Background Suicidal behavior is an important global health problem affecting also significant others. Both genetic and environmental influences play an important role in the development of suicidal behavior. There is a need of interventions for family and friends after a suicide attempt. The aim of this thesis was to assess the impact of family history of suicide (FHS) and early life adversity (ELA) on severity of suicidal behavior and on level of interpersonal problems in suicide attempters. Furthermore it aimed to evaluate a DBT-based skills training program, Family Connections (FC), for relatives and friends of suicide attempters. Methods Studies I and II included 181 suicide attempters. FHS was assessed with the Karolinska Self-Harm History Interview or in patient records. ELA was assessed with the Karolinska Interpersonal Violence Scale (KIVS) measuring exposure to interpersonal violence in childhood. Suicide intent was measured with the Freeman scale. Interpersonal problems were assessed with the Inventory of Interpersonal Problems (IIP). Study III, a pilot study evaluating the effect of FC for family members of suicide attempters, included 13 participants who completed the program with pre- and post-questionnaires. The experience of burden was assessed with the Burden Assessment Scale (BAS), general wellbeing with Brief Symptom Inventory (BSI) and level of depression was assessed with Beck Depression Inventory (BDI). The Swedish scale Questions About Family Members (QAFM) was used to explore the quality of the participants’ relationship with the patient and the Quality of Life Inventory (QOLI) was used to measure satisfaction with life situation. Study IV included 132 family members, and investigated the feasibility and preliminary efficacy of FC in psychiatric care. Participants were assessed pre- and post-intervention with the following self-report questionnaires: BAS, QAFM and Five Facet Mindfulness Questionnaire. Results Male suicide attempters with FHS made more serious and well planned suicide attempts and had higher suicide risk. FHS and exposure to interpersonal violence as a child were independent predictors of suicide in male suicide attempters. Regarding interpersonal problems, suicide attempters with FHS had significantly more often an intrusive personal style, indicating that they might have an impaired ability to create stable, long-lasting relationships. In the pilot study the participants reported a significant reduction in burden, an improved psychic health and an improvement in the relationship with the patient after completing FC. In the fourth study, FC showed to be feasible and effectively implemented in a psychiatric outpatient services clinic. Regarding burden, results were in line with the pilot study, with a significant reduction in all subscales in BAS. Conclusions High-risk patients call for a consideration of both ELA and FHS in clinical suicide risk assessment. In suicide attempters at biological risk, suicide might be prevented with the early recognition of environmental risks. Further, the interpersonal problems associated with FHS may cause difficulties for suicide attempters to accept or benefit from treatment, and caregivers should take into account the characteristics of the suicide attempter´s interpersonal functioning. The results from the pilot study provide support for the need and importance of an educational program addressed specifically to family members of suicide attempters. Preliminary results support the feasibility and potential value of an implementation of FC in psychiatric open care clinics.

This study examines how the taboo subject of suicide is communicated, perceived and experienced on the largest Swedish online discussion platform Flashback Forum. The aim is to describe and analyze how the subject is constructed and reconstructed in 2.484 suicide specific discussion posts initiated by suicidal individuals on the forum. The empirical material is based on 25 threads active during a one-year period. The sample was categorized by using an analytical tool designed by Malin Wreder (2007) based on concepts from Laclau and Mouffe’s discourse theory. Two conflicting approaches to suicide were identified. The suicide tolerant discourse views suicide as an accepted way out of prolonged suffering. The other suicide critical discourse has an opposing view. Within these discourses four key concepts (suicide, freedom, responsibility and future) was identified as nodal points. Frank’s theory of illness narratives was used to place the stories of the discussion participants within a larger theoretical framework. One conclusion is that the cultural preferred idea about suicide as a temporary curable condition is challenged by the suicide tolerant discourse. For a suicidal individual suffering can be experienced as eternal hence a reception with one-sided focus on restitution may hinder rather than help.

Master’s thesis submitted to Faculty of Humanities in partial fulfilment of Master of Arts: Applied Ethics for Professionals University of the Witwatersrand Department of Philosophy, 2017 / In this thesis I explore the issue of voluntary assisted suicide in a South African constitutional context through the tri-coloured normative prism of autonomy, dignity and human well-being. I will focus on the way South Africa, as a secular society, ought to engage with this highly emotive issue in light of the socio-legal framework in which we are embedded and which framework carries with it profound normative implications. I divide the discussion into two broad sections. In the first section I articulate, from an ethical standpoint, what I take to be the strongest positive case for South African society to permit voluntary assisted suicide. I argue that by permitting voluntary assisted suicide South African society would be giving proper expression to (i) individual autonomy (ii) human dignity, and (iii) human well-being. In articulating the positive case I also analyse the triumvirate concepts of individual autonomy, dignity and human well-being as well as their relationship to each other. I argue that individual autonomy is an essential component of a good human life, that is to say, a worthwhile life and that to speak of a dignified life is, in turn, to speak of the sort of life that is worthy of respect, reverence and honour. I then turn to an examination of two of the principal ethical arguments against the moral permissibility of voluntary assisted suicide in the literature, namely (i) the Sanctity of Life Argument, and (ii) the Social Harm Argument. I argue that neither argument is sufficiently persuasive to rebut the positive case in favour of voluntary assisted suicide. However, certain critical considerations are raised that do speak to the need for effective oversight and regulation of such a practice in South African society. Accordingly, I advance the view that, in light of the failure of these two principal arguments (and in the absence of any stronger arguments) voluntary assisted suicide ought to be permitted in South Africa subject to uniform, public and specifiable oversight criteria applicable to each individual who wishes to end his life with the assistance of another. In the second section, I describe the South African legal standpoint on voluntary assisted suicide in light of (i) the normative underpinnings of the Constitution of the Republic of South Africa, 1996 (and in particular the Bill of Rights) and (ii) the present legal status of voluntary assisted suicide, taking into account both the common law and the South African Law Commission Report on Euthanasia and Artificial Preservation of Life, 1998. This analysis involves an examination of (i) the recent decision of Stransham-Ford v Minister of Justice and Correctional Services & Others1 handed down on 4 May 2015 in which the North Gauteng High Court granted, for the first time in South African legal history, an application allowing a terminally ill man the right to die and to be actively assisted to do so by a consenting physician; as well as (ii) the subsequent Supreme Court of Appeal decision in The Minister of Justice and Correctional Services & Others v Estate Late Stransham Ford2 that overturned the original decision. I argue that the best way to understand the socio-legal framework in which we find ourselves is as a social contract that ‘instantiates’ or ‘gives expression to’ a rights-based ethic, which in turn protects vital human interests. I argue further that this constitutional legal framework is capable of tracking and incorporating the positive ethical case for voluntary assisted suicide admirably. Finally, I posit that the quickest and most effective way to implement a permissive policy for voluntary assisted suicide is through the development of the common law. In the process, I tentatively suggest what appropriate safeguards and oversight of voluntary assisted suicide might look like, the practical implementation of which would allow South African society – specifically through the judicial branch of government - to more sagaciously and compassionately judge lives. / XL2018

A tentativa de suicídio é uma causa muito freqüente de atendimento em urgências psiquiátricas. O presente estudo relacionou o fenômeno do suicídio com a adolescência, que é um período de conflitos e de grande vulnerabilidade. Teve como objetivo traçar um perfil epidemiológico descritivo de adolescentes, admitidos em uma unidade de emergência psiquiátrica, diagnosticados como Tentativa de Suicídio. Para isso, foram examinados todos os atendimentos de adolescentes na faixa etária entre 10 e 19 anos, admitidos na Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, com o diagnóstico referido, no ano de 2002, obtidos através do Serviço de Arquivo Médico deste Hospital. Os dados foram analisados de forma quantitativa-descritiva. Os resultados mostraram que (77,8%) dos casos de tentativa de suicídio pertencem ao sexo feminino, a maioria está na faixa etária entre 15 e 19 anos com predominância do estado civil solteiro, a cor branca e estudantes, com residência em bairros de baixo nível sócio-econômico. O método mais utilizado foi a ingestão de drogas (medicamentos) e as maiores freqüências foram encontradas nos meses de fevereiro e agosto. A segunda-feira foi o dia da semana preferido e o maior número de atendimentos foi constatado no horário entre as 18 e 24 horas. Esses resultados são semelhantes aos descritos na literatura e sugerem maior atenção a esse problema de saúde pública. / Suicide attempts are a very frequent cause of psychiatric urgency assistance. This study established a relation between the suicide phenomenon and adolescence, which is a period characterized by conflicts and great vulnerability. We aimed to outline a descriptive epidemiological profile of adolescents admitted at a psychiatric emergency unit who were diagnosed as Suicide Attempt. Thus, we examined the assistance given to adolescents between 10 and 19 years, who were admitted at the Emergency Unit of the University of São Paulo at Ribeirão Preto Medical School Hospital das Clínicas, Brazil, with the above mentioned diagnosis, in 2002. This information was obtained through the Medical Record Service of this Hospital. Data were analyzed quantitatively and descriptively. Results demonstrated that (77,8%) of suicide attempt cases refer to women, most of which are between 15 and 19 years old, predominantly single, white and students, while live in low class neighborhoods. The most frequently used method was drugs (medication) intake and the highest frequency rates were found in February and August. Monday was the most preferred day of the week and most assistance was delivered between 18 and 24 hours. These results are similar to what is found in literature and suggest that greater attention should be given to this public health problem.

Suicidal behaviors are common and problematic among young populations, and attitudes held towards such behavior likely impact the frequency of its occurrence. The present study was conducted to gain insight into the attitudes held towards suicide attempt victims amongst a traditional college population. Undergraduate students (n = 360) were administered a survey to assess demographics, suicide ideation levels, and perceptions formed after reading a short suicide attempt report. Results indicated that ideation levels had the most impact on perceptions, with ideators being significantly more likely than non-ideators to view suicide attempters as more intelligent, more justified in their actions, more likable, more trusting, and more likely to be a personal friend. These findings signify that acceptance of suicidal behavior is positively correlated with one’s own level of suicidal ideation. The understanding of these attitudes is an essential aspect to address when developing prevention programs for suicidal behaviors in the future.

Nonsuicidal self-injury (NSSI) involves the deliberate damage of one’s own bodily tissue without suicidal intent. A number of psychological disorders and indicators of distress are correlated with the behavior, including suicidal behaviors (e.g. Whitlock & Knox, 2007), depression (e.g. Ross & Heath, 2002), and anxiety (e.g. Victor & Klonksy, 2014), and yet the research literature has been mixed on whether increased frequency of NSSI is correlated with increased levels of these variables. The present study hypothesized that these relationships are curvilinear. Data from a larger study were analyzed using curvilinear regression analyses, and hypotheses were partially supported. Curvilinear relationships were found between NSSI frequency and both depression and anxiety, such that the relationships were positive until approximately 300 incidents, after which they became negative. The relationship between NSSI and suicide ideation was positive and linear. Among the whole sample, there were curvilinear relationships between both NSSI and suicide attempts as well as NSSI and suicide threats. Among only the portion of the sample who reported a history of these variables, there was no relationship between frequency and suicide attempts, and a curvilinear relationship between frequency and suicide threats that declined after 325 incidents. Results add to the current understanding of NSSI frequency and provide support for evidence that conflict with the proposed frequency criterion for nonsuicidal self-injury disorder.

In 2005, suicide was the third leading cause of death among youth 10-24 years of age in the U.S. —accounting for 4,482 deaths. Youth suicide is an important public health problem in the U.S. and research focusing specifically on gender differences is needed and warranted since recent research shows that rates of suicide attempts have increased specifically among young girls. Analyses of the recently released 2007 YRBS data (n=14,041; girls=7,036; boys=6,992) of high school students in 9-12th grades, show that 6.9% of adolescents attempted suicide (9.3% of girls versus 4.6% of boys) and 14.5% seriously considered a suicide attempt (18.7% of girls versus 10.3% of boys). Girls are 2.89 (95% CI: 2.31-3.61) times more likely than boys to report attempting suicide in the past 12 months. Moreover, girls who reported attempting suicide were significantly more likely to also report other risk factors such as depression (OR= 5.74), weapon carrying (OR= 1.48), experiencing intimate partner violence (OR=1.60), being forced to have sexual intercourse (1.72), huffing glue (OR=2.04), and being a minority (OR 1.65). However, boys who reported attempting suicide were significantly more likely to also report weapon carrying (OR=1.66), being forced to have sexual intercourse (OR=2.60), huffing glue (OR=1.63), participating in sports (OR=1.52), depression (OR=10.96), hard drug use (OR=2.18), and being a minority (OR=1.93). Furthermore, analyses of 1991 – 2007 YRBS data revealed that these gender specific risks have remained fairly constant over time. These findings will help guide prevention and intervention strategies to prevent suicide and suicidal behaviors among both girls and boys.

In 2005, suicide was the third leading cause of death among youth 10-24 years of age in the U.S. —accounting for 4,482 deaths. Youth suicide is an important public health problem in the U.S. and research focusing specifically on gender differences is needed and warranted since recent research shows that rates of suicide attempts have increased specifically among young girls. Analyses of the recently released 2007 YRBS data (n=14,041; girls=7,036; boys=6,992) of high school students in 9-12th grades, show that 6.9% of adolescents attempted suicide (9.3% of girls versus 4.6% of boys) and 14.5% seriously considered a suicide attempt (18.7% of girls versus 10.3% of boys). Girls are 2.89 (95% CI: 2.31-3.61) times more likely than boys to report attempting suicide in the past 12 months. Moreover, girls who reported attempting suicide were significantly more likely to also report other risk factors such as depression (OR= 5.74), weapon carrying (OR= 1.48), experiencing intimate partner violence (OR=1.60), being forced to have sexual intercourse (1.72), huffing glue (OR=2.04), and being a minority (OR 1.65). However, boys who reported attempting suicide were significantly more likely to also report weapon carrying (OR=1.66), being forced to have sexual intercourse (OR=2.60), huffing glue (OR=1.63), participating in sports (OR=1.52), depression (OR=10.96), hard drug use (OR=2.18), and being a minority (OR=1.93). Furthermore, analyses of 1991 – 2007 YRBS data revealed that these gender specific risks have remained fairly constant over time. These findings will help guide prevention and intervention strategies to prevent suicide and suicidal behaviors among both girls and boys.

<p>Finding an indicator that can point to a high risk group for suicide has long been a desirable aid for the prevention of completed suicides. The studies reviewed in this essay presume that a biological aspect can point out the high risk individual. The focus of the studies lies on the serotonin 5-hydroxytryptamine (5-HT) monoamine neurotransmitter and cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5-HIAA) which is the principal metabolite of 5-HT in depression. The studies on 5-HT metabolites have led to the belief that these may play a key role in the neurochemistry of suicidal behaviour. It is suggested that the core behavioural effect of low CSF 5-HIAA concentration might result in an increase in impulsive and violent behaviour to self and others. The predictability is based on the fact that patients with low CSF 5-HIAA are more prone to reattempt and complete suicide by violent means. A number of well-designed studies concerning suicidal individuals and control subjects have however not shown any difference in concentration of CSF 5-HIAA in suicide attempters compared to non-suicide attempters which could be explained by methodological flaws. Low CSF 5-HIAA does seem to characterize the high risk individual, but it is not yet determined what role it plays in actual suicidality.</p>

A tentativa de suicídio é uma causa muito freqüente de atendimento em urgências psiquiátricas. O presente estudo relacionou o fenômeno do suicídio com a adolescência, que é um período de conflitos e de grande vulnerabilidade. Teve como objetivo traçar um perfil epidemiológico descritivo de adolescentes, admitidos em uma unidade de emergência psiquiátrica, diagnosticados como Tentativa de Suicídio. Para isso, foram examinados todos os atendimentos de adolescentes na faixa etária entre 10 e 19 anos, admitidos na Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, com o diagnóstico referido, no ano de 2002, obtidos através do Serviço de Arquivo Médico deste Hospital. Os dados foram analisados de forma quantitativa-descritiva. Os resultados mostraram que (77,8%) dos casos de tentativa de suicídio pertencem ao sexo feminino, a maioria está na faixa etária entre 15 e 19 anos com predominância do estado civil solteiro, a cor branca e estudantes, com residência em bairros de baixo nível sócio-econômico. O método mais utilizado foi a ingestão de drogas (medicamentos) e as maiores freqüências foram encontradas nos meses de fevereiro e agosto. A segunda-feira foi o dia da semana preferido e o maior número de atendimentos foi constatado no horário entre as 18 e 24 horas. Esses resultados são semelhantes aos descritos na literatura e sugerem maior atenção a esse problema de saúde pública. / Suicide attempts are a very frequent cause of psychiatric urgency assistance. This study established a relation between the suicide phenomenon and adolescence, which is a period characterized by conflicts and great vulnerability. We aimed to outline a descriptive epidemiological profile of adolescents admitted at a psychiatric emergency unit who were diagnosed as Suicide Attempt. Thus, we examined the assistance given to adolescents between 10 and 19 years, who were admitted at the Emergency Unit of the University of São Paulo at Ribeirão Preto Medical School Hospital das Clínicas, Brazil, with the above mentioned diagnosis, in 2002. This information was obtained through the Medical Record Service of this Hospital. Data were analyzed quantitatively and descriptively. Results demonstrated that (77,8%) of suicide attempt cases refer to women, most of which are between 15 and 19 years old, predominantly single, white and students, while live in low class neighborhoods. The most frequently used method was drugs (medication) intake and the highest frequency rates were found in February and August. Monday was the most preferred day of the week and most assistance was delivered between 18 and 24 hours. These results are similar to what is found in literature and suggest that greater attention should be given to this public health problem.