Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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suicide in the face of emotional adversity
- Arnob Chakraborti, Radhika Soni (19 March 2006)
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Lethal medications
- Peter Byrne (19 March 2006)
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Grief and mourning are suicidal risk factors in vulnerable people
- Sergio A Pérez Barrero (19 March 2006)
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Supporting the health professionals who care for grieving patients may benefit all
- Svetlin V Vrabtchev (21 March 2006)
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Preventing suicide of bereaved parents
- Nilamadhab Kar (21 March 2006)
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Arnob Chakraborti, senior house officer, child psychiatry walsall PCT, WS2 9XH, Radhika Soni
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The main problem identified with suicide prevention is that it remains a rare and unpredictable event, even among people who are already classified high risk. There have been debates whether directive interventions can prevent suicide in those identified with a high risk, as statistically, comparative and longitudinal studies demonstrate a significantly high number needed to treat. Adversities especially emotional adversities have always been identified as a significant risk factor towards suicide, given that such an adversity results in feelings of hopelessness, helplessness, low mood and applies a paint of the dark on everything that constitutes life and living. This may lead to suicidal ideation, suicidal intent, plans and acts. However, the impulsivity, the crests and troughs of suicidal intent, which fluctuate ever so suddenly and unexpectedly when faced with an emotional adversity, contributes against predictability. Grieving the death of a child the parents are faced with stress- an emotional adversity which has been scored to be significantly significant in quantitative analysis on the impact of life events. And factors like only child, coveted pregnancy would only be additive. As identified, when a child dies suddenly- homicidal, suicidal or accidental death, grief is complicated by trauma. However, the cases published add a new element to the mental state of the griever- impending, predictable demise, a stressor - an emotional adversity which is obviously and ominously present. On the mind of the care giver, this experience of impending object loss can be regarded as a type 2 (repeated) or a type 3 (complex cumulative) trauma. It is certainly established that diagnosis of a life threatening illness in self or loved one has a moderate impact and can precede PTSD (post traumatic stress disorder) in 5-20%. But what remains to be established is; would this not be a cumulative effect on someone faced with such a certainty or ambivalence? Or does it result in learned helplessness which predisposes to the vicious depressogenic cycle? Studies (as cited by the editor) have been able to establish a heightened risk of suicide in similarly disposed parents in the first month post event, and increased incidence of anxiety and depression in longitudinal follow up. A model commonly used to describe individual reaction to trauma, grief and suicide is the stress-diathesis model. While the stress is very apparent in such cases, the individual diathesis would remain to be explored. Individual diathesis could be genetic, early adverse experiences, learnt behaviour, also, presence or absence of support or confidants. Previously, authors have explored the reasons for continuing desire to live during a major depressive episode and discovered that the subjective perception of stressful life events may be more appropriate and relevant to the expression of suicide than the objective value of such events. This has led to suggestions that assessment of the reasons for living should be included into the evaluation of suicidal risk. This however, is not a generalised practise. Case-control studies also highlight the protective role of engagement in care and support (of whatever kind) against suicide, which should also be considered in assessment. Provision of comprehensive care would involve assessment of all the interplaying factors and individualising on strengths and weaknesses: beliefs related to the child, survival and coping beliefs, responsibility to and from rest of the family, fears about death by suicide and its moral and social paradigms. But given recent proactive approach in the mental health services’ agenda towards suicide prevention, and despite all its uncertainties the case of parental vulnerability of suicide after expected death of a child at home needs identification as a predictable very high risk situation, and individual focussed measures directed to address the same. Unfortunately, the available literature on the matter is scarce. Competing interests: RS is not related to Walsall PCT. However, she is a post-graduate in psychology and currently training in counselling and psychotherapy.The authors are also married. |
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Peter Byrne, Liaison Psychiatrist Oldchurch Hospital, Romford RM7 0BE
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Sir, Professor Davis’ case reports of completed suicide in recently bereaved parents (1) are a timely reminder of one of the few areas in suicide prevention (access to lethality) where clinicians can intervene to save life. Within the anger of acute grief – Case 1 describes “holding on” to the decreased person beyond the usual grief experience (1) – the child’s medications can acquire a symbolic value. The same applies to bereaved spouses who may also come to see their late partner’s tablets as hope that betrayed them. Gunnell and Lewis (2) provide a useful conceptual framework in which to consider a person’s risk of suicide: it is a combination of predisposing plus facilitating factors minus protective factors such as social role, parenthood, help seeking behaviours during crisis and religious belief. In the context of the sudden loss of many protective factors, where most people’s coping skills would be overwhelmed by the loss of a child, clinicians must identify access to lethal overdose. It may seem unthinkable to ask grieving parents to “hand over the medications” in the immediate aftermath of a death, but preparation for this should be part of the anticipatory grieving process (3). One solution would be for carers to sign for controlled medications when home care is being arranged: “these drugs are for the treatment of X and must be returned to (named key worker) if X leaves this address”. For other lethal medications, for example insulin and cardiac drugs, written consent from carers formalises their safe return in the event of death or other change in circumstances. As Davis (1) points out, relatives with high suicidal intent are likely to deny this, making psychiatric assessment unreliable during the immediate aftermath of a death. There are lessons here for all hospital and community practitioners. 1. Davis, DE. Parental suicide after the expected death of a child at home BMJ 2006;332:647-648. 2. Gunnell, D and Lewis, S. Studying suicide from the life course perspective: implications for prevention. British Journal of Psychiatry (2005) 187: 206-208. 3. B. Raphael. Grieving the death of a child BMJ 2006; 332: 620 - 621. Competing interests: None declared |
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Sergio A Pérez Barrero, Founder of the World Suicidology Net Founder of WPA Suicidology Section
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Dear colleagues: The reactions presented by human beings after the loss of the beloved are known and they receive the name of grief, which is composed of different stages, which vary according to the researcher being referred to. Thus, for some, the stages of grief are: denial, bargaining, depression and acceptance. For others depression, anger, forgiveness and acceptance conform the reaction of normal grief. Still others consider avoidance, confrontation and restatement as the stages of this state. The collapse of Ego, aggression, the search of indifference, forward escape, ideologization and acceptance have also been mentioned. Finally, the stages of normal grief comprise denial, depression, separation and individualisation, anger and restatement. Of all these proposals, the one with a wider universal acceptance is the one which considers denial, anger, bargaining, depression and acceptance as the stages of normal grief. Depression is one of the most painful stages of grief, this pain being more intense during the first two weeks, in which the person feels deep sadness, crying, little or no desire to communicate with people other than the closest relatives, sleeping disorders, anorexia and guilt . Grief is associated with the incorporation of risk conducts such as the excessive consumption of alcohol, cigarettes or psychotropic drugs with suicidal risk mainly in vulnerable individuals if they have the methods available. Sincerely yours Prof. Dr. Sergio Perez Founder WPA Suicidology Section Founder World Suicidology Net WHO/PAHO Temporal Advisor for Suicide Prevention In The Americas. IASP National Representative. www.redsuicidiologos.com.ar Competing interests: None declared |
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Svetlin V Vrabtchev, Specialist Registrar in Psychotherapy Psyhotherapy, Cedar House, Blackberry Hill Hospital, Bristol BS16 2EG
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Dear Colleagues, I was moved by the two tragic accounts of loss described by Davies (1). I would like to comment on the care for grieving parents and on the need to support the professionals looking after terminally ill children and their families. Two cases of palliative care in the community for children where their mothers committed suicide following the death of the child by using the remaining opioid drugs were outlined by Davies (1). It is clear that the suicide had been committed during the process of natural, albeit inconsolable, grief. The details of the two accounts tell us also about the effort of the palliative care teams to support the parents before and after the death of their child. I can only imagine that the effect of the suicides on these professionals is comparable to the bereavement of the families. I believe that supporting the health care professionals who work in this field and particularly in such circumstances could be as helpful for them as it may be for their patients. There is literature that has recognised that patient suicide does have an impact on psychiatrists (2, 3). In the qualitative study that I am currently involved in which involves Senior House Officers (SHOs) in psychiatry, one of the themes has been the traumatic effect of suicide risk assessment on the SHOs where the patient subsequently attempted or committed suicide. It was recognised that the emotional effects of such experiences has a lasting influence on the SHOs’ practice by denting their professional confidence. The feedback from the focus group interviews that I have so far conducted included comments on the helpful aspects of sharing such experiences and the feelings of guilt and being blamed. In the editorial response to the above article, Professor Raphael (4) has addressed the complex issue of supporting parents whose child is dying from a terminal illness and the complexities of grief in such circumstances. Despite recognising the invaluable role of such support she seems to be unconvinced by the evidence for providing bereavement support for families and calls for “controlled trials” that would inform the practice. I believe that the medical profession should not need controlled trials to justify such care. Anyone who is working with grieving people will benefit from education and training and from more informal ongoing support in their work place. All this will inform professionals about the complex psychological reaction to loss, facilitate empathy, improve the therapeutic relationship and will ultimately be helpful to the patients. Sharing of such experience in peer reviewed journals, as Davies (1) has just done, is for the benefit of all who work in the health care. 1. Davies DE. Parental suicide after the expected death of a child at home. BMJ 2006;332:647-8 2. Alexander DA et al. Suicide by patients: questionnaire study of its effect on consultant psychiatrists. BMJ 200; 320: 1571-4 3. Ruskin R et al. Impact of patient suicide on psychiatrists and psychiatric trainees. Academic Psychiatry 2004; 28:104-110 4. Raphael B. Grieving he death of a child. BMJ 2006;332:620-1 Competing interests: None declared |
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Nilamadhab Kar, Consultant Psychiatrist, Wolverhampton City Primary Care Trust, Corner House Resource Centre, 300 Dunstall Road, Wolverhampton, WV6 0NZ
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The case studies in the article of Davies portray an extremely painful outcome of the parents who have undergone bereavement of their child.[1] Death of child is a catastrophic event and has a potentiality for major psychological destabilisation for parents. With their ‘reason for living’ lost, hopes and future gone, their ‘world ceases to exist’; many parents report an irremediable void, emptiness in their life. Some part with their emotional being, become a changed individual; their behaviour becomes a stereotyped reminder of their previous self, and their cognition persevere ‘how to cope’ and ‘why to live on’. Many find their long held faith challenged and shaken. And it is known that such grief can lead to suicide.[2] While some succumb to a self harm event, many others just wither away in a slow prolonged suffering. What can be done look so meagre in the face of such a catastrophe. Professional support around such events, support from the specific voluntary organisations and other parents with similar experience are invaluable when available during this painful period. These should be continued till the parents restart using their coping resources adequately. The first few weeks are the critical period and need utmost care and attention.[3] While many parents wish to be left alone to grieve, it may be worthwhile for clinicians, family members or other supporters to ‘be with the parents’ sensibly during this critical period. There may not be words that can comfort the parents but by just ‘being there’, quietly holding the hands may help. When worldly explanations fail to answer ‘why my child’, spiritual resources support many parents. It may be difficult to find an answer but it may shift the paradigm to a more tolerable one auguring a possibility of emotional healing. It may lead to greater understanding and a state where other coping strategies may start functioning again. But the carers should never forget, as many bereaved parents put it, that they ‘do not cope’, they merely ‘try to live on in spite of such a terrible tragedy’; contrast to many who have given up and gone into despair. That still makes much difference. 1 Davies DE. Parental suicide after the expected death of a child at home. BMJ 2006; 332: 647-8. 2 Raphael B. Grieving the death of a child. BMJ 2006; 332: 620-621. 3 Qin P, Mortensen P. The impact of parental status on the risk of completed suicide. Arch Gen Psychiatry 2003; 60; 797-802. Competing interests: None declared |
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