Preventing suicide and premature death by education and treatment

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Abstract

Suicide is a leading cause of mortality. It is, in principle, preventable — given the fact that we possess effective treatments for depressive illness, the major contributor to such mortality. Nonetheless, complex logistic problems have prevented the institution of successful suicide prevention programs. The present review summarizes the author’s work on the island of Gotland in Sweden, where the small size of the population permitted the institution of an educational and treatment program aimed at the general medical practitioners. The program was successful in reducing suicide rates by 60%. This was accompanied by reduction of different indices measuring depressive morbidity. Prevention was successful for as long as the program was instituted. The author provides his reflections on the public health implications of his data — particularly for Eastern Europe which is experiencing widespread stress in the workplace and in economic situations. More hypothetically, he presents his views on a serotonin-mediated ‘male suicide syndrome’.

Introduction

Depression is an endemic disease with an increasing morbidity in some European countries and increasing morbidity as well as mortality in others (Hagnell, 1990). As we know, suicide is linked to depression. Research shows that most (70%) suicides are not committed in a state of free-will and intellectual autonomy, but in a condition of clinical and deep depression where a depressive cognitive distortion can be found and realistic judgements are no longer possible (Robins, 1986). Thus, solely ‘existential’ or ‘philosophical’ suicides are in the minority, even if in the background for a depression causing a suicide often psychosocial and existential factors can be found.

Twenty to 25% of all insufficiently treated depressions lead to suicide, and depressions with associated suicidal attempts and earlier depressive periods, as well as indications for disturbed serotonin metabolism, have a 1-year mortality, exceeding that of many malignant diseases (Goodwil and Jamison, 1990). A history of depression is today considered to be as strong a suicide predictor as earlier suicide attempts (Rihmer, 1996b). Suicide is, in principle, a preventable, if major contributing psychiatric illnesses such as depression are adequately treated (Khuri and Akiskal, 1983).

General practitioners are the most important contact regarding depression and depressiogenic suicide but still today often shown to lack capability. Less than 50% of all depressions in primary care are recognised by the general practitioner, and only a small number get specific pharmacological treatment (Tylee et al., 1993). On the other hand, up to 50% of all suicidal patients are in contact with their general practitioner at the time of their death (Priest, 1944).

From Hungary, we know that high suicidality in certain regions corresponds to a low degree of recognised depression in that area and that improvements in the diagnosis of depression are seen to lower suicidal rates (Rihmer et al., 1990). In Sweden and other countries, it has been shown that only about 15% of all suicides are undergoing specific anti-depressive treatment at their time of death, despite the fact that a majority of them probably were depressed (Isacsson et al., 1994).

The increased prevalence of depression and the concomitant dramatic increase of suicide in at least some European countries has led to the question formulated by a well-known Swedish epidemiologist: ‘Are we entering an age of melancholy?’ (Hagnell et al., 1982). However, looking around Europe, it is interesting to see that despite an increasing prevalence of depression and the continuous existence of psychosocial and existential depressiogenic factors in many European societies, some countries show stable or decreasing suicide rates. The question has been raised, and more and more evidence can be found to support it, as to whether one of the factors behind this phenomenon could be the increasing and sometimes good access to the detection, treatment and monitoring of depression in these countries (Rutz, 1996).

Section snippets

The Gotland educational program

The Swedish island of Gotland has 58 000 inhabitants and is one psychiatric catchment area with one psychiatric institution. The Gotlandian society is currently changing from an agricultural structure to a more touristic and industrialised one, with its transparency offering an ideal epidemiological laboratory situation with regard to possibilities of following-up interventions in the sociological or public health structure of the island. An educational project directed at all general

Limitations of the educational program

However, a detailed study on all suicides on Gotland during the 1980s showed the shortcomings and partial failures of the project. It appeared that the main decrease in suicides was in the group of suicidal patients with a diagnosis of major depression and in those in contact with general practitioners. This was expected, due to the fact that the education was directed at general practitioners, improving their knowledge, and considered matters of depression. Also, the number of drastic and

Male depression syndrome

Today, considerable scientific information exists about the linkage between serotonin metabolism, aggression, acting-out and outbursts of anger as an associated feature of especially male major depression (Praag, 1991). There is also evidence about the significance of serotonin levels in acute suicidality and in relation to stress-related conditions (Laakman and Becker, 1996). Furthermore, there is increasing clinical experience about the usefulness of serotonin active drugs in the treatment of

Possible background factors for male depression

Studies of the Amish people show that male depression in a society where violence and abuse are strictly banned, is as prevalent as female depression. Even the number of depressive patients amongst suicidants is above 90% there, reflecting that depression in this kind of society cannot be camouflaged by symptoms of violence and abuse (Jakubaschk, 1994).

In our countries, it is still a recognised truth that females are twice as often depressed as males. Paradoxically, however, males commit

Outlook

There seems to be a male depressive suicidal serotonin-related syndrome, probably as frequent as female depression, but phenomenologically often different. New diagnostic tools are needed. Male high suicidality is still a matter of increasing concern throughout Europe; probably often caused by unrecognised and untreated depressions. However, diagnosis, treatment and good monitoring of depression counteract suicidality, and educational programmes have been shown to increase recognition and

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