human Rights professionals and professionals from other areas involved. In this regard, suicide risk assessment is considered a challenging strategy in the context of public health and a key factor for prevention, appropriate management of the suicide crisis and health promotion. RBPS collaboration with the discussion about suicide is even more relevant because there is a lack of studies on suicide regarding factors and circumstances that promote healthy development and strengthen internal resources to cope with the suicidal crisis. Much of what is already known involves the risk and its implications in the life of the vulnerable person. To fill this gap, RBPS aims to bring up these issues, which need to be discussed by academics, practitioners and health managers, thus indicating the importance of expanding the focus of research from different approaches, perspectives and fields of knowledge. Knowing the aspects that make it possible to overcome the suicidal crisis can be a great tool for the construction of more precise prevention strategies, to which all must be attentive.