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For most of us, hearing about the topic of suicide, we will associate it with psychiatric disorders. When we learn about the most frequent disorders associated with suicide attempts, mood disorders such as major depression and bipolar disorder will quickly come to mind. We should not lose sight of the fact that anxiety disorders, such as panic disorder and obsessive-compulsive disorder also carry a risk for suicidal ideation and acts.
One of the other disorders that does not receive as much attention, but equally important is anorexia nervosa. While considered a psychiatric disorder, it also carries a significant risk for medical complications. As we think about medical disorders and their association with suicidal ideation and behavior, there is not as much attention paid to the topic.
In one study of adults, they demonstrated there was an increased risk of death associated with HIV/AIDS, malignancies, Huntington disease, multiple sclerosis, peptic ulcer, renal disease, spinal cord injury and systemic lupus erythematosus.
In adolescents, research has shown those with a chronic medical condition are more vulnerable to the biopsychosocial risk factors associated with suicidal behavior. This may be mediated through the presence of comorbid depression and anxiety, poor coping strategies or illicit substance exposure. These risks, coupled with the developmental challenge adolescents face of feeling invincible, may come together to create a higher risk environment for youth with chronic medical conditions.
Heightened awareness
There is now heightened awareness to screen for potential suicide within the medical setting because of these facts. Asking about prior thoughts or behaviors, as well as current thoughts about suicide are important first steps in the prevention. Identifying patients who suffer from trauma related disorders, depression, anxiety, substance use and other psychopathology is key to the first steps in preventing self-harm.
Caregivers and parents should routinely ask about past, as well as current thoughts and actions related to self-harm. Identifying changes in social contacts and activities including increased isolation, a change in sleeping habits, weight fluctuations, and overall school performance, may be early clues that someone is requiring further evaluation and assistance.
‘Fitting in’
Another area to monitor is non-compliance with medical treatment. Caregivers and the medical team should be monitoring for subtle signs, such as not following care plans or deliberately missing medication as early indicators that there may be a problem. Open discussions are important with the patient about how they are coping, the impact of their illness on social activities, their peer group and their future plans. It is not uncommon in the quest to “fit in.” that having a chronic illness makes them feel different from their peer group.
In the discussion, it would be important to evaluate for not only the risks for suicide, but the protective factors as well. Does the person have good resilience skills? Is there a strong support network around them? Are they forward thinking?
Community and school involvement serve as critical components to assist in building resilience skills in individuals. If there is a concern for underlying psychopathology and suicide, knowing the community resources and who to turn to are important first steps. The primary pediatrician may be the first contact, or even the medical specialist, to screen and then make appropriate referrals for mental health care. Recognizing chronic medical conditions carry a significant risk to subsequent suicidal ideation and behavior is critical information in addition to screening for psychopathology in youth.
Resources
Harris, EC; Barraclough, BM, Suicide as an outcome for medical disorders. Medicine 01 Nov 1994, 73(6):281-296 DOI: 10.1097/00005792-199411000-00001 PMID: 7984079