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| EDITORIAL |
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| Year : 2022 | Volume
: 12
| Issue : 3 | Page : 97-99 |
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Understanding suicide: A biopsychosocial framework
Soumya Tandon
Institute of Psychiatry and Behavioural Sciences, Sir Ganga Ram Hospital, New Delhi, India
| Date of Submission | 02-Jun-2022 |
| Date of Decision | 06-Jun-2022 |
| Date of Acceptance | 08-Jun-2022 |
| Date of Web Publication | 30-Jun-2022 |
Correspondence Address:
Dr. Soumya Tandon
Sir Ganga Ram Hospital, Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/cmrp.cmrp_48_22
How to cite this article:
Tandon S. Understanding suicide: A biopsychosocial framework. Curr Med Res Pract 2022;12:97-9 |
The World Health Organization reports that around 8 lakh people die by suicide each year. This accounts for about 1.5% of all deaths globally.[1] Suicide is also the leading cause of death worldwide in the age group of 15–24 years. The underlying risk factors for suicide have been evaluated both at individual and population levels. These factors are known to be mediated in turn by genetic factors, psychological factors and personality characteristics. An understanding of 'life course analysis' gives an overview that different risk factors play a role at different stages of life and the outcome, i.e., deliberate self-harm/suicide could be seen as a cumulative result of these factors over the lifespan of an individual.[2]
As discussed prior, individual factors are crucial for the understanding of suicidal behaviour. These include psychiatric disorders that are known to have the strongest effect on suicide.[3] These include depressive disorders, bipolar affective disorder, schizophrenia and substance use disorders. Other disorders include traumatic brain injury and seizure disorder. Other factors included are a history of suicidal attempt(s), early parental loss or family history of suicide. Information obtained for persons who have committed suicide, by means of 'psychological autopsy' has indicated that mood and substance use disorders are the major risk factors.[4]
Data from high-income countries estimate that psychiatric disorders are present in 30%–50% of those who have died by suicide.[5] On the other hand, suicide can also occur in the absence of an identifiable risk factor. There is a role of precipitating (e.g. disturbed interpersonal relationships, difficulties with spouse and marital separation/divorce and suicide of someone close) and predisposing factors (e.g. tendency to ruminate, irritability, various levels of anxiousness and sleep disturbances) for people who have committed suicide.[2] These factors interact with the resilience that acts as a protective factor. Overall, cumulative factors add up to induce psychological symptoms of feeling alone, having hopelessness and social withdrawal. This combined with access to lethal means can allow for acts of deliberate self-harm/suicidal behaviour.[6]
On a population-based level, the COVID-19 pandemic has played an important role in the context of increase in suicidal behaviour.[7] The COVID-19 pandemic resulted in social isolation, lack of a routine/structure, job losses, financial instability, psychosocial problems, stigma, fear of contracting the infection and stress and mass panic. COVID-19 has been known to be associated with mild-severe cytokine storms.[8] Interleukin-6 (IL-6) plays a role in cytokine storm and blockade in this signal transduction pathway is known to improve outcomes (e.g. tocilizumab). In addition, IL-6 levels have also been found to be elevated in CSF of patients with suicidal attempts.[9] This possibly adds a new perspective to the role of immunity in patients with suicidal behaviour. Hence, a combination of biological factors, immune-mediated mechanisms and proneness to stress may lead vulnerability to suicide.
Possible underlying mechanisms between the immune system and suicide indicate the changes in the Toll-like receptors (TLRs). These receptors interact with pathogen-associated molecular patterns and damage-associated molecular patterns; in turn, activating the nuclear factor-κB), thereby leading to cytokine release.[10] There has been an increase in the mRNA and protein expression of TLR-3 and TLR-4 found in individuals suffering from depression with suicide. These indicate that some specific TLRs could be potential targets for the treatment of suicidal behaviour in translational psychiatry.
The analysis of C-reactive protein (CRP) as an inflammatory marker remains one of the most widely used tests in medicine.[11] CRP is commonly used as a marker in inflammation and stratification of cardiac risk factors. It is also relevant in research due to the short half-life of other cytokines and the detectability of CRP at low levels. Studies have shown the association of increased CRP levels with suicidal ideations/attempts in patients suffering from depressive disorders. Two recent systematic reviews and meta-analyses have shown increased CRP levels in patients with suicidal behaviour.[12],[13]
A hospital-based study assessed 508 patients presenting with deliberate self-harm at the emergency unit of a tertiary care centre in South India and analysed the demographic characteristics, presentation, clinical correlates, and patient outcomes. The mean age in the group was 33.3 ± 13.8 years. The majority of patients were females with age <25 years. People belonging to nuclear family set-up, without regular employment, homemakers and students were predominant, with the majority of the attempts being low in lethality. The most common reasons implicated were reported as disturbances in interpersonal issues, substance abuse (commonly alcoholism) and health-related issues. The most common methods for self-harm were drug overdose (paracetamol, benzodiazepines and simultaneous ingestion of multiple substances), rodenticide (rat killer), plant poisoning (mostly Cerbera odollum), pesticide poisoning, cut injuries and hanging. In addition, biochemical parameters included the assessment of mean cholesterol level and mean TSH that did not have any statistical difference between the two genders.
A psychiatric evaluation was carried out in all patients. Psychiatric diagnosis could not be made in 28.4% of male and 52.5% of female patients. Substance use disorders were more common in men whereas mood disorders and adjustment disorders were more common in women. Most of the patients were discharged in a stable condition. Reported in-hospital deaths occurred in 16 cases that included 12 males and 4 females. More lethal ways were planned and attempted by men.
The aforementioned study gives an overview about the clinical correlates of suicidal behaviour in the Southern region of India. Both clinical and biochemical parameters were highlighted that is the strength of the study. There are certain limitations of the study. First, the study does not include a control or a comparison group. Second, the crucial impact of COVID-19 on the patient population was not evaluated. Third, mechanisms by which tendencies at self-harm become established/intensified or reversed have not been looked into as this would give vital information regarding the evolution of psychopathology and a guide in treatment planning.
To conclude, deliberate self-harm/suicide is a heterogeneous entity in terms of both presentation and management. It is somewhat challenging to formulate an all-encompassing model that explains suicidal risk. Ongoing advances have focused on biomarkers that would be critical for prediction and intervention. Although currently there is handful of studies, replication is required to confirm the findings. These can be seen as promising starting points that may aid in future research, thereby benefiting both patients and clinicians.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | World Health Organization. Age-Standardized Suicide Rates (Per 100 000 Population), Both Sexes, 2016. Geneva: World Health Organization; 2018.  |
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| 5. | Arsenault-Lapierre G, Kim C, Turecki G. Psychiatric diagnoses in 3275 suicides: A meta-analysis. BMC Psychiatry 2004;4:37. |
| 6. | Rogers JP, Chesney E, Oliver D, Begum N, Saini A, Wang S, et al. Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: A systematic review and meta-analysis. Epidemiol Psychiatr Sci 2021;30:e32. |
| 7. | Pandey GN, Rizavi HS, Bhaumik R, Ren X. Innate immunity in the postmortem brain of depressed and suicide subjects: Role of toll-like receptors. Brain Behav Immun 2019;75:101-11. |
| 8. | Banerjee D, Vaishnav M, Rao TS, Raju M, Dalal PK, Javed A, et al. Impact of the COVID-19 pandemic on psychosocial health and well-being in South-Asian (world psychiatric association zone 16) countries: A systematic and advocacy review from the Indian psychiatric society. Indian J Psychiatry 2020;62:S343-53. |
| 9. | Zhang C, Wu Z, Li JW, Zhao H, Wang GQ. Cytokine release syndrome in severe COVID-19: Interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality. Int J Antimicrob Agents 2020;55:105954. |
| 10. | Lindqvist D, Janelidze S, Hagell P, Erhardt S, Samuelsson M, Minthon L, et al. Interleukin-6 is elevated in the cerebrospinal fluid of suicide attempters and related to symptom severity. Biol Psychiatry 2009;66:287-92. |
| 11. | Pandey GN, Rizavi HS, Ren X, Bhaumik R, Dwivedi Y. Toll-like receptors in the depressed and suicide brain. J Psychiatr Res 2014;53:62-8. |
| 12. | Osimo EF, Baxter LJ, Lewis G, Jones PB, Khandaker GM. Prevalence of low-grade inflammation in depression: A systematic review and meta-analysis of CRP levels. Psychol Med 2019;49:1958-70. |
| 13. | Miola A, Dal Porto V, Tadmor T, Croatto G, Scocco P, Manchia M, et al. Increased C-reactive protein concentration and suicidal behavior in people with psychiatric disorders: A systematic review and meta-analysis. Acta Psychiatr Scand 2021;144:537-52. |
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