1936 – W. D. Hamilton, Egyptian born British biologist, psychologist, and academic (d. 2000).
W.D. Hamilton
William Donald Hamilton FRS (01 August 1936 to 07 March 2000) was an Egyptian-born British evolutionary biologist, widely recognised as one of the most significant evolutionary theorists of the 20th century.
Hamilton became famous through his theoretical work expounding a rigorous genetic basis for the existence of altruism, an insight that was a key part of the development of the gene-centred view of evolution. He is considered one of the forerunners of sociobiology. Hamilton also published important work on sex ratios and the evolution of sex. From 1984 to his death in 2000, he was a Royal Society Research Professor at Oxford University.
1958 – Eino Kaila, Finnish philosopher and psychologist, attendant of the Vienna circle (b. 1890).
Eino Kaila
Eino Sakari Kaila (09 August 1890 to 31 July 1958) was a Finnish philosopher, critic and teacher. He worked in numerous fields including psychology (sometimes considered to be the founder of Finnish psychology), physics and theatre, and attempted to find unifying principles behind various branches of human and natural sciences.
He graduated from the University of Helsinki in 1910. In the 1920s he worked in the field of literary criticism and psychology as a professor at the University of Turku and is said to have been the first to introduce gestalt psychology to Finland. He was a part of the cultural circles of the time with the likes of Jean Sibelius and Frans Eemil Sillanpää. In 1916 he married the painter Anna Lovisa Snellman, who was granddaughter of Johan Vilhelm Snellman. He had University positions as lecturer in Helsinki and professor in Turku, and in 1930 he was appointed professor of theoretical philosophy at the University of Helsinki. In the 1930s, Kaila was closely associated with the Vienna Circle.
During World War II, Kaila lectured in Germany. In 1948 Kaila became a member of the Finnish Academy. He died in Kirkkonummi on 31 July 1958.
Erwadi fire incident is an accident that occurred on 06 August 2001, when 28 inmates of a faith-based mental asylum died in the fire. All these inmates were bound by chains at Moideen Badusha Mental Home in Erwadi Village in Tamil Nadu.
Large number of mental homes existed in Erwadi which was famous for the dargah of Quthbus Sultan Syed Ibrahim Shaheed Valiyullah, from Medina, Saudi Arabia who came to India to propagate Islam. Various people believe that holy water from the dargah and oil from the lamp burning there have the power to cure all illnesses, especially mental problems. The treatment also included frequent caning, beatings supposedly to “drive away the evil”. During the day, patients were tied to trees with thick ropes. At night, they were tied to their beds with iron chains. The patients awaited a divine command in their dreams to go back home. For the command to come, it was expected to take anything from two months to several years.
As the number of people seeking cure at dargah increased, homes were set up by individuals to reportedly take care of the patients. Most of these homes were set up by people who themselves had come to Erwadi seeking cure for their relatives.
The origins of the fire are unknown, but once it spread, there was little hope of saving most of the 45 inmates, who were chained to their beds in the ramshackle shelter in which they slept, though such shackling was against Indian law. Some inmates whose shackles were not as tight escaped, and five people were hospitalised for severe burns. The bodies of the dead were not identifiable.
Aftermath and Legacy
All mental homes of this type were closed on 13 August 2001, and more than 500 inmates were placed under government’s care. As per Supreme Court directions, a commission headed by N. Ramdas was set up to enquire into these deaths. The commission recommended that care of mentally ill people is to be improved, that anybody wishing to set up a mental home to acquire a license, and that all inmates be unchained.
In 2007, the owner of the Badsha Home for the Mentally Challenged, his wife and two relatives were sentenced to seven years imprisonment by a magistrate Court.
It is not a diagnosis, but is a symptom of some mental disorders and can also occur in response to adverse events without the presence of a mental disorder.
On suicide risk scales, the range of suicidal ideation varies from fleeting thoughts to detailed planning. Passive suicidal ideation is thinking about not wanting to live or imagining being dead. Active suicidal ideation is thinking about different ways to die or forming a plan to die.
Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered a risk factor. During 2008-2009, an estimated 8.3 million adults aged 18 and over in the United States, or 3.7% of the adult US population, reported having suicidal thoughts in the previous year. An estimated 2.2 million in the US reported having made suicide plans in 2014. Suicidal thoughts are also common among teenagers.
Suicidal ideation is generally associated with depression and other mood disorders; however, it seems to have associations with many other mental disorders, life events, and family events, all of which may increase the risk of suicidal ideation. Mental health researchers indicate that healthcare systems should provide treatment for individuals with suicidal ideation, regardless of diagnosis, because of the risk for suicidal acts and repeated problems associated with suicidal thoughts. There are a number of treatment options for people who experience suicidal ideation.
Definitions
The ICD-11 describes suicidal ideation as “thoughts, ideas, or ruminations about the possibility of ending one’s life, ranging from thinking that one would be better off dead to formulation of elaborate plans”.
The DSM-5 defines it as “thoughts about self-harm, with deliberate consideration or planning of possible techniques of causing one’s own death”.
The CDC defines suicidal ideation “as thinking about, considering, or planning suicide”.
Terminology
Another term for suicidal ideation is suicidal thoughts.
When someone who has not shown a history of suicidal ideation experiences a sudden and pronounced thought of performing an act which would necessarily lead to their own death, psychologists call this an intrusive thought. A commonly experienced example of this is the high place phenomenon, also referred to as the call of the void. The urge to jump is called “mountain fever” in Brian Biggs’ book Dear Julia.
Euphemisms related to mortal contemplation include internal struggle, voluntary death, and eating one’s gun.
Risk Factors
The risk factors for suicidal ideation can be divided into three categories:
Psychiatric disorders;
Life events; and
Family history.
Psychiatric Disorders
Suicidal ideation is a symptom for many mental disorders and can occur in response to adverse life events without the presence of a mental disorder.
There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation. For example, many individuals with borderline personality disorder exhibit recurrent suicidal behaviour and suicidal thoughts. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts. The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. These are not the only disorders that can increase risk of suicidal ideation. The disorders in which risk is increased the greatest include:
Antidepressant medications are commonly used to decrease the symptoms in patients with moderate to severe clinical depression, and some studies indicate a connection between suicidal thoughts and tendencies and taking antidepressants, increasing the risk of suicidal thoughts in some patients.
Some medications, such as selective serotonin re-uptake inhibitors (SSRIs), can have suicidal ideation as a side effect. Moreover, these drugs’ intended effects, can themselves have unintended consequence of an increased individual risk and collective rate of suicidal behaviour: Among the set of persons taking the medication, a subset feel bad enough to want to attempt suicide (or to desire the perceived results of suicide) but are inhibited by depression-induced symptoms, such as lack of energy and motivation, from following through with an attempt. Among this subset, a “sub-subset” may find that the medication alleviates their physiological symptoms (such as lack of energy) and secondary psychological symptoms (e.g. lack of motivation) before or at lower doses than it alleviates their primary psychological symptom of depressed mood. Among this group of persons, the desire for suicide or its effects persists even as major obstacles to suicidal action are removed, with the effect that the incidences of suicide attempt and of completed suicide increase.
In 2003, the US Food and Drug Administration (FDA) issued the agency’s strictest warning for manufacturers of all antidepressants (including tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) due to their association with suicidal thoughts and behaviours. Further studies disagree with the warning, especially when prescribed for adults, claiming more recent studies are inconclusive in the connection between the drugs and suicidal ideation.
Individuals with anxiety disorders who self-medicate with drugs or alcohol may also have an increased likelihood of suicidal ideation.
Life Events
Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previous listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk most significantly are:
Alcohol use disorder.
Studies have shown that individuals who binge drink, rather than drink socially, tend to have higher rates of suicidal ideation.
Certain studies associate those who experience suicidal ideation with higher alcohol consumption.
Not only do some studies show that solitary binge drinking can increase suicidal ideation, but there is a positive feedback relationship causing those who have more suicidal ideation to have more drinks per day in a solitary environment.
Minoritised gender expression and/or sexuality.
Unemployment.
Chronic illness or pain.
Death of family members or friends.
End of a relationship or being rejected by a romantic interest.
Major change in life standard (e.g. relocation abroad).
Other studies have found that tobacco use is correlated with depression and suicidal ideation.
Unplanned pregnancy.
Bullying, including cyberbullying and workplace bullying.
Previous suicide attempts.
Having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts.
Women: increased BMI increases chance of suicidal ideation.
Men: severe decrease in BMI increases chance of suicidal ideation.
In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight.
Exposure and attention to suicide related images or words.
Family History
Parents with a history of depression.
Valenstein et al. studied 340 adult offspring whose parents had depression in the past.
They found that 7% of the offspring had suicidal ideation in the previous month alone.
Abuse.
Childhood: physical, emotional and sexual abuse.
Adolescence: physical, emotional and sexual abuse.
Family violence.
Childhood residential instability.
Certain studies associate those who experience suicidal ideation with family disruption.
Relationships with Parents and Friends
According to a study conducted by Ruth X. Liu of San Diego State University, a significant connection was found between the parent-child relationships of adolescents in early, middle and late adolescence and their likelihood of suicidal ideation. The study consisted of measuring relationships between mothers and daughters, fathers and sons, mothers and sons, and fathers and daughters. The relationships between fathers and sons during early and middle adolescence show an inverse relationship to suicidal ideation. Closeness with the father in late adolescence is “significantly related to suicidal ideation”. Liu goes on to explain the relationship found between closeness with the opposite sex parent and the child’s risk of suicidal thoughts. It was found that boys are better protected from suicidal ideation if they are close to their mothers through early and late adolescence; whereas girls are better protected by having a close relationship with their father during middle adolescence.
An article published in 2010 by Zappulla and Pace found that suicidal ideation in adolescent boys is exacerbated by detachment from the parents when depression is already present in the child. Lifetime prevalence estimates of suicidal ideation among nonclinical populations of adolescents generally range from 60% and in many cases its severity increases the risk of completed suicide.
Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts.[citation needed] If signs, symptoms, or risk factors are detected early then the individual might seek treatment and help before attempting to take their own life. In a study of individuals who did commit suicide, 91% of them likely suffered from one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness. This emphasizes the importance of early detection; if a mental illness is detected, it can be treated and controlled to help prevent suicide attempts. Another study investigated strictly suicidal ideation in adolescents. This study found that depression symptoms in adolescents early as 9th grade is a predictor of suicidal ideation. Most people with long-term suicidal ideation do not seek professional help.
The previously mentioned studies point out the difficulty that mental health professionals have in motivating individuals to seek and continue treatment. Ways to increase the number of individuals who seek treatment may include:
Increasing the availability of therapy treatment in early stage.
Increasing the public’s knowledge on when psychiatric help may be beneficial to them.
Those who have adverse life conditions seem to have just as much risk of suicide as those with mental illness.
A study conducted by researchers in Australia set out to determine a course of early detection for suicidal ideation in teens stating that “risks associated with suicidality require an immediate focus on diminishing self-harming cognitions so as to ensure safety before attending to the underlying etiology of the behavior”. A Psychological Distress scale known as the K10 was administered monthly to a random sample of individuals. According to the results among the 9.9% of individuals who reported “psychological distress (all categories)” 5.1% of the same participants reported suicidal ideation. Participants who scored “very high” on the Psychological Distress scale “were 77 times more likely to report suicidal ideation than those in the low category”.
In a one-year study conducted in Finland, 41% of the patients who later committed suicide saw a health care professional, most seeing a psychiatrist. Of those, only 22% discussed suicidal intent on their last office visit. In most of the cases, the office visit took place within a week of the suicide, and most of the victims had a diagnosed depressive disorder.
There are many centers where one can receive aid in the fight against suicidal ideation and suicide. Hemelrijk et al. (2012) found evidence that assisting people with suicidal ideation via the internet versus more direct forms such as phone conversations has a greater effect. In a 2021 research study, Nguyen et al. (2021) propose that maybe the premise that suicidal ideation is a kind of illness has been an obstacle to dealing with suicidal ideation. They use a Bayesian statistical investigation, in conjunction with the mindsponge theory, to explore the processes where mental disorders have played a very minor role and conclude that there are many cases where the suicidal ideation represents a type of cost-benefit analysis for a life/death consideration, and these people may not be called “patients”.
Assessment
Assessment seeks to understand an individual by integrating information from multiple sources such as clinical interviews; medical exams and physiological measures; standardised psychometric tests and questionnaires; structured diagnostic interviews; review of records; and collateral interviews.
Interviews
Psychologists, psychiatrists, and other mental health professionals conduct clinical interviews to ascertain the nature of a patient or client’s difficulties, including any signs or symptoms of illness the person might exhibit.
Clinical interviews are “unstructured” in the sense that each clinician develops a particular approach to asking questions, without necessarily following a predefined format.
Structured (or semi-structured) interviews prescribe the questions, their order of presentation, “probes” (queries) if a patient’s response is not clear or specific enough, and a method to rate the frequency and intensity of symptoms.
Treatment of suicidal ideation can be problematic due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include:
Therapy;
Hospitalisation;
Outpatient treatment; and
Medication or other modalities.
Therapy
In psychotherapy a person explores the issues that make them feel suicidal and learns skills to help manage emotions more effectively.
Hospitalisation
Hospitalisation allows the patient to be in a secure, supervised environment to prevent the suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalised involuntarily. These circumstances are:
If an individual poses danger to self or others; and/or
If an individual is unable to care for oneself.
Hospitalisation may also be a treatment option if an individual:
Has access to lethal means (e.g. a firearm or a stockpile of pills).
Does not have social support or people to supervise them.
Has a suicide plan.
Has symptoms of a psychiatric disorder (e.g. psychosis, mania, etc.).
Outpatient Treatment
Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Being at home may improve quality of life for some patients, because they will have access to their personal belongings, and be able to come and go freely. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patient’s level of social support, impulse control and quality of judgment. After the patient passes the evaluation, they are often asked to consent to a “no-harm contract”. This is a contract formulated by the physician and the family of the patient. Within the contract, the patient agrees not to harm themselves, to continue their visits with the physician, and to contact the physician in times of need. There is some debate as to whether “no-harm” contracts are effective. These patients are then checked on routinely to assure they are maintaining their contract and avoiding dangerous activities (drinking alcohol, driving fast, and not wearing a seat belt, etc.).
Medication
Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients’ energy levels before lifting their mood. This puts them at greater risk of following through with attempting suicide. Additionally, if a person has a comorbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation.
Antidepressants may be effective. Often, SSRIs are used instead of TCAs as the latter typically have greater harm in overdose.
Antidepressants have been shown to be a very effective means of treating suicidal ideation. One correlational study compared mortality rates due to suicide to the use of SSRI antidepressants within certain counties. The counties which had higher SSRI use had a significantly lower number of deaths caused by suicide. Additionally, an experimental study followed depressed patients for one year. During the first six months of that year, the patients were examined for suicidal behaviour including suicidal ideation. The patients were then prescribed antidepressants for the six months following the first six observatory months. During the six months of treatment, experimenters found suicide ideation reduced from 47% of patients down to 14% of patients. Thus, it appears from current research that antidepressants have a helpful effect on the reduction of suicidal ideation.
Although research is largely in favour of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation. Upon the start of using antidepressants, many clinicians will note that sometimes the sudden onset of suicidal ideation may accompany treatment. This has caused the FDA to issue a warning stating that sometimes the use of antidepressants may actually increase the thoughts of suicidal ideation. Medical studies have found antidepressants help treat cases of suicidal ideation and work especially well with psychological therapy. Lithium reduces the risk of suicide in people with mood disorders. Tentative evidence finds clozapine in people with schizophrenia reduces the risk of suicide.
It is focused on reducing social stigmas and ambiguity, by bringing attention to suicide statistically and sociologically, and encouraging positive dialogue and engagement as a means to prevent suicide. Suicide awareness is linked to suicide prevention as both address suicide education and the dissemination of information to ultimately decrease the rate of suicide. Awareness is a first stage that can ease the need for prevention.
Awareness signifies a fundamental consciousness of the threat, while prevention focuses on stopping the act. Suicide awareness is not a medical engagement, but a combination of medical, social, emotional and financial counselling. Suicide awareness in adolescents focuses on the age group between 10-24 years, beginning with the onset of puberty.
Stigma and Ambiguity
Stigma is a negative impact that society can often attribute to the suicidal condition, and which can hinder and prevent positive engagement with those demonstrating suicidal behaviour. It can be experienced as self-stigma or cultural, public stigma. Self-stigma is the adverse effect of internalised prejudice, manifesting itself in reduced self-esteem, decreased self-efficacy, and a feeling of “why try” or self-deprecation (undervaluing any attempts to get a job, be social, etc. because of lack of self-worth). It is experienced not only by those facing suicidal thoughts, but also by those directly and indirectly affected such as family members and friends. Public stigma is experienced by prejudice and discrimination through public misuse of stereotypes associated with suicide.
Stigma can create a detrimental barrier for some seeking help. Research has consistently illustrated the physical link between suicide and mental illness, but ignorance and outdated beliefs can sometimes lead to these disorders being identified as a weakness or a lack of willpower. Stigma can prevent survivors of suicide attempts, and those affected by suicide deaths, from reaching out for support from professionals and advocates to make positive change.
Historical Stigma
Historically, suicide has not always been considered a societal taboo. It is critical to understand the historical context in order to raise awareness of suicide’s impact on our current culture.
Suicide was embraced as a philosophical escape by the followers of the Greek philosopher Epicurus when life’s happiness seemed lost. It has been glorified in self-immolation as an act of martyrdom as in the case of Thich Quang Duc who burned himself to death in protest of South Vietnam’s religious policy. Assisted suicide as a release from suffering can be traced back to ancient Roman society. In Jewish culture, there is a reverence for the mass suicide at Masada in the face of attack by the Roman empire, showing how suicide has sometimes had a contradictory relationship with established religion. This indicates a tension between the presentation of suicide in this historical context, and its associations in our current society with personal anguish. Today, suicide is generally perceived as an act of despair or hopelessness, or a criminal act of terrorism (suicide attack). This negative backdrop was seen in Colonial America, where suicides were considered criminal and brought to trial, even if mental illness had been present.
Suicide was identified in Roman Catholicism as a sinful act, with religious burial prohibited until 1983, when the Catholic Church altered the canon law to allow funerals and burials within the church of those who died by suicide. Today, many current societies and religious traditions condemn suicide, especially in Western culture. Public consideration of suicide in our culture is further complicated by society’s struggle to rationalize such cult events as the Jonestown mass suicide. In light of these mixed historical messages, it can be confusing for youth, presented with an academic and historical profile for suicide. The ambiguity of accepted suicide and suicidal behaviour definitions impedes progress with its utilisation of variable terminology.
Public and Cultural Stigma
Today, even though suicide is considered a public health issue by advocates, the general public often still consider it a private shame; a final desperate solution for the emotionally weak. It is stigmatised in the public perception by being associated with weakness, a “cry for attention,” shame, and depression, without understanding the contributing factors. There can be a visceral and emotional reaction to suicide rather than an attempt to understand it. This reaction is based on stereotypes (overgeneralisations about a group: weak or crazy), prejudices (agreement with stereotypical beliefs and related emotional reactions: Sue attempted suicide; ‘I’m afraid of her’), and discrimination (unfair behaviour towards the suicidal individual or group: avoidance; ‘suicidal persons should be locked up’). Erving Goffman defined courtesy stigma as the discrimination, prejudice and stereotypes which family and friends experience as suicide survivors. Public stigma is felt by medical professionals whose clients die by suicide and whose treatment is then questioned by colleagues and in lawsuits, often contributing to their being less inclined to work with suicidal patients. Property can also be stigmatized by suicide: property sellers in certain jurisdictions in the United States, in California for example, are required by law to reveal if a suicide or murder occurred on the premises in the past three years, putting suicide in the same category as homicide. These issues compound and perpetuate the public stigma of suicide, exacerbating the inclination for suicidal individuals, and their family and friends, to bury their experiences, creating a barrier to care.
Emotional Stigma
Emotionally, the negative stigma of suicide is a powerful force creating isolation and exclusion for those in suicidal crisis. The use of stereotypes, discrimination and prejudices can strip the dignity of those experiencing suicidal behaviour. It also has the potential to inhibit compassion from others and to diminish hope. Fear of being socially rejected and labelled suicidal can prevent communication and support. Distress and reduced life satisfaction are directly affected by subjective feelings of being devalued and marginalised. This develops into an internalized stigma; it creates self-stigmatised emotions, self-deprecation and self-actualisation of negative stereotypes, causing further withdrawal, reduction in quality of life and the inhibiting access to care.
This emotional stigma also affects suicide survivors: those suffering a loved one’s loss, stirring up guilt, self-blame, isolation, depression and post-traumatic stress. Subjective experiences of feeling shunned or blamed for an incident can cause those close to the victim to bury the truth of what transpired.
Awareness Factors
Suicide awareness expresses the need for open constructive dialogue as an initial step towards preventing incidents of adolescent suicide. Once the stigmas have been overcome, there is an increased possibility that education, medical care and support can provide a critical framework for those at risk. Lack of information, awareness of professional services, judgement and insensitivity from religious groups, and financial strain have all been identified as barriers to support access for those youth in suicidal crisis. The critical framework is a necessary component to implementing suicide awareness and suicide prevention, and breaking down these barriers.
Protective Factors
Protective factors are characteristics or conditions that may have a positive effect on youth and reduce the possibility of suicide attempts. These factors have not been studied in as much depth as risk factors, so there is less research. They include:
Receiving effective mental health care.
Positive social connections and support with family and peers provides coping skills.
Participation in community and social groups (i.e. religious) that foster resilience.
Optimism enables youth to engage and acquire adaptive skills in reinterpreting adverse experiences to find meaning and benefit.
Life satisfaction, spiritual wellbeing and belief that a person can survive beyond their pain is protective against suicide.
Resiliency based on adaptive coping skills has can reduce suicide risk, and research suggests these skills can be taught.
Finding hope can be a key protective factor and a catalyst for the recovery process.
It is important to note, however, that in-depth training is paramount for those involved in any service that looks to the awareness and needs of those touched by suicide.
Social Media
Suicide awareness and prevention have in the past only relied on research from clinical observation. In bringing insights, intimate experience, and real-world wisdom of suicide attempt survivors to the table, professionals, educators, other survivors and suicide attempt survivors can learn firsthand from their “lived experience.”
Media and journalism, when reporting on suicide, have moved forward in their discussion of suicide. The Recommendations for Reporting on Suicide discovered the powerful impact media coverage, newspapers and journalists can have on the perpetuating stigma of suicide, and that it can lead to greater risk of occurrence. The specific rules that media representatives should follow are:
Don’t sensationalise the suicide.
Don’t talk about the contents of the suicide note, if there is one.
Don’t describe the suicide method.
Report on suicide as a public health issue.
Don’t speculate why the person might have done it.
Don’t quote or interview police or first responders about the causes of suicide.
Describe suicide as “died by suicide” or “completed” or “killed themselves,” rather than “committed suicide.”
Don’t glamorise suicide.
This is to prevent certain types of messaging around suicide that could increase the chances of at-risk youth considering or attempting suicide. This initiative brought awareness to the sensitivity of reporting on suicide in a constructive, destigmatised method of messaging.
Social Agency
Education in a non-threatening environment is critical to a growth in awareness among adolescents. Health education is closely related to health awareness. School can be the best place to implement a suicide education program because it is the pivotal location that brings together the major influences in an adolescent’s life. Pilot programmes for awareness, and coping and resiliency training should be put into place for all adolescent school-aged children to combat life stressors and to encourage healthy communication.
Suicide prevention is a collection of efforts to reduce the risk of suicide. These efforts may occur at the individual, relationship, community, and society level. Suicide is often preventable.
Beyond direct interventions to stop an impending suicide, methods may include:
Treating mental illness.
Improving coping strategies of people who are at risk.
Reducing risk factors for suicide, such as poverty and social vulnerability.
Giving people hope for a better life after current problems are resolved.
Call a suicide hotline number.
General efforts include measures within the realms of medicine, mental health, and public health. Because protective factors such as social support and social engagement – as well as environmental risk factors such as access to lethal means – play a role in suicide, suicide is not solely a medical or mental-health issue.
Suicide prevention measures suggested by the US Centres for Disease Control and Prevention.
Interventions
Lethal Mean Reduction
Means reduction - reducing the odds that a suicide attempter will use highly lethal means -— is an important component of suicide prevention. This practice is also called “means restriction”.
It has been demonstrated that restricting lethal means can help reduce suicide rates, as delaying action until the desire to die has passed. In general, strong evidence supports the effectiveness of means restriction in preventing suicides. There is also strong evidence that restricted access at so-called suicide hotspots, such as bridges and cliffs, reduces suicides, whereas other interventions such as placing signs or increasing surveillance at these sites appears less effective. One of the most famous historical examples of means reduction is that of coal gas in the United Kingdom. Until the 1950s, the most common means of suicide in the UK was poisoning by gas inhalation. In 1958, natural gas (virtually free of carbon monoxide) was introduced, and over the next decade, comprised over 50% of gas used. As carbon monoxide in gas decreased, suicides also decreased. The decrease was driven entirely by dramatic decreases in the number of suicides by carbon monoxide poisoning. A 2020 Cochrane review on means restrictions for jumping found tentative evidence of reductions in frequency.
In the United States, firearm access is associated with increased suicide completion. About 85% of attempts with a gun result in death while most other widely used suicide attempt methods result in death less than 5% of the time. Although restrictions on access to firearms have reduced firearm suicide rates in other countries, such restrictions are difficult in the United States because the Second Amendment to the United States Constitution limits restrictions on weapons.
Crises Hotline
Crisis hotlines connect a person in distress to either a volunteer or staff member. This may occur via telephone, text messaging, online chat, or in person. Even though crisis hotlines are common, they have not been well studied. One study found a decrease in psychological pain, hopelessness, and desire to die from the beginning of the call through the next few weeks; however, the desire to die did not decrease long term.
Tromsø Bridge suicide prevention fence
As a suicide prevention initiative, signs on the Golden Gate Bridge promote special telephones that connect to a crisis hotline, as well as a 24/7 crisis text line.
Social Intervention
In the United States, the 2012 National Strategy for Suicide Prevention promotes various specific suicide prevention efforts including:
Developing groups led by professionally trained individuals for broad-based support for suicide prevention.
Screening and reducing at-risk behaviour through psychological resilience programs that promotes optimism and connectedness.
Education about suicide, including risk factors, warning signs, stigma related issues and the availability of help through social campaigns.
Increasing the proficiency of health and welfare services at responding to people in need. e.g. sponsored training for helping professionals, increased access to community linkages, employing crisis counselling organisations.
Reducing domestic violence and substance abuse through legal and empowerment means are long-term strategies.
Reducing access to convenient means of suicide and methods of self-harm. e.g. toxic substances, poisons, handguns.
Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g. aspirin.
School-based competency promoting and skill enhancing programmes.
Interventions and usage of ethical surveillance systems targeted at high-risk groups.
Improving reporting and portrayals of negative behaviour, suicidal behaviour, mental illness and substance abuse in the entertainment and news media.
Research on protective factors & development of effective clinical and professional practices.
Media Guidelines
Recommendations around media reporting of suicide include not sensationalizing the event or attributing it to a single cause. It is also recommended that media messages include suicide prevention messages such as stories of hope and links to further resources. Particular care is recommended when the person who died is famous. Specific details of the method or the location are not recommended.
There; however, is little evidence regarding the benefit of providing resources for those looking for help and the evidence for media guidelines generally is mixed at best.
TV shows and news media may also be able to help prevent suicide by linking suicide with negative outcomes such as pain for the person who has attempted suicide and their survivors, conveying that the majority of people choose something other than suicide in order to solve their problems, avoiding mentioning suicide epidemics, and avoiding presenting authorities or sympathetic, ordinary people as spokespersons for the reasonableness of suicide.
Medication
The medication lithium may be useful in certain situations to reduce the risk of suicide. Specifically it is effective at lowering the risk of suicide in those with bipolar disorder and major depressive disorder. Some antidepressant medications may increase suicidal ideation in some patients under certain conditions.
Counselling
There are multiple talk therapies that reduce suicidal thoughts and behaviours including dialectical behaviour therapy (DBT). Cognitive behaviour therapy for suicide prevention (CBT-SP) is a form of DBT adapted for adolescents at high risk for repeated suicide attempts. The brief intervention and contact technique developed by the World Health Organisation (WHO) also has shown benefit.
The WHO recommends “specific skills should be available in the education system to prevent bullying and violence in and around the school”.
Coping Planning
Coping planning is an strengths-based intervention that aims to meet the needs of people who ask for help, including those experiencing suicidal ideation. By addressing why someone asks for help, the risk assessment and management stays on what the person needs, and the needs assessment focuses on the individual needs of each person. The coping planning approach to suicide prevention draws on the health-focused theory of coping. Coping is normalised as a normal and universal human response to unpleasant emotions and interventions are considered a change continuum of low intensity (e.g. self-soothing) to high intensity support (e.g. professional help). By planning for coping, it supports people who are distressed and provides a sense of belongingness and resilience in treatment of illness. The proactive coping planning approach overcomes implications of ironic process theory. The biopsychosocial strategy of training people in healthy coping improves emotional regulation and decreases memories of unpleasant emotions. A good coping planning strategically reduces the inattentional blindness for a person while developing resilience and regulation strengths.
Strategies
The traditional approach has been to identify the risk factors that increase suicide or self-harm, though meta-analysis studies suggest that suicide risk assessment might not be useful and recommend immediate hospitalization of the person with suicidal feelings as the healthy choice. In 2001, the US Department of Health and Human Services, published the National Strategy for Suicide Prevention, establishing a framework for suicide prevention in the US The document, and its 2012 revision, calls for a public health approach to suicide prevention, focusing on identifying patterns of suicide and suicidal ideation throughout a group or population (as opposed to exploring the history and health conditions that could lead to suicide in a single individual). The ability to recognise warning signs of suicide allows individuals who may be concerned about someone they know to direct them to help.
Suicide gesture and suicidal desire (a vague wish for death without any actual intent to kill oneself) are potentially self-injurious behaviours that a person may use to attain some other ends, like to seek help, punish others, or to receive attention. This behaviour has the potential to aid an individual’s capability for suicide and can be considered as a suicide warning, when the person shows intent through verbal and behavioural signs.
A United States Army suicide prevention poster.
Specific Strategies
Suicide prevention strategies focus on reducing the risk factors and intervening strategically to reduce the level of risk. Risk and protective factors, unique to the individual can be assessed by a qualified mental health professional.
Some of the specific strategies used to address are:
Crisis intervention.
Structured counselling and psychotherapy.
Hospitalisation for those with low adherence to collaboration for help and those who require monitoring and secondary symptom treatment.
Supportive therapy like substance abuse treatment, psychotropic medication, Family psychoeducation and Access to emergency phone call care with emergency rooms, suicide prevention hotlines, etc.
Restricting access to lethality of suicide means through policies and laws.
Creating and using crisis cards, an easy-to-read uncluttered card that describes a list of activities one should follow in crisis until the positive behaviour responses settles in the personality.
Person-centred life skills training. e.g. problem solving.
Registering with support groups like Alcoholics Anonymous, Suicide Bereavement Support Group, a religious group with flow rituals, etc.
Therapeutic recreational therapy that improves mood.
Motivating self-care activities like physical exercise’s and meditative relaxation.
Psychotherapies that have shown most successful or evidence based are dialectical behaviour therapy (DBT), which has shown to be helpful in reducing suicide attempts and reducing hospitalisations for suicidal ideation and cognitive behavioural therapy (CBT), which has shown to improve problem-solving and coping abilities.
After a Suicide
Postvention is for people affected by an individual’s suicide. This intervention facilitates grieving, guides to reduce guilt, anxiety, and depression and to decrease the effects of trauma. Bereavement is ruled out and promoted for catharsis and supporting their adaptive capacities before intervening depression and any psychiatric disorders. Postvention is also provided to minimise the risk of imitative or copycat suicides, but there is a lack of evidence based standard protocol. But the general goal of the mental health practitioner is to decrease the likelihood of others identifying with the suicidal behaviour of the deceased as a coping strategy in dealing with adversity.
Risk Assessment
Warning Signs
Warning signs of suicide can allow individuals to direct people who may be considering suicide to get help.
Behaviours that may be warning signs include:
Talking about wanting to die or wanting to kill themselves.
Suicidal ideation: thinking, talking, or writing about suicide, planning for suicide.
Substance abuse.
Feelings of purposelessness.
Anxiety, agitation, being unable to sleep, or sleeping all the time.
Feelings of being trapped.
Feelings of hopelessness.
Social withdrawal.
Displaying extreme mood swings, suddenly changing from sad to very calm or happy.
Recklessness or impulsiveness, taking risks that could lead to death, such as driving extremely fast.
Mood changes including depression.
Feelings of uselessness.
Settling outstanding affairs, giving away prized or valuable possessions, or making amends when they are otherwise not expected to die (as an example, this behaviour would be typical in a terminal cancer patient but not a healthy young adult).
Strong feelings of pain, either emotional or physical considering oneself burdensome.
Increased use of drugs or alcohol.
Additionally, the National Institute for Mental Health includes feeling burdensome, and strong feelings of pain – either emotional or physical – as warning signs that someone may attempt suicide.
Direct Talks
An effective way to assess suicidal thoughts is to talk with the person directly, to ask about depression, and assess suicide plans as to how and when it might be attempted. Contrary to popular misconceptions, talking with people about suicide does not plant the idea in their heads. However, such discussions and questions should be asked with care, concern and compassion. The tactic is to reduce sadness and provide assurance that other people care. The WHO advises to not say everything will be all right nor make the problem seem trivial, nor give false assurances about serious issues. The discussions should be gradual and specifically executed when the person is comfortable about discussing their feelings. ICARE (Identify the thought, Connect with it, Assess evidences for it, Restructure the thought in positive light, Express or provide room for expressing feelings from the restructured thought) is a model of approach used here.
Screening
The US Surgeon General has suggested that screening to detect those at risk of suicide may be one of the most effective means of preventing suicide in children and adolescents. There are various screening tools in the form of self-report questionnaires to help identify those at risk such as the Beck Hopelessness Scale and Is Path Warm?. A number of these self-report questionnaires have been tested and found to be effective for use among adolescents and young adults. There is however a high rate of false-positive identification and those deemed to be at risk should ideally have a follow-up clinical interview. The predictive quality of these screening questionnaires has not been conclusively validated so it is not possible to determine if those identified at risk of suicide will actually die by suicide. Asking about or screening for suicide does not create or increase the risk.
In approximately 75% of completed suicides, the individuals had seen a physician within the year before their death, including 45 to 66% within the prior month. Approximately 33 to 41% of those who completed suicide had contact with mental health services in the prior year, including 20 percent within the prior month. These studies suggest an increased need for effective screening. Many suicide risk assessment measures are not sufficiently validated, and do not include all three core suicidality attributes (i.e. suicidal affect, behaviour, and cognition). A study published by the University of New South Wales has concluded that asking about suicidal thoughts cannot be used as a reliable predictor of suicide risk.
Underlying Condition
The conservative estimate is that 10% of individuals with psychiatric disorders may have an undiagnosed medical condition causing their symptoms, with some estimates stating that upwards of 50% may have an undiagnosed medical condition which if not causing is exacerbating their psychiatric symptoms. Illegal drugs and prescribed medications may also produce psychiatric symptoms. Effective diagnosis and if necessary medical testing which may include neuroimaging to diagnose and treat any such medical conditions or medication side effects may reduce the risk of suicidal ideation as a result of psychiatric symptoms, most often including depression, which are present in up to 90-95% of cases.
Risk Factors
All people can be at risk of suicide. Risk factors that contribute to someone feeling suicidal or making a suicide attempt may include:
Depression, other mental disorders, or substance abuse disorder.
Certain medical conditions.
Chronic pain.
A prior suicide attempt.
Family history of a mental disorder or substance abuse.
Family history of suicide.
Family violence, including physical or sexual abuse.
Having guns or other firearms in the home.
Having recently been released from prison or jail.
Being exposed to others’ suicidal behaviour, such as that of family members, peers, or celebrities.
Being male.
Support Organisations
Many non-profit organisations exist, such as the American Foundation for Suicide Prevention in the United States, which serve as crisis hotlines; it has benefited from at least one crowd-sourced campaign. The first documented programme aimed at preventing suicide was initiated in 1906 in both New York, the National Save-A-Life League and in London, the Suicide Prevention Department of the Salvation Army.
Suicide prevention interventions fall into two broad categories: prevention targeted at the level of the individual and prevention targeted at the level of the population. To identify, review, and disseminate information about best practices to address specific objectives of the National Strategy Best Practices Registry (BPR) was initiated. The Best Practices Registry of Suicide Prevention Resource Centre is a registry of various suicide intervention programmes maintained by the American Association of Suicide Prevention. The programs are divided, with those in Section I listing evidence-based programmes: interventions which have been subjected to in depth review and for which evidence has demonstrated positive outcomes. Section III programmes have been subjected to review.
If you or someone you know displays sign or symptoms of suicidal thoughts or actions these prevention organisations are available:
Befrienders Worldwide.
American Foundation for Suicide Prevention.
Campaign Against Living Miserably.
Crisis Text Line.
International Association for Suicide Prevention.
The Jed Foundation.
National Suicide Prevention Lifeline.
Samaritans.
SOSAD Ireland.
Suicide Prevention Action Network USA.
The Trevor Project.
Trans Lifeline.
Economics
In the United States it is estimated that an episode of suicide results in costs of about $1.3 million. Money spending on appropriated interventions is estimated to result in a decrease in economic losses that are 2.5 fold greater than the amount spent.
Substance dependence, also known as drug dependence, is a biopsychological situation where-by an individual’s functionality is dependent on the necessitated re-consumption of a psychoactive substance, because of an adaptive state that has developed with the individual from psychoactive substance consumption, which results in the experience of withdrawal, which necessitates the re-consumption of the drug.
A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioural and drug addictions, but not dependence.
The International Classification of Diseases classifies substance dependence as a mental and behavioural disorder. Within the framework of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), substance dependence is redefined as a drug addiction, and can be diagnosed without the occurrence of a withdrawal syndrome. It was described accordingly: “When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders.” In the DSM-5 (released in 2013), substance abuse and substance dependence have been merged into the category of substance use disorders and they no longer exist as individual diagnoses.
Brief History
The phenomenon of drug addiction has occurred to some degree throughout recorded history (see “Opium”). Modern agricultural practices, improvements in access to drugs, advancements in biochemistry, and dramatic increases in the recommendation of drug usage by clinical practitioners have exacerbated the problem significantly in the 20th century. Improved means of active biological agent manufacture and the introduction of synthetic compounds, such as fentanyl and methamphetamine, are also factors contributing to drug addiction.
For the entirety of US history, drugs have been used by some members of the population. In the country’s early years, most drug use by the settlers was of alcohol or tobacco.
The 19th century saw opium usage in the US become much more common and popular. Morphine was isolated in the early 19th century, and came to be prescribed commonly by doctors, both as a painkiller and as an intended cure for opium addiction. At the time, the prevailing medical opinion was that the addiction process occurred in the stomach, and thus it was hypothesized that patients would not become addicted to morphine if it was injected into them via a hypodermic needle, and it was further hypothesized that this might potentially be able to cure opium addiction. However, many people did become addicted to morphine. In particular, addiction to opium became widespread among soldiers fighting in the Civil War, who very often required painkillers and thus were very often prescribed morphine. Women were also very frequently prescribed opiates, and opiates were advertised as being able to relieve “female troubles”.
Many soldiers in the Vietnam War were introduced to heroin and developed a dependency on the substance which survived even when they returned to the US. Technological advances in travel meant that this increased demand for heroin in the US could now be met. Furthermore, as technology advanced, more drugs were synthesized and discovered, opening up new avenues to substance dependency.
Terms
Addiction: A biopsychosocial disorder characterised by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences.
Addictive drug: Psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug’s effect on brain reward systems.
Dependence: An adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g. drug intake).
Drug sensitisation or reverse tolerance: The escalating effect of a drug resulting from repeated administration at a given dose.
Drug withdrawal: Symptoms that occur upon cessation of repeated drug use.
Physical dependence: Dependence that involves persistent physical-somatic withdrawal symptoms (e.g. fatigue and delirium tremens).
Psychological dependence: Dependence that involves emotional-motivational withdrawal symptoms (e.g. dysphoria and anhedonia).
Reinforcing stimuli: Stimuli that increase the probability of repeating behaviours paired with them.
Rewarding stimuli: Stimuli that the brain interprets as intrinsically positive and desirable or as something to approach.
Sensitisation: An amplified response to a stimulus resulting from repeated exposure to it.
Substance use disorder: A condition in which the use of substances leads to clinically and functionally significant impairment or distress.
Tolerance: The diminishing effect of a drug resulting from repeated administration at a given dose.
Withdrawal
Withdrawal is the body’s reaction to abstaining from a substance upon which a person has developed a dependence syndrome. When dependence has developed, cessation of substance-use produces an unpleasant state, which promotes continued drug use through negative reinforcement; i.e. the drug is used to escape or avoid re-entering the associated withdrawal state. The withdrawal state may include physical-somatic symptoms (physical dependence), emotional-motivational symptoms (psychological dependence), or both. Chemical and hormonal imbalances may arise if the substance is not re-introduced. Psychological stress may also result if the substance is not re-introduced.
Infants also suffer from substance withdrawal, known as neonatal abstinence syndrome (NAS), which can have severe and life-threatening effects. Addiction to drugs such as alcohol in expectant mothers not only causes NAS, but also an array of other issues which can continually affect the infant throughout their lifetime.
Risk Factors
Dependence Potential
The dependence potential of a drug varies from substance to substance, and from individual to individual. Dose, frequency, pharmacokinetics of a particular substance, route of administration, and time are critical factors for developing a drug dependence.
An article in The Lancet compared the harm and dependence liability of 20 drugs, using a scale from zero to three for physical dependence, psychological dependence, and pleasure to create a mean score for dependence. Selected results can be seen in the chart below.
Mental health as a risk factor for illicit drug dependency or abuse.
Capture rates enumerate the percentage of users who reported that they had become dependent to their respective drug at some point (Drug/% users):
Cannabis: 9%.
Alcohol: 15.4%.
Cocaine: 16.7%.
Heroin: 23.1%.
Tobacco: 31.9%.
Biomolecular Mechanisms
Psychological Dependence
Two factors have been identified as playing pivotal roles in psychological dependence: the neuropeptide “corticotropin-releasing factor” (CRF) and the gene transcription factor “cAMP response element binding protein” (CREB). The nucleus accumbens (NAcc) is one brain structure that has been implicated in the psychological component of drug dependence. In the NAcc, CREB is activated by cyclic adenosine monophosphate (cAMP) immediately after a high and triggers changes in gene expression that affect proteins such as dynorphin; dynorphin peptides reduce dopamine release into the NAcc by temporarily inhibiting the reward pathway. A sustained activation of CREB thus forces a larger dose to be taken to reach the same effect. In addition, it leaves the user feeling generally depressed and dissatisfied, and unable to find pleasure in previously enjoyable activities, often leading to a return to the drug for another dose.
In addition to CREB, it is hypothesized that stress mechanisms play a role in dependence. Koob and Kreek have hypothesized that during drug use, CRF activates the hypothalamic-pituitary-adrenal axis (HPA axis) and other stress systems in the extended amygdala. This activation influences the dysregulated emotional state associated with psychological dependence. They found that as drug use escalates, so does the presence of CRF in human cerebrospinal fluid. In rat models, the separate use of CRF inhibitors and CRF receptor antagonists both decreased self-administration of the drug of study. Other studies in this review showed dysregulation of other neuropeptides that affect the HPA axis, including enkephalin which is an endogenous opioid peptide that regulates pain. It also appears that µ-opioid receptors, which enkephalin acts upon, is influential in the reward system and can regulate the expression of stress hormones.
Increased expression of AMPA receptors in nucleus accumbens MSNs is a potential mechanism of aversion produced by drug withdrawal.
Physical Dependence
Upregulation of the cAMP signal transduction pathway in the locus coeruleus by CREB has been implicated as the mechanism responsible for certain aspects of opioid-induced physical dependence. The temporal course of withdrawal correlates with LC firing, and administration of α2 agonists into the locus coeruleus leads to a decrease in LC firing and norepinephrine release during withdrawal. A possible mechanism involves upregulation of NMDA receptors, which is supported by the attenuation of withdraw by NMDA receptor antagonists. Physical dependence on opioids has been observed to produce an elevation of extracellular glutamate, an increase in NMDA receptor subunits NR1 and NR2A, phosphorylated CaMKII, and c-fos. Expression of CaMKII and c-fos is attenuated by NMDA receptor antagonists, which is associated with blunted withdrawal in adult rats, but not neonatal rats While acute administration of opioids decreases AMPA receptor expression and depresses both NMDA and non-NMDA excitatory postsynaptic potentials in the NAC, withdrawal involves a lowered threshold for LTP and an increase in spontaneous firing in the NAc.
Diagnosis
DSM Classification
“Substance dependence”, as defined in the DSM-IV, can be diagnosed with physiological dependence, evidence of tolerance or withdrawal, or without physiological dependence. DSM-IV substance dependencies include:
303.90 Alcohol dependence.
304.00 Opioid dependence.
304.10 Sedative, hypnotic, or anxiolytic dependence (including benzodiazepine dependence and barbiturate dependence).
Addiction is a complex but treatable condition. It is characterized by compulsive drug craving, seeking, and use that persists even if the user is aware of severe adverse consequences. For some people, addiction becomes chronic, with periodic relapses even after long periods of abstinence. As a chronic, relapsing disease, addiction may require continued treatments to increase the intervals between relapses and diminish their intensity. While some with substance issues recover and lead fulfilling lives, others require ongoing additional support. The ultimate goal of addiction treatment is to enable an individual to manage their substance misuse; for some this may mean abstinence. Immediate goals are often to reduce substance abuse, improve the patient’s ability to function, and minimise the medical and social complications of substance abuse and their addiction; this is called “harm reduction”.
Treatments for addiction vary widely according to the types of drugs involved, amount of drugs used, duration of the drug addiction, medical complications and the social needs of the individual. Determining the best type of recovery programme for an addicted person depends on a number of factors, including: personality, drugs of choice, concept of spirituality or religion, mental or physical illness, and local availability and affordability of programmes.
Many different ideas circulate regarding what is considered a successful outcome in the recovery from addiction. Programs that emphasize controlled drinking exist for alcohol addiction. Opiate replacement therapy has been a medical standard of treatment for opioid addiction for many years.
Treatments and attitudes toward addiction vary widely among different countries. In the US and developing countries, the goal of commissioners of treatment for drug dependence is generally total abstinence from all drugs. Other countries, particularly in Europe, argue the aims of treatment for drug dependence are more complex, with treatment aims including reduction in use to the point that drug use no longer interferes with normal activities such as work and family commitments; shifting the addict away from more dangerous routes of drug administration such as injecting to safer routes such as oral administration; reduction in crime committed by drug addicts; and treatment of other comorbid conditions such as AIDS, hepatitis and mental health disorders. These kinds of outcomes can be achieved without eliminating drug use completely. Drug treatment programmes in Europe often report more favourable outcomes than those in the US because the criteria for measuring success are functional rather than abstinence-based. The supporters of programmes with total abstinence from drugs as a goal believe that enabling further drug use means prolonged drug use and risks an increase in addiction and complications from addiction.
Residential
Residential drug treatment can be broadly divided into two camps: 12-step programs and therapeutic communities. 12-step programs are a nonclinical support-group and spiritual-based approach to treating addiction. Therapy typically involves the use of cognitive-behavioural therapy, an approach that looks at the relationship between thoughts, feelings and behaviours, addressing the root cause of maladaptive behaviour. Cognitive-behavioural therapy treats addiction as a behaviour rather than a disease, and so is subsequently curable, or rather, unlearnable. Cognitive-behavioural therapy programmes recognise that, for some individuals, controlled use is a more realistic possibility.
One of many recovery methods are 12-step recovery programs, with prominent examples including Alcoholics Anonymous, Narcotics Anonymous, Drug Addicts Anonymous and Pills Anonymous. They are commonly known and used for a variety of addictions for the individual addicted and the family of the individual. Substance-abuse rehabilitation (rehab) centres offer a residential treatment programme for some of the more seriously addicted, in order to isolate the patient from drugs and interactions with other users and dealers. Outpatient clinics usually offer a combination of individual counselling and group counselling. Frequently, a physician or psychiatrist will prescribe medications in order to help patients cope with the side effects of their addiction. Medications can help immensely with anxiety and insomnia, can treat underlying mental disorders (cf. self-medication hypothesis, Khantzian 1997) such as depression, and can help reduce or eliminate withdrawal symptomology when withdrawing from physiologically addictive drugs. Some examples are using benzodiazepines for alcohol detoxification, which prevents delirium tremens and complications; using a slow taper of benzodiazepines or a taper of phenobarbital, sometimes including another antiepileptic agent such as gabapentin, pregabalin, or valproate, for withdrawal from barbiturates or benzodiazepines; using drugs such as baclofen to reduce cravings and propensity for relapse amongst addicts to any drug, especially effective in stimulant users, and alcoholics (in which it is nearly as effective as benzodiazepines in preventing complications); using clonidine, an alpha-agonist, and loperamide for opioid detoxification, for first-time users or those who wish to attempt an abstinence-based recovery (90% of opioid users relapse to active addiction within eight months or are multiple relapse patients); or replacing an opioid that is interfering with or destructive to a user’s life, such as illicitly-obtained heroin, dilaudid, or oxycodone, with an opioid that can be administered legally, reduces or eliminates drug cravings, and does not produce a high, such as methadone or buprenorphine – opioid replacement therapy – which is the gold standard for treatment of opioid dependence in developed countries, reducing the risk and cost to both user and society more effectively than any other treatment modality (for opioid dependence), and shows the best short-term and long-term gains for the user, with the greatest longevity, least risk of fatality, greatest quality of life, and lowest risk of relapse and legal issues including arrest and incarceration.
In a survey of treatment providers from three separate institutions, the National Association of Alcoholism and Drug Abuse Counsellors, Rational Recovery Systems and the Society of Psychologists in Addictive Behaviours, measuring the treatment provider’s responses on the “Spiritual Belief Scale” (a scale measuring belief in the four spiritual characteristics of AA identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider’s responses on the “Addiction Belief Scale” (a scale measuring adherence to the disease model or the free-will model of addiction).
Behavioural Programming
Behavioural programming is considered critical in helping those with addictions achieve abstinence. From the applied behaviour analysis literature and the behavioural psychology literature, several evidence based intervention programmes have emerged:
Behavioural marital therapy;
Community reinforcement approach;
Cue exposure therapy; and
Contingency management strategies.
In addition, the same author suggests that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious. Community reinforcement has both efficacy and effectiveness data. In addition, behavioural treatment such as community reinforcement and family training (CRAFT) have helped family members to get their loved ones into treatment. Motivational intervention has also shown to be an effective treatment for substance dependence.
Alternative Therapies
Alternative therapies, such as acupuncture, are used by some practitioners to alleviate the symptoms of drug addiction. In 1997, the American Medical Association (AMA) adopted, as policy, the following statement after a report on a number of alternative therapies including acupuncture:
There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.
Treatment and Issues
Medical professionals need to apply many techniques and approaches to help patients with substance related disorders. Using a psychodynamic approach is one of the techniques that psychologists use to solve addiction problems. In psychodynamic therapy, psychologists need to understand the conflicts and the needs of the addicted person, and also need to locate the defects of their ego and defence mechanisms. Using this approach alone has proven to be ineffective in solving addiction problems. Cognitive and behavioural techniques should be integrated with psychodynamic approaches to achieve effective treatment for substance related disorders. Cognitive treatment requires psychologists to think deeply about what is happening in the brain of an addicted person. Cognitive psychologists should zoom in to neural functions of the brain and understand that drugs have been manipulating the dopamine reward centre of the brain. From this particular state of thinking, cognitive psychologists need to find ways to change the thought process of the addicted person.
Cognitive Approach
There are two routes typically applied to a cognitive approach to substance abuse: tracking the thoughts that pull patients to addiction and tracking the thoughts that prevent them from relapsing. Behavioural techniques have the widest application in treating substance related disorders. Behavioural psychologists can use the techniques of “aversion therapy”, based on the findings of Pavlov’s classical conditioning. It uses the principle of pairing abused substances with unpleasant stimuli or conditions; for example, pairing pain, electrical shock, or nausea with alcohol consumption. The use of medications may also be used in this approach, such as using disulfiram to pair unpleasant effects with the thought of alcohol use. Psychologists tend to use an integration of all these approaches to produce reliable and effective treatment. With the advanced clinical use of medications, biological treatment is now considered to be one of the most efficient interventions that psychologists may use as treatment for those with substance dependence.
Medicinal Approach
Another approach is to use medicines that interfere with the functions of the drugs in the brain. Similarly, one can also substitute the misused substance with a weaker, safer version to slowly taper the patient off of their dependence. Such is the case with Suboxone in the context of opioid dependence. These approaches are aimed at the process of detoxification. Medical professionals weigh the consequences of withdrawal symptoms against the risk of staying dependent on these substances. These withdrawal symptoms can be very difficult and painful times for patients. Most will have steps in place to handle severe withdrawal symptoms, either through behavioural therapy or other medications. Biological intervention should be combined with behavioural therapy approaches and other non-pharmacological techniques. Group therapies including anonymity, teamwork and sharing concerns of daily life among people who also suffer from substance dependence issues can have a great impact on outcomes. However, these programs proved to be more effective and influential on persons who did not reach levels of serious dependence.
Society and Culture
Demographics
Internationally, the US and Eastern Europe contain the countries with the highest substance abuse disorder occurrence (5-6%). Africa, Asia, and the Middle East contain countries with the lowest worldwide occurrence (1-2%). Across the globe, those that tended to have a higher prevalence of substance dependence were in their twenties, unemployed, and men. The National Survey on Drug Use and Health (NSDUH) reports on substance dependence/abuse rates in various population demographics across the US When surveying populations based on race and ethnicity in those ages 12 and older, it was observed that American Indian/Alaskan Natives were among the highest rates and Asians were among the lowest rates in comparison to other racial/ethnic groups.
When surveying populations based on gender in those ages 12 and older, it was observed that males had a higher substance dependence rate than females. However, the difference in the rates are not apparent until after age 17. Drug and Alcohol Dependence reports that older adults abuse drugs including alcohol at a rate of 15-20%. It’s estimated that 52 million Americans beyond 12 years old have abused a substance.
Alcohol dependence or abuse rates were shown to have no correspondence with any person’s education level when populations were surveyed in varying degrees of education from ages 26 and older. However, when it came to illicit drug use there was a correlation, in which those that graduated from college had the lowest rates. Furthermore, dependence rates were greater in unemployed populations ages 18 and older and in metropolitan-residing populations ages 12 and older.
The National Opinion Research Centre at the University of Chicago reported an analysis on disparities within admissions for substance abuse treatment in the Appalachian region, which comprises 13 states and 410 counties in the Eastern part of the US While their findings for most demographic categories were similar to the national findings by NSDUH, they had different results for racial/ethnic groups which varied by sub-regions. Overall, Whites were the demographic with the largest admission rate (83%), while Alaskan Native, American Indian, Pacific Islander, and Asian populations had the lowest admissions (1.8%).
Legislation
Depending on the jurisdiction, addictive drugs may be legal, legal only as part of a government sponsored study, illegal to use for any purpose, illegal to sell, or even illegal to merely possess.
Most countries have legislation which brings various drugs and drug-like substances under the control of licensing systems. Typically this legislation covers any or all of the opiates, amphetamines, cannabinoids, cocaine, barbiturates, benzodiazepines, anaesthetics, hallucinogenics, derivatives and a variety of more modern synthetic drugs. Unlicensed production, supply or possession is a criminal offence.
Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, while others rarely cause any form of compulsive need whatsoever. Also, under legislation specifically about drugs, alcohol and nicotine are not usually included.
Although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vulnerable to both criminal abuse and legal punishment.
It is unclear whether laws against illegal drug use do anything to stem usage and dependency. In jurisdictions where addictive drugs are illegal, they are generally supplied by drug dealers, who are often involved with organized crime. Even though the cost of producing most illegal addictive substances is very low, their illegality combined with the addict’s need permits the seller to command a premium price, often hundreds of times the production cost. As a result, addicts sometimes turn to crime to support their habit.
United States
In the United States, drug policy is primarily controlled by the federal government. The Department of Justice’s Drug Enforcement Administration (DEA) enforces controlled substances laws and regulations. The Department of Health and Human Services’ Food and Drug Administration (FDA) serve to protect and promote public health by controlling the manufacturing, marketing, and distribution of products, like medications.
The United States’ approach to substance abuse has shifted over the last decade, and is continuing to change. The federal government was minimally involved in the 19th century. The federal government transitioned from using taxation of drugs in the early 20th century to criminalising drug abuse with legislations and agencies like the Federal Bureau of Narcotics (FBN) mid-20th century in response to the nation’s growing substance abuse issue. These strict punishments for drug offenses shined light on the fact that drug abuse was a multi-faceted problem. The President’s Advisory Commission on Narcotics and Drug Abuse of 1963 addressed the need for a medical solution to drug abuse. However, drug abuse continued to be enforced by the federal government through agencies such as the DEA and further legislations such as The Controlled Substances Act (CSA), the Comprehensive Crime Control Act of 1984, and Anti-Drug Abuse Acts.
In the past decade, there have been growing efforts through state and local legislations to shift from criminalizing drug abuse to treating it as a health condition requiring medical intervention. 28 states currently allow for the establishment of needle exchanges. Florida, Iowa, Missouri and Arizona all introduced bills to allow for the establishment of needle exchanges in 2019. These bills have grown in popularity across party lines since needle exchanges were first introduced in Amsterdam in 1983. In addition, AB-186 Controlled substances: overdose prevention program was introduced to operate safe injection sites in the City and County of San Francisco. The bill was vetoed on 30 September 2018 by California Governor Jerry Brown. The legality of these sites are still in discussion, so there are no such sites in the United States yet. However, there is growing international evidence for successful safe injection facilities.
1951 – Susan Blackmore, English psychologist and theorist.
Susan Blackmore
Susan Jane Blackmore (born 29 July 1951) is a British writer, lecturer, sceptic, broadcaster, and a Visiting Professor at the University of Plymouth. Her fields of research include memetics, parapsychology, consciousness, and she is best known for her book The Meme Machine. She has written or contributed to over 40 books and 60 scholarly articles and is a contributor to The Guardian newspaper.
Career
In 1973, Susan Blackmore graduated from St Hilda’s College, Oxford, with a BA (Hons) degree in psychology and physiology. She received an MSc in environmental psychology in 1974 from the University of Surrey. In 1980, she earned a PhD in parapsychology from the same university; her doctoral thesis was entitled “Extrasensory Perception as a Cognitive Process.” In the 1980s, Blackmore conducted psychokinesis experiments to see if her baby daughter, Emily, could influence a random number generator. The experiments were mentioned in the book to accompany the TV series Arthur C. Clarke’s World of Strange Powers. Blackmore taught at the University of the West of England in Bristol until 2001. After spending time in research on parapsychology and the paranormal, her attitude towards the field moved from belief to scepticism. In 1987, Blackmore wrote that she had an out-of-body experience shortly after she began running the Oxford University Society for Psychical Research (OUSPR):
Within a few weeks I had not only learned a lot about the occult and the paranormal, but I had an experience that was to have a lasting effect on me—an out-of-body experience (OBE). It happened while I was wide awake, sitting talking to friends. It lasted about three hours and included everything from a typical “astral projection,” complete with silver cord and duplicate body, to free-floating flying, and finally to a mystical experience. It was clear to me that the doctrine of astral projection, with its astral bodies floating about on astral planes, was intellectually unsatisfactory. But to dismiss the experience as “just imagination” would be impossible without being dishonest about how it had felt at the time. It had felt quite real. Everything looked clear and vivid, and I was able to think and speak quite clearly.
In a New Scientist article in 2000, she again wrote of this:
It was just over thirty years ago that I had the dramatic out-of-body experience that convinced me of the reality of psychic phenomena and launched me on a crusade to show those closed-minded scientists that consciousness could reach beyond the body and that death was not the end. Just a few years of careful experiments changed all that. I found no psychic phenomena—only wishful thinking, self-deception, experimental error and, occasionally, fraud. I became a sceptic.
She is a Fellow of the Committee for Sceptical Inquiry (formerly CSICOP) and in 1991, was awarded the CSICOP Distinguished Sceptic Award.
In an article in The Observer on sleep paralysis Barbara Rowland wrote that Blackmore, “carried out a large study between 1996 and 1999 of ‘paranormal’ experiences, most of which clearly fell within the definition of sleep paralysis.”
Blackmore has done research on memes (which she wrote about in her popular book The Meme Machine) and evolutionary theory. Her book Consciousness: An Introduction (2004), is a textbook that broadly covers the field of consciousness studies. She was on the editorial board for the Journal of Memetics (an electronic journal) from 1997 to 2001, and has been a consulting editor of the Sceptical Inquirer since 1998.
She acted as one of the psychologists who was featured on the British version of the television show Big Brother,[16] speaking about the psychological state of the contestants. She is a Patron of Humanists UK.
Blackmore debated Christian apologist Alister McGrath in 2007, on the existence of God. In 2018 she debated Jordan Peterson on whether God is needed to make sense of life.
In 2017, Blackmore appeared at the 17th European Skeptics Congress (ESC) in Old Town Wrocław, Poland. This congress was organised by the Klub Sceptyków Polskich (Polish Skeptics Club) and Český klub skeptiků Sisyfos (Czech Skeptic’s Club). At the congress she joined Scott Lilienfeld, Zbyněk Vybíral and Tomasz Witkowski on a panel on sceptical psychology which was chaired by Michael Heap.
Tacrine is a centrally acting acetylcholinesterase inhibitor and indirect cholinergic agonist (parasympathomimetic).
It was the first centrally acting cholinesterase inhibitor approved for the treatment of Alzheimer’s disease, and was marketed under the trade name Cognex. Tacrine was first synthesised by Adrien Albert at the University of Sydney in 1949. It also acts as a histamine N-methyltransferase inhibitor.
Clinical Use
Tacrine was the prototypical cholinesterase inhibitor for the treatment of Alzheimer’s disease. William K. Summers received a patent for this use in 1989. Studies found that it may have a small beneficial effect on cognition and other clinical measures, though study data was limited and the clinical relevance of these findings was unclear.
Tacrine has been discontinued in the US in 2013, due to concerns over safety.
Tacrine was also described as an analeptic agent used to promote mental alertness.
Adverse Effects
Very common (>10% incidence) adverse effects include:
Increased LFTs.
Nausea.
Vomiting.
Diarrhoea.
Headache.
Dizziness.
Common (1-10% incidence) adverse effects include:
Indigestion.
Belching.
Abdominal pain.
Myalgia – muscle pain.
Confusion.
Ataxia – decreased control over bodily movements.
Insomnia.
Rhinitis.
Rash.
Fatigue.
Weight loss.
Constipation.
Somnolence.
Tremor.
Anxiety.
Urinary incontinence.
Hallucinations.
Agitation.
Conjunctivitis (a link to tacrine treatment has not been conclusively proven).
Hepatotoxicity (that is toxic effects on the liver).
Ototoxicity (hearing/ear damage; a link to tacrine treatment has not been conclusively proven).
Seizures.
Agranulocytosis (a link between treatment and this adverse effect has not been proven) – a potentially fatal drop in white blood cells, the body’s immune/defensive cells.
Taste changes.
Unknown incidence adverse effects include:
Urinary tract infection.
Delirium.
Other optic effects such as glaucoma, cataracts, etc. (also not conclusively linked to tacrine treatment).
Depression.
Suicidal ideation and behaviour.
Hypotension.
Bradycardia.
Overdose
As stated above, overdosage of tacrine may give rise to severe side effects such as nausea, vomiting, salivation, sweating, bradycardia, hypotension, collapse, and convulsions. Atropine is a popular treatment for overdose.
Pharmacokinetics
Major form of metabolism is in the liver via hydroxylation of benzylic carbon by CYP1A2. This forms the major metabolite 1-hydroxy-tacrine (velnacrine) which is still active.
Thioridazine (Mellaril or Melleril) is a first generation antipsychotic drug belonging to the phenothiazine drug group and was previously widely used in the treatment of schizophrenia and psychosis.
The branded product was withdrawn worldwide in 2005 because it caused severe cardiac arrhythmias. However, generic versions are still available in the US.
Brief History
The manufacturer Novartis/Sandoz/Wander of the brands of thioridazine, Mellaril in the US and Canada and Melleril in Europe, discontinued the drug worldwide in June 2005.
Indications
Thioridazine was voluntarily discontinued by its manufacturer, Novartis, worldwide because it caused severe cardiac arrhythmias.
Its primary use in medicine was the treatment of schizophrenia. It was also tried with some success as a treatment for various psychiatric symptoms seen in people with dementia, but chronic use of thioridazine and other anti-psychotics in people with dementia is not recommended.
Side Effects
Thioridazine prolongs the QTc interval in a dose-dependent manner. It produces significantly less extrapyramidal side effects than most first-generation antipsychotics. Its use, along with the use of other typical antipsychotics, has been associated with degenerative retinopathies. It has a higher propensity for causing anticholinergic side effects coupled with a lower propensity for causing extrapyramidal side effects and sedation than chlorpromazine, but also has a higher incidence of hypotension and cardiotoxicity. It is also known to possess a relatively high liability for causing orthostatic hypotension compared to other antipsychotics. Similarly to other first-generation antipsychotics it has a relatively high liability for causing prolactin elevation. It is moderate risk for causing weight gain. As with all antipsychotics thioridazine has been linked to cases of tardive dyskinesia (an often permanent neurological disorder characterised by slow, repetitive, purposeless and involuntary movements, most often of the facial muscles, that is usually brought on by years of continued treatment with antipsychotics, especially the first-generation (or typical) antipsychotics such as thioridazine) and neuroleptic malignant syndrome (a potentially fatal complication of antipsychotic treatment). Blood dyscrasias such as agranulocytosis, leukopenia and neutropenia are possible with thioridazine treatment. Thioridazine is also associated with abnormal retinal pigmentation after many years of use. Thioridazine has been correlated to rare instances of clinically apparent acute cholestatic liver injury.
Metabolism
Thioridazine is a racemic compound with two enantiomers, both of which are metabolised, according to Eap et al., by CYP2D6 into (S)- and (R)-thioridazine-2-sulfoxide, better known as mesoridazine, and into (S)- and (R)-thioridazine-5-sulfoxide. Mesoridazine is in turn metabolized into sulforidazine. Thioridazine is an inhibitor of CYP1A2 and CYP3A4.
Antibiotic Activity
Thioridazine is known to kill extensively drug-resistant tuberculosis and to make methicillin-resistant Staphylococcus aureus sensitive to β-lactam antibiotics. A possible mechanism of action for the drug’s antibiotic activity is via the inhibition of bacterial secretion pumps. The β-lactam antibiotic resistance is due to the secretion β-lactamase a protein that destroys antibiotics. If the bacteria cannot secrete the β-lactamase, then the antibiotic will be effective.
Mental Health Matters 
You must be logged in to post a comment.