Veterinary Surgeons and Suicide a Structured Review of Possible Influences on Increased Risk

Summary

Suicide is an important contributor to premature mortality accounting for over 800 000 deaths worldwide every year Environmental and genetic factors interim from before birth to one-time age touch on an individual's risk of suicide. Risk is influenced not simply past psychiatric disease and impulsive behaviour but too by factors such as the cultural acceptability of suicide, the ease of availability of lethal suicide methods, assist-seeking behaviours in times of crisis and access to constructive treatments post-obit self-harm. Suicide prevention programmes might usefully focus on 2 discrete areas: the prevention of the psychiatric illnesses that precede suicide and tackling those risk factors particular to suicide such as media influences, help-seeking, the availability of methods and the medical management of self-impairment.

Delcaration of interest

None.

Suicide is an important contributor to global patterns of bloodshed, accounting for over 800 000 deaths a year (World Health Organization, 2002). Since the publication of the government's suicide prevention strategy (Department of Wellness, 2002), it has become a key focus for psychiatric services in the Great britain.

Unlike many causes of death, suicide is not the result of a single affliction process. Information technology occurs every bit a consequence non only of a range of psychiatric disorders – most commonly low, substance misuse and schizophrenia – only besides of impulsive behaviour in moments of crisis and in the context of serious concrete illness (Fig. 1). In this editorial nosotros consider whether the study of suicide contributes important aetiological and preventive insights over and above those gained by studying its 'constituent' disorders (i.e. depression, schizophrenia, etc). We then summarise research evidence for the influence on suicide risk of factors acting at different stages of the life course; this evidence is function of a growing body of literature suggesting that prenatal and childhood exposures, as well as adult hazard factors, may modify an private's health in adulthood (Reference Kuh and Ben ShlomoKuh & Ben Shlomo, 1997). These influences are integrated into a model of suicidal behaviour that may facilitate a more focused arroyo for suicide prevention strategies.

Fig. i Life course influences on suicide.

WHY STUDY SUICIDE RATHER THAN ITS 'COMPONENT' DISORDERS?

Although suicide is unusual in the absence of mental distress, most people with psychiatric disorder and/or suicidal thoughts do non impale themselves. Other triggers or vulnerability factors contribute to risk. For case, in the Christchurch cohort, a detached set of risk factors – including sexual abuse, a family history of cocky-harm and low educational achievement – appeared to influence vulnerability to suicidal behaviour amid individuals with low (Reference Fergusson, Beautrais and HorwoodFergusson et al, 2003).

Several other observations indicate that suicide results from factors over and above those causing psychiatric disorder. Start, the incidence of depression – the most common antecedent of suicide – is higher in women than in men, whereas in well-nigh countries suicide occurs 3–4 times more ofttimes in men. Several factors may account for these differences, including stronger social bonds (particularly motherhood) in women, gender differences in help-seeking behaviour and gender differences in preferred methods of suicide – women tend to favour less lethal methods such as self-poisoning. Second, in that location are some discrete neurobiological features of suicidal behaviour (such as deficiency of serotonergic function) that appear to be associated with suicide, regardless of the underlying psychiatric disorder (Reference Isle of mannMann, 1998). Third, there are x-fold differences in national suicide rates within Europe that are unlikely to be due to differences in the prevalence of mental disorder. Variations in the cultural acceptability of suicide, socioeconomic conditions, legal definitions of suicide and, maybe, genetic differences are likely to contribute to international variations. Fourth, an important influence on an private successfully acting on a suicidal impulse is the availability of lethal methods of suicide (Reference Clarke and LesterClarke & Lester, 1989); this observation is borne out past the fluctuating levels of suicide in Samoa in the 1970s and 1980s, which closely mirrored changes in imports of paraquat, a highly toxic pesticide commonly used as a method of suicide in developing nations (Reference Bowles and DiekstraBowles, 1995). Finally, instance fatality post-obit a suicide endeavor is influenced not but by choice of method but as well by access to effective treatments. For example, reductions in mortality from paracetamol overdose followed the introduction of N-acetylcysteine in the UK (Reference Flanagan and RooneyFlanagan & Rooney, 2002), and in Sri Lanka monthly fluctuations in case fatality rates for cocky-poisoning mirrored the availability of appropriate antidotes (Reference Eddleston, Senarathna and MohamedEddleston et al, 2003). It is noteworthy that near suicide prevention strategies pay trivial attention to the medical management of self-harm. This fail is understandable for methods of suicide that result in decease soon after the attempt is fabricated, such as hanging and use of firearms, but is less and then for other methods of suicide, particularly self-poisoning, where advisable medical treatment may be life-saving.

Suicide prevention therefore depends not just on an understanding of how to prevent psychiatric disorder, only also on knowledge apropos how other social, economic and medical factors bear on suicide run a risk.

PRE-ADULT AND GENETIC INFLUENCES ON SUICIDE RISK

A few studies accept examined associations of suicide with indirect markers of preadult arduousness – nascency weight and tiptop. Influences on body growth may as well bear on neurodevelopment and the adventure of developing mental illness. Birth weight is a marker of foetal growth and may be influenced by maternal nutrition, body size, smoking, health and socio-economic position. Height, also as beingness influenced past genes, is influenced by diet, wellness and psychosocial adversity throughout the growing years (Reference Mascie-TaylorMascie-Taylor, 1991). An emerging literature suggests that there are associations of suicide with low nascence weight (Reference Mittendorfer-Rutz, Rasmussen and WassermanMittendorfer-Rutz et al, 2004), poor infant growth (Reference Barker, Osmond and RodinBarker et al, 1995) and short stature (Reference Magnusson, Gunnell and TyneliusMagnusson et al, 2005). Explanations for these associations are unclear. They may not be independent of the associations of these measures with depression, schizophrenia and other psychiatric disorders (Reference Thompson, Syddall and RodinThompson et al, 2001; Reference Cannon, Jones and MurrayCannon et al, 2002). Programming of the hypothalamic – pituitary axis has been suggested every bit a possible explanation for observed associations of suicide with measures of growth in early on life (Reference Barker, Osmond and RodinBarker et al, 1995).

Every bit already described, vulnerability to self-damage may be increased past factors such as a history of childhood sexual abuse and a family history of self-harm (Reference Fergusson, Beautrais and HorwoodFergusson et al, 2003). The association with a family unit history of self-harm highlights the importance either of genetic susceptibility or of behaviours learnt from other family members – or a combination of the two phenomena. Twin and adoption studies bespeak that in that location is a genetic component to suicide. Although a number of brain pathways have been investigated, the strongest evidence is for a role of the serotonergic organization (Reference Isle of manIsle of man, 1998). This pathway is also implicated in aggressive and impulsive behaviours, both of which may contribute to suicidal behaviour. It is probable, although not proved, that the effects of environmental stressors on suicide hazard may differ in those with and those without genetic predisposition to suicidal behaviour.

Psychological mechanisms underlying associations of babyhood adversity with suicidal behaviour are non fully understood. A possible pathway is through the effects of babyhood trauma on the memory system. The hypothesis has been put forrard that traumatic events in childhood result in dumb autobiographical memory, which impairs problem-solving and may result in suicidal behaviour in times of crunch (Reference Williams, Pollock, Hawton and van HeeringenWilliams & Pollock 2000).

ADULT INFLUENCES ON SUICIDE

The main psychiatric disorders contributing to suicide risk in adults are depression and schizophrenia. A number of social and economic factors – unemployment, divorce, serious medical disease and substance misuse – are as well commonly associated with suicide. In dissimilarity, parenthood and being in a stable human relationship appear to exist protective (Reference Qin, Agerbo and MortensenQin et al, 2003).

1 problem that besets observational inquiry into the relative importance of mental affliction and socio-economic risk factors for suicide is our limited understanding of the nature of the underlying causal pathways for these associations. For example, Danish studies suggest that there is only a weak clan between unemployment and suicide after decision-making for an individual'southward by psychiatric history among other exposures (Reference Mortensen, Agerbo and EriksonMortensen et al, 2000). This may be interpreted as suggesting that people with psychiatric illness are more than likely to lose their chore or find it difficult to gain employment, and that this explains the association of unemployment with suicide. However, analysis of temporal trends in unemployment and suicide shows that rises in unemployment are associated with increases in suicide (Reference Gunnell, Lopatatzidis and DorlingGunnell et al, 1999). Information technology seems improbable that the rises in unemployment are acquired by rises in mental disease. More plausibly, increases in unemployment issue in greater levels of depression and distress and this in turn influences trends in suicide. Both pathways are probable to contribute to associations of suicide with unemployment. Similarly, existence unmarried is associated with an increased run a risk of suicide (Reference Qin, Agerbo and MortensenQin et al, 2003) – but does the absence of a close relationship cause psychiatric disease, or vice versa? Multivariable analyses of large data-sets suggest that both pathways may contribute (Reference Qin, Agerbo and MortensenQin et al, 2003).

Serious physical disease in adulthood is as well associated with increased suicide risk. Prove is strongest for cancer and neurological disorders such as multiple sclerosis. It is noteworthy that the increased run a risk of suicide associated with AIDS appears to have declined with the advent of new therapies (Reference Stenager, Stenager, Hawton and van HeeringenStenager & Stenager, 2000).

Religious beliefs and other cultural factors may influence the likelihood of an individual acting upon suicidal thoughts (Reference Neeleman and LewisNeeleman & Lewis, 1999). The reporting and portrayal of fictional or actual suicides in the media has also been found to influence patterns of suicidal behaviour (Reference Hawton and WilliamsHawton & Williams, 2002). The media and religious beliefs may influence both the acceptability of suicide and an individual'southward selection of method of suicide. More crudely, irresolute availability of peculiarly lethal methods of suicide may influence rates. In Britain, the decreased lethality of domestic gas, the most commonly used method of suicide in the 1960s, is thought to have contributed to the decline in the national suicide rate at this time (Reference KreitmanKreitman, 1976).

CONCLUSIONS

Genetic and environmental factors acting at different stages of the life class are associated with the risk of suicide. Such gamble factors are more extensive than those of relevance to the aetiology of psychiatric disorder. An individual'southward risk is too influenced by the chosen suicide method and the availability of medical services to manage the consequences of the suicide attempt. Figure 1 illustrates the possible pathways through which factors interim from earlier birth to immediately proximal to the suicide attempt might influence an individual'southward determination to attempt suicide and the outcome of such a decision. A fuller understanding of factors operating across the life form that either protect against or precipitate suicide, as well every bit the key periods of development when they human activity, volition provide useful insights into its prevention.

The evidence reviewed here suggests that national suicide prevention programmes might usefully ascertain two discrete areas of work. The first should focus on the prevention of psychiatric disorder. The 2nd should focus on take a chance factors particular to suicide, such as media influences and the availability of methods of suicide and medical treatment. Striking a balance between these 2 approaches is important and at that place might be times when the two would disharmonize. For example, although prevention of suicide is a priority for all mental wellness services, there is a possibility that some methods used to reduce gamble in those with psychiatric disorder, such as increased in-patient observation and removal of belts and shoelaces, could reduce the therapeutic value of in-patient handling. In the wider customs, prevention of suicide past reducing access to means lonely does not address the root cause of distress that results in some people taking their own lives, and does not necessarily signal an improvement in the mental wellness of the wider population.

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