# Motivation and emotion/Book/2014/Suicide prevention
## Overview

Suicide statistics are scary. This is the simple, awful truth. The sheer numbers with regard to suicide should scare everyone. According to the World Health Organisation (2014, para. 1), over 800,000 people per annum die because of suicide. To put that in perspective, that is like losing the population of San Francisco each and every year to suicide (World Population Review, 2014, para. 2).
In Australia, suicide is the 14th leading cause of death in Australia, with approximately 11 people in everyone 100,000 dying because of suicide (Australian Bureau of Statistics, 2012). Given that the Australian population is currently sitting at 23,660,647, this means an approximate loss of 2,603 Australians each year to suicide (Australian Bureau of Statistics, 2014).
As such, suicide is a serious, serious mental health issue that many researchers have dedicated a lot of time to over the years. At present, there are a few therapies in place as support vehicles for people who seem to be in danger of attempting to take their own lives. These include Cognitive Behaviour Therapy (CBT), Dialectical Behaviour Therapy (DBT), various kinds of medication, electroconvulsive therapy, and hospitalisation.
Back in 1989, Möller came to the conclusion that different treatments for suicidal behaviours are more effective for some individuals than others, depending on a wide range of factors. There are many mysterious factors that contribute to why some unfortunate souls see suicide as a viable option, but in this chapter we will focus on the motivations behind this fact and how each of the therapies mentioned above address these motivations.

## Did you know?

Earlier this year, Guintivano and a group of other researchers (2014) discovered that low levels of one gene, known as the SKA2 gene, can make a person more susceptible to attempting suicide, or parasuicide. The SKA2 gene is connected to the prefrontal cortex, which is the part of the brain responsible for both curbing negative thoughts and controlling impulsive behaviour. According to Guintivano et al, interaction between the chemical variations in the SKA2 gene and their participants' anxiety and stress levels explained approximately 80 per cent of the suicidal behaviour exhibited by said subjects. Furthermore, the researchers developed a model to predict which of their subjects were exhibiting suicidal behaviours such as suicidal thoughts or actual attempts at suicide, based solely on these subjects' blood samples. These predictions were 90 per cent accurate.
What does this mean? Well, this could mean that it is theoretically possible to develop a blood test to see which individuals are at a higher risk of suicide and suicidal behaviours. Of course, this will not be true in all cases, as suicide and all of its surrounding issues are incredibly complex, but this could still be a major win for the mental health industry.

## Common Motivations for Suicide
##### Maslow's Hierarchy of Needs

Maslow (1943) believed that our needs feel into a sort of hierarchy; that some needs were more important than others. This hierarchy has been changed and revised many times since Maslow first published this theory, but the most common version of Maslow's hierarchy breaks down our needs into five sub-sections, with our most basic needs on the bottom layer. Maslow was of the opinion that we could not progress to a higher level in his hierarchy until our needs on the lowest levels were met[factual?]. For example, it would not be possible to pursue our self-esteem needs until our love and belongingness needs had been met. Of course, there are many problems with the Maslow's Hierarchy of Needs. In 2011, Tay and Diener conducted a huge study that consisted of over 60,000 participants across over 120 countries and found that the hierarchy was incorrect. We as humans are able to enjoy the company of our loved ones while also feeling hungry or thirsty, even though according to Maslow, we would need to sate our thirst and hunger before such enjoyment would be possible.
However, if we operate under Maslow's paradigm, then we may be able to see a potential motivation for suicide. As mentioned above, social isolation and low self-esteem are among the more common motivators for suicide. These two issues also find themselves on Maslow's Hierarchy of Needs. According to Maslow's theory, we are motivated to fulfil our needs so that we can progress further up into his hierarchy and closer to self-actualisation. But what happens when we are unable to fulfil these needs? What happens when an individual is unable to feel safe in their surroundings, to feel as if they belong, or to increase their feelings of self-worth? According to Maslow, this means that the individual cannot progress and is stuck where they are. Long, Long, and Smyth (1998) state that individuals struggling with mental health issues require a positive environment in order to move up through Maslow's levels. So if this isn't possible, individuals may find it nigh on impossible to escape the horrifying thoughts plaguing them, edging them towards suicide.

### Escape

In many studies that look at reasons for suicide or parasuicide, escape has been found to be one of the more common motivations. Baumeister (1990) found that some individuals with suicidal tendencies were trying to escape their perceived inadequacies via suicide. A few decades earlier, in 1976, Bancroft, Skrimshire, and Simkins found that one of the most common reasons people gave for taking overdoses, which has been identified as a common method of parasuicide (Michel et al, 2000), was to escape from an awful state of mind, as well as trying to avoid terrible situations.

### Mental State

When people hear the word suicide, a lot of the time they think "depression". In 2009, Fairweather-Schmidt, Anstey, and Mackinnon found that, while there is a strong correlation between depression and suicide, these two factors can be separated. The researchers went on to highlight the need for inventories that measured suicidality symptoms as separate from symptoms of depression.
Depression is not the only mental health issue with a risk of suicide. Balhara and Verma (2012) found that 15 to 26 per cent of people living with schizophrenia had made at least one suicide attempt before they sought help, with up to 11 per cent making yet another attempt during their first year of treatment.

### Social Isolation

Van Orden, Witte, Gordon, Bender, and Joiner (2008) identified two causes of social isolation in individuals with suicidal tendencies, "thwarted belonging", which describes the unfulfilled need to belong; and "perceived burdensomeness", which describes the unfulfilled need [missing something?] help with people's well-being. Van Orden et al found that a higher level of suicidality was found in patients with both of these mental processes. The belief that an individual is a burden on loved ones, or that an individual doesn't belong in their current social setting, have long been seen as predictors of suicidality. In fact, back in 1980, Trout found that social isolation is fundamentally linked to suicidal and parasuicidal behaviours.

### Environment

Environment is an interesting motivation for suicide. Baumeister (1990) found that it is common for the recent lives of those who attempt suicide to be fraught with unusually distressing events. For example, suicidal behaviour in prison usually occurs within the first month of imprisonment (Backett, 1987) and people are more likely to suicide within their first week of admission to a psychiatric facility (Copas & Robin, 1982). In contrast to this, Baumeister (1990) also found that favourable external environments can produce high expectations of happiness and, if the individual fails to feel that expected happiness, this results in higher rates of suicide. For example, in the US, states that have better living conditions and quality of life also have higher rates of suicide (Lester, 1987). Not only this, but the rate of suicide is higher in societies that encourage individual freedom (Farberow, 1975).

### Low self-esteem

Research through the years has demonstrated a link between suicide and low self-esteem. Rosen (1975) interviewed survivors of suicidal jumps from the bridges in San Francisco Bay, in order to understand their experiences and their mental processes. Rosen found that the majority of these people were plagued by feelings of worthlessness. Similarly, Rothberg and Jones (1987) discovered that the main causes of suicides within the military community were hostile feelings toward the self and a perceived inadequacy. A more modern example was the study Wilburn and Smith undertook in 2005. These two researchers studied a group of college-aged students and found that both stress and low self-esteem had a significant correlation with suicidal behaviour, specifically suicidal ideation.

### Medical illness

Hendin (1998) found that approximately 50 per cent of the people who committed suicide over the age of 50, and 70 per cent of the people who committed suicide that occurred over the age of 70, were suffering from some kind of medical illness before the suicide occurred. In fact in 1986, Farrer found that over a quarter of people who live with Huntington's Disease attempt suicide at least once after being diagnosed. And in 1998 Chochinov, Wilson, Enns, and Lander found that patients living with terminal cancer felt that suicide was a preferable option over a natural decline to death. However, Hendin (1998) also found that when the physical and psychological issues of people meeting the previous criteria (over 50, or over 70, and suffering from a medical illness) were addressed, the wish to hasten death was diminished and these people seemed thankful for their remaining time.

## Current Treatments for Suicidality

At present there are many different treatments for those individuals who present with suicidal and parasuicidal behaviours. What this chapter aims to do is to give a brief overview of what each treatment entails and then how these treatments address the above motivations for suicidal behaviour.

### Medication

Medication is a touchy subject when it comes to mental health issues. Although there is a wealth of information espousing the benefits of pharmacotherapy for various mental illnesses (Thornley & Adams, 1998), there are an astonishing number of patients who refuse to take their medication, or that they choose to prematurely stop taking their medication[factual?]. There are also people who are resistant to the effects of medication and require alternate therapy options. Roe, Goldblatt, Baloush-Klienman, Swarbrick, and Davidson (2009) investigated the reasons behind people refusing, or ceasing, to take their medication. Despite the subjects of this study knowing that the medication was having a positive effect on their respective mental illnesses, they still chose to stop their medication. The reasons for this included a feeling that the subjects had lost a part of themselves to the drugs, the social and personal stigma attached to taking medication, and the lack of empathy in the authority figures prescribing the medication.
Pharmacotherapy addresses the "mental state" motivation for suicide. However, it could also be argued that it also addresses the "medical illness" state as well, given that the medication tries to correct the physiology behind the feelings of suicidality. Given the sheer number of medications available to treat suicidality, we[who?] will narrow the scope of this section to the pharmacotherapy for schizophrenia and depression.
According to the American Foundation for Suicide Prevention (2014, para. 2), clozapine, an atypical antipsychotic, is the only medication approved by the Food and Drug Authority (FDA) in the United States for the treatment of suicidality in schizophrenia sufferers. Meltzer et al (2003) found that clozapine was able to significantly reduce the risk of suicide in patients with schizophrenia or schizoaffective disorders. Clozapine also seriously reduced the number of deaths, the numbers of serious suicide attempts, and the number of preventative hospitalisations within the cohort.
In the case of depression, Gibbons, Hur, Bhaumik, and Mann (2005) found that there was no significant relationship between antidepressants and the rate of suicide. However, when the researchers looked at each individual kind of antidepressant, they found that selective serotonin reuptake inhibitors (SSRIs) and the newest non-SSRI antidepressants were related to lower suicide rates. In the same vein, March et al (2004) found that fluoxetine, an SSRI that is commercially sold as Prozac, was more successful in reducing suicide rates than cognitive behaviour therapy. However, it is worth noting that when fluoxetine and cognitive behaviour therapy were combined, this combination yielded the strongest results with regards to lowering suicide rates.

### Cognitive Behaviour Therapy (CBT)

Cognitive behaviour therapy addresses both the cognitive and behavioural aspects of an issue. CBT can be adapted to suit many different issues, including suicidality and eating disorders, by changing the balance of cognitive and behavioural approaches; some issues are better addressed by looking at behaviours and so behavioural therapy would be emphasised. One of the reasons that CBT is such an effective therapy is that it looks at both a person's thought patterns and the behaviours that occur because of those thoughts patterns and seeks to alter any problem behaviours or cognitions that are impeding on an individual's well-being (Australian Association for Cognitive Behaviour Therapy, 2014, para. 7).
CBT can address all of those issues that are caused by negative thoughts and behaviours (that is, Escape, Low Self-Esteem). When discussing clients' attitudes toward themselves and their problems, therapists can work out which thoughts are most detrimental to the clients' mental health and try and help clients to change these patterns. In fact, Townsend et al (2001) found that the problem-solving aspects of cognitive behaviour therapy better reduced levels of hopelessness and depression in their cohort than their control treatment. CBT also helped improve the subject's attitudes toward their problems.
CBT has been long believed to be one of the strongest and most effective methods of approaching suicidality. Van der Sande, Buskens, Graaf, and Engeland (1997) found that, when compared to other therapeutic techniques, CBT had the most significant reductions in the number of suicide attempts within their cohort. However, as discussed in the Medication section, when March et al (2004) compared CBT to fluoxetine, the results for CBT weren't as strong as for the SSRI medication condition. The risk of suicide was most significantly reduced when these two therapies were combined.

### Dialectical Behaviour Therapy (DBT)

Dialectical Behaviour Therapy, or DBT, is a subset of Cognitive Behaviour Therapy that emphasises the ways in which an individual psychologically interacts with their social environment. DBT focuses on the idea that some people have a more intense and unusual reaction in some emotional scenarios. Not only this, but that these people are physiologically more sensitive to emotion and take a lot longer to return to a baseline state (PsychCentral, 2014, para. 1). DBT also focuses on the clients' cognitive patterns and the collaboration between client and therapist. The structure of DBT is two-fold. The first part of the therapy is individualistic, with one-one-one sessions between the client and the therapist once a week. The second part is a weekly group session which is led by a DBT trained therapist (PsychCentral, 2014, para. 1).
Linehan et al (1987) took a deeper look at the use of DBT to specifically address parasuicidal behaviour. They found that DBT therapists based their programs on the idea that parasuicidal behaviour is a way for patients to solve the problems presented by adverse internal and external environments. What causes parasuicide to seem like a viable option to these individuals were three core issues:
* too high a value placed on the possibility of positive consequences of suicide
* inadequate coping mechanisms
* inadequate tolerance for distressing situations, or lack of resiliency.
A few years after this study was conducted, Linehan, Armstrong, and Suarez (1991) found that, when compared to a control therapy, DBT not only reduced the risk of parasuicidal behaviour, but also resulted in more patients staying in therapy, and less time spent in psychiatric faciities. Wasserman et al (2012) also found that DBT has been effective in reducing both suicidal behaviour and self-harming behaviour, especially in patients who present with bipolar disorder. The researchers identified that social support is crucial in helping suicidal patients to overcome their issues.
Much in the same way as CBT, DBT addresses the thought and behavioural patterns that can lead to suicide; that is, the belief that suicide can act as an escape, the belief that one is not "good enough", and constant negative self-talk that can lead to a suicidal state-of-mind, as well as the core beliefs Linehan et al (1987) found. However, with the addition of mutual collaboration between client and therapist plus the weekly group session, DBT could also help people who present with suicidal tendencies to feel less socially isolated.

### Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is reserved for the most severe cases of depression, bipolar disorder, and psychotic disorders such as schizophrenia, where medication and psychotherapy haven't worked. What happens is that electrodes are placed on the scalp and an electrical pulse is passed through them. This electrical pulse tries to correct the electrical processes in the brain that have been effected by mental illness, much in the same way medication tries to correct chemical imbalances in the brain. (SANE, 2014, para. 2).
As such, ECT works much like medication with regard to how it approaches the motivations for suicide. ECT attempts to correct the Mental State of those suffering from mental illness. Not only this, but ECT could also be argued to address the Medical Illness motivation for suicide as all of the mental illnesses mentioned above, are also recognised medical conditions. Thus, when an individual is treated with ECT, the symptoms of their disease are alleviated.
In 2000, Grunhaus et al undertook a study to investigate the effectiveness of ECT in treating Major Depressive Disorder (MDD). What the researchers found was that ECT was the most effective treatment for MDD, both with and without psychosis, however it is worth noting that patients with MDD and not psychosis also responded similarly to repetitive transcranial magnetic stimulation (rTMS), which stimulates the central nervous system instead of the brain. Furthermore, Husain et al (2004) found that they were able to achieve remission in 75 per cent of MDD patients, with 65 per cent of the patients achieving remission before the tenth session of ECT. And finally, when ECT was compared with pharmacotherapy in a study that followed up with patients who had been hospitalised for their suicidality, the patients who had been treated with ECT had a lower mortality rate that the group who were treated with pharmacotherapy (Avery & Winokur, 1976; Avery & Winokur, 1978).

### Hospitalisation

Admission to a psychiatric facility is usually reserved for the very worst cases of mental illness. These people may be unable to look after themselves or there is a risk that they may be a danger to themselves or others. Sometimes, however, a person's therapist may just need to monitor their clients because they've either changed medication or their client may need a type of treatment that's only available in a hospital setting, such as ECT. Finally, a client's therapist may simple decide that their client may just need a break from the stressors of everyday life and pull them into a hospital setting in order to given their client a break (WebMD, 2014, para. 5).
Comtois (2002) goes further and says that hospitalisation provides, not only a calm and soothing environment, but also allows patients to focus solely on perfecting their problem-solving skills without the distractions of everyday life. However, Comtois also identifies that patients who develop their problem-solving skills in a hospital environment may be unable to transfer these skills into real world situations and therefore, when stressful problems arise, these patients may return to their old habits and fall back on suicide ideation as dealing with the problems.
In 1990, Waterhouse and Platt investigated the differences in caring for parasuicidal patients either in hospital or at home and found that there were no statistically significant differences between the two treatments. Similarly, Babalola, Gormez, Alwan, Johnstone, and Simpson, (2012) found that the effects of long-stay and short-stay psychiatric admission on suicidal behaviours were remarkably similar, with the only differences being that short-stay patients scored higher on social functioning measures and were more likely to leave on their predicted discharge date.
Hospitalisation is unique among the treatments previously mentioned as it is really an amalgamation of various combinations of those treatments, but in a sheltered environment. As such, hospitalisation has the potential to cover all of the motivations for suicide in varying degrees. However, the one motivation that hospitalisation tackles better than the other treatments is Environment. By taking a patient out of their regular environment, there is a good chance that many of the sources of stress will no longer be able to upset the patient, and therefore the patient will simply be able to focus on altering their dangerous thoughts and behaviours through a mixture of CBT, DBT, medication, and possibly, ECT.

## Strengths and Weaknesses of Current Treatments

As with anything, all of the above treatments have their own sets of strengths and weaknesses. Not all treatments are viable options for all of the people who need them. Therapists have to make decisions on a case-to-case basis as to whether one treatment will be more relevant for their client over another kind.

### Medication

The biggest strength with regards to medication as therapy is that it attacks the physiological symptoms of mental illness. Medications such as fluoxetine and clozapine go directly to the source of the chemical imbalances in the brain and aim to correct them. Therapies such as CBT and DBT have limited effect on physiology and as such, this is a strength unique to medication (and ECT). However, the medication can take up to fourteen days to have any measurable effect and therefore these medications initially require supplementary treatments (Wasserman et al, 2012). Not only this, but some studies have shown that some antidepressant treatments may actually increase suicide rates in adolescents (Wasserman et al, 2012).
A major weakness with pharmacotherapy is that many patients on these programs fail to adhere to the programs assigned to them by their therapists. Roe et al (2009) found that patients who stopped taking their medication did so for a myriad of reasons, including social stigma, lack of empathy from the assigning physicians, and the sense of losing oneself to the medication. However, there are also physical side effects, such as weight gain and sexual impotence (Better Health, 2014, para. 10) that cause patients to stop taking their medication. There is also the fact that some patients start to feel as though they have completely recovered and so choose to stop taking their medication prematurely (Hoffman, Moore, & O'Dea, 1974). Not only this, but approximately a third of the patients who are treated for their suicidal behaviours with pharmacotherapy either suffered from a relapse or dropped out of the study (Kellner et al, 2006).
Finally, medication doesn't treat damaging thought patterns and behaviours. Although it is true that thoughts and behaviours can be distorted due to chemical imbalances, it doesn't mean that these damaging behaviours automatically dissipate. This is why the strongest treatments for suicidality combine pharmacotherapy with psychological therapies such as CBT (March et al, 2004).

### Cognitive Behaviour Therapy (CBT)

CBT is one of the most effective psychological treatments available for suicidal behaviours. As Townsend et al (2001) point out, the problem-solving nature of CBT helps patients to deal with their problems in a healthy manner and as such, can overcome feelings of depression and hopelessness. Furthermore, Stanley et al (2009) found that CBT had a high retention rate among adolescents as they felt that the therapy was more useful than traditional therapies as the adolescents were learning skills that could help them in their everyday lives.
The main strength of CBT is the problem-solving approach the therapy takes to cognitive (thought) patterns and behaviours. By addressing issues with these variables, the therapist can help their clients to fix problems in these areas and help them to develop healthier ways of thinking and behaving. Van der Sande et al (1997) came to the conclusion that CBT is more effective than other therapies when it comes to reducing suicide attempts. However, as March et al (2004) note in their study, CBT is most effective when paired with pharmacotherapy.
The main weakness of CBT is that the therapy doesn't effect the physiological causes of a patient's suicidal behaviours. While CBT can reduce depression and hopelessness scores (Townsend et al 2001), it doesn't actually change the brain chemistry that causes those extreme reactions, but merely helps the patient to deal with the thoughts and behaviours that occur due to their physiological symptoms. While this is no small thing, CBT still does not change any underlying causes of suicidality, but only changes how the person deals with these underlying causes.

### Dialectic Behaviour Therapy (DBT)

The strengths and weaknesses of DBT are similar to those of CBT, given that DBT is a type of CBT. However, a strength of this therapy in addition to those of CBT, is its social aspect. DBT encourages patients to interact with people in similar situations and therefore this therapy alleviates patients' social isolation. This is something that is lacking from CBT, pharmacotherapy, and ECT. DBT has been found to reduce suicidal behaviours, completed suicides, and the number of days that patients have spent in psychiatric facilities more so than other therapies (Linehan, 1987; Linehan et al, 1991; Linehan et al, 2006). Wasserman et al (2012) also espouse the importance of social support networks when it comes to dealing with suicidal behaviours, saying that it is of the utmost importance that family, friends, and partners should become involved in a patient's therapy. While DBT does not directly encourage this kind of social interaction, the work that DBT therapists do in their group sessions may make it easier for patients to open up with loved ones about their problems and therefore help the patients to overcome them.

### Electroconvulsive Therapy (ECT)

ECT shares its strengths and weaknesses with the Medication section above. While ECT deals with the physiology of suicidality, it doesn't change the thoughts and behaviours of the patients who undergo this kind of therapy. However, given that ECT is reserved for the most severe cases of depression, schizophrenia, and other such mental illness, ECT is unique in its position as a therapy for suicidality. Husain et al (2004) found that 75 per cent of patients who underwent ECT went into remission. Furthermore, Sackeim et al (2000) found that the stronger the dosage of ECT, the more effective the therapy was, with the high dosage ECT patients having a more significant reduction in their symptoms than those patients who only received low or moderate doses.
However, Kellner et al (2006) found that there was a significant relapse rate once the treatment came to an end. As such, ECT would have to be supplemented with other forms of therapy in order to ensure its efficacy.

### Hospitalisation

Hospitalisation is unique among the therapies mentioned because it shares its strengths and weaknesses with all of them, given that hospitalisation can include any number of combinations of the above therapies. So, instead of rehashing those strengths and weaknesses, this section will focus on those strengths and weaknesses specific to hospitalisation.
One important factor of hospitalisation is that it pulls patients out of their usual situations. This is a double-edged sword as, while hospitalisation gives patients a place to escape the stresses of everyday life, it also means that any skills learnt within hospital regarding problem solving and thought patterns may not transfer to the real world, where problems are compounded by their everyday context (Comtois, 2002).
Then there is also the fact that hospitalisation costs a lot of money. Yeo (1992) estimated that, in Britain, it costs $788 to move one suicidal patient from the emergency room to a psychiatric facility. Furthermore, Runeson and Wasserman (1994) found that the direct cost of managing psychiatric in-patients in Sweden equates to $21 million per annum.
Finally, Copas and Robin (1982) found that patients have an increased risk of suicide during their first week in a psychiatric facility, suggesting that the stress of a new situation, new rules and regulations can be too much for some patients in which to adjust and therefore they turn to suicide as a response. However, Qin and Nordentoft (2005) also found that suicide rates spike during the first week after a patient has been discharged. These findings suggest that readjusting to everyday life, with its stresses and problems and social issues, may be too difficult after the predictable routine of the psychiatric facility and so patients, again, turn to suicide.