ON SUICIDE AND DELIBERATE SELF HARM

SUICIDE AND DELIBERATE SELF-HARM

Suicide and deliberate self harm are among the most common manifestations of psychiatric illness, often being their first presentation in the accident and emergency department. Indeed DSH is the most common reason why women under the age of 65 years attend hospital in the UK, and the second most common for men of the same age group, after ischaemic heart disease.

Now this is incredible, and an even more major concern arises with the terrible prognosis following deliberate self harm – 1% will commit suicide in the next year, and 10% will commit suicide in the next 10 years after a DSH attempt. About a quarter of those successful at committing suicide attend hospital in the year prior. Thus the deep importance of early hospital intervention when a patient with overdose presents.

Over 90% of cases of DSH involve drug overdose and the rest are mostly self-injury of some sort.

It is impossible to predict who is going to successfully commit suicide and who isn’t; this reminds me of the he novel, ‘The Virgin Suicides’ by Jeffrey Eugenides:

“In the novel, the narrator describes the reactions of several teenaged boys to the suicides of five sisters. The boys keep a collection of the dead girls' belongings, repeatedly sifting through them in a vain attempt to understand their deaths…In the end we had the pieces of the puzzle, but no matter how we put them together, gaps remained, oddly shaped emptinesses mapped by what surrounded them, like countries we couldn't name.” (Eugenides 1993, 246)”.

However, there are two common factors among all of those who commit suicide, or at high risk of suicide. Firstly, the fact that “clinicians have always known to be true... (That) people who die by suicide do not want to die. They simply want to end the pain. If there were another way to end the pain, they would choose it”. Geo Stone put it thus:

“Thousands of books have attempted to answer the question of why people kill themselves. To summarize their findings in three words: to stop pain. Sometimes this pain is physical, as in chronic or terminal illness; more often it is emotional, caused by a myriad of problems. In any case, suicide is not a random or senseless act, but an effective, if extreme, solution.”

Secondly, is that fact that they are invariably irrational and sad, and there is definitely a connection between the two – the sadder you are, the more irrational you can become. And the more irrational you are the sadder you can become.

Combined, these two factors constitute what I have mentioned in the very first chapter of this work – that suicidal people (and those with suicidal tendencies) have lost a sense of purpose in life. They have lost the answer to that, the deepest of all philosophical questions - what is the purpose of life? What is the purpose of humanity? What is the meaning of it all.
They are not to blame for this. This is related to the crisis of modern civilisation. Alexis Carrel put it this way in his, ‘Reflections on Life’:

“Modern society has been preoccupied with material values. It has neglected fundamental human problems, which are both material and spiritual. Not only has it not brought us happiness but it has shown itself incapable of preventing our deterioration. The conquest of health is not enough. We must also bring about in every individual the finest development of his hereditary power and of his personality, for the quality of life is more important than life itself”.

A contemporary psychiatrist, Dr. Victor Frankl also made the following testimony about his practice:

“More and more of our patients are crowding out our clinics and consulting rooms complaining of an inner emptiness, a sense of total and ultimate meaninglessness of their lives.”

The American philosopher James Christian explains:

“Modern humans are caught in an ‘existential vacuum’…We are struck with the total meaninglessness of our lives. Increasingly we find nothing worth living for. There is an inner emptiness within us all. We can understand this spiritual void, for it has two sources that have emerged since we began to be human beings. The first was the loss of our instincts, that set of instructions that we, along with all the other animals, carried embedded in our very natures. That was an ancient loss. A more recent trauma to our souls happened when we lost the binding myths and traditions that secured our behaviour. Modern man is therefore lost, Frankl writes, “for no instinct tells him what to do, and no tradition tells him what he ought to do; soon he will not know what to do””.

That indeed is the most difficult of questions. Why live. Why continue in the face of all the pain that pervades all of life.

It is clear that it is not the events themselves that occur to people’s lives that determine their wish for suicide. If that were the case, then all great men and women, who faced tragedies or very difficult times, would have implemented it. Indeed, many have contemplated it. But very few actually did it. To give an extreme examples, Victor Frankl, a victim of the Holocaust, did not commit suicide, despite being imprisoned in a Nazi concentration camp, where he ““found himself stripped to naked existence”, (having) lost all his immediate family except his sister; they had either died in the camps or been sent to the gas ovens…(he) lost everything a human normally values in life – possessions, loved ones, hope, self-esteem, ideals – and (faced) at any moment starvation, pain, and even extermination”. Instead he lived to the grand old age of 92, and spent his life teaching people about the meaning of life, and how to live it. He found a purpose in life, and taught that, “To live is to suffer, to survive is to find meaning in the suffering.” James Christian elaborates:

“If a human life has meaning at all, then there must be meaning in all of it, including especially one’s suffering and dying. This is a very private journey that each person must undertake for himself. No one can tell another what that purpose is, or how to find it. And when the answer is finally found, it must be accepted and lived. If one succeeds in giving his suffering meaning, then one will continue to grow no matter what happens. Frankl liked to quote Nietzsche, “He who has a why to live can bear with almost any how””.

Another great man who considered suicide when young was the great Bertrand Russell, who when young became very isolated, and was “rendered very unhappy by the gradual loss of belief,” to the extent that he used to go alone in his youth, to “a footpath leading across fields to New Southgate…to watch the sunset and contemplate suicide”. He did not, because he “wished to know more of mathematics” (Russell, ‘Autobiography’, p.36-38). He too lived to the grand old age of 97, contributing to the worlds of mathematics, philosophy and many other topics in his time.

Alas, the exhilarating pace of modern life allows for minimal time for contemplation, or even the ability to contemplate. The instincts of man and the demands of everyday living take priority, for without them, life becomes impossible. When faced with a ‘tragedy’ related to them, man is blown away in a state of shock. Because he or she often does not have the answer to the question, “can life continue beyond this? Should life continue beyond this?” the possibility of suicide raises itself strongly. Ill-equipped with prophylaxis against suicide, and pro-life advice, it becomes almost a necessity.

And herein lays the greatest problem. The atheist or agnostic, who has no predetermined purpose in life, who has to rely on his or her own judgements and ability to devise a meaning for their life, who has not found a deeper meaning of his or her own life by the time of a great tragedy, is at the highest risk of suicide. There is no doubt about it.

And what is worst, is that he or she can never provide a solution to the problem of suicide, the problem Albert Camus described as the “one truly serious philosophical problem”. This is because the atheist (or agnostic, which I regard as a synonym) has no higher purpose in life. To him, the world has no meaning except the meaning they impart to it themselves. Bertrand Russell, the agnostic, put it this way:

“I do not think that life in general has any purpose. It just happened. But individual human beings have purposes, and there is nothing in agnosticism to cause them to abandon these purposes.”

A contemporary writer, David Hren, writes:

“Atheists think that purpose in life is subjective and not dependent on what a god has decided. An atheist may think there is no purpose to their life. That life just is. However, many atheists believe that their purpose is what they make of it: without the need of a god to provide a purpose.”

The latter proceeds to say, “Many atheists live a purposeful life. They decide what they think gives meaning to life, and they pursue those goals. They try to make their lives count, not by wishing for eternal life, but by having an influence on other people who will live on. For example, an atheist may dedicate his life to political reform, in the hope of leaving his mark on history”, as if atheist societies and other societies neglectful of God are the ultimate examples of altruism and humanity.

He then proceeds to talk about answer the question, "So how do atheists find comfort in time of danger?", saying, “There are many ways of obtaining comfort (for an atheist): Your family and friends, pets, food and drink, music, television, literature, arts and entertainment, sports or exercise, meditation, psychotherapy, drugs and work”. I am yet to read a more superficial answer than that. What if one does not have a family, or friends, or pets, or cannot afford food and drink, or listen to music, or watch television or the other forms of entertainment he mentions. What if work is making one suicidal?

Geo Stone, author of the once best selling, ‘Suicide and Attempted Suicide’ brilliantly put the reason why people commit suicide as follows:

“Thousands of books have attempted to answer the question of why people kill themselves. To summarize their findings in three words: to stop pain”.

The atheist commits suicide with belief in two things – firstly, the belief that life has no meaning beyond that which we impart to it ourselves, which by necessity, is transitory. Secondly, that the pain which one became suicidal for would end completely with the act.

The true theist, with a wholehearted belief in God cannot commit suicide, because he or she believes that life has a predetermined meaning, independent of us. It is the worship of God. To the Christian, this is a belief embodied in many verse of the Bible, such as Colossians (1:16), "All things were created by him and for him." and Isaiah (43:21), “The people which I formed for Myself, that they might tell of My praise”. To the Muslims, two similar verses embody that belief, “I have created not the jinn and men except that they should worship Me” (51:56-58) and, “So glorify the praises of your Lord and be of those who prostrate themselves (to Him). And worship your Lord until there comes unto you the Hour that is certain (i.e., death)” (15:98-99).

The belief in God, and in this duty of man – which is to worship Him, is the only 100% effective prophylaxis against suicide. It spares man from ‘worship’ of desire, which is essentially what every one who commits himself or herself to something other than God does:

“O you who have attained to faith! Be ever steadfast in upholding equity, bearing witness to the truth for the sake of God, even though it be against your own selves or your parents and kinsfolk. Whether the person concerned be rich or poor, God's claim takes precedence over [the claims of] either of them. Do not, then, follow your own desires, lest you swerve from justice: for if you distort [the truth], behold, God is indeed aware of all that you do!” (4:135).

“Have you seen him who takes his desires for his god? Will you then be a protector over him?” (25:43).


With attachment to the most beautiful, eternal One, man is spared allegiance to all transient things, for how could man desire anything more than that.

With a true belief in God, there would be no romantic suicides, none of that, "My life is not worth living without him”, a sentiment most celebrated among the young, as in Romeo and Juliet, though nowadays it is more common to find the cause of death not the death of a loved one but separation because one partner left. As I said before, I am yet to see, in my medical practice a man or woman who has attempted to commit suicide for a reason other than a relationship breakdown or difficulty. Here is one real life example:

“I was really upset and depressed. My life just seemed to be in total chaos. My boyfriend just dumped me flat, and he said he loved the other girl and didn't love me at all. My parents and I also just got into another fight again about some really dumb things, so I just went into my room and closed the door. There was this bottle of sleeping pills my mother was using, and I had them with me. I sat and stared at it for a long time, weighing out the good and the bad things in my life. The bad things came out ahead. I poured some of the pills in my hand, and figured ten or fifteen ought to be enough to do it. Those pills... they all looked so innocent and peaceful, like they couldn't do much to hurt anyone. Well, I put them in my mouth and held them there for a long time, wondering if I should or shouldn't. I took a glass of water and swallowed. At first nothing happened, and then they all hit me at once. The room started to blur and spin, small sounds were going on in my head. The last thing I remembered was trying to move and not being able to. I woke up in the hospital. They were pumping out my stomach—one of the worst things you can have done to you. My mother came into the room, and she apologized for the fight we had.”

There would be no political suicides in the manner of the Hamas or the Japanese Kamikazes, for allegiance cannot be for a nation, but only to the Eternal One, who says clearly, "And do not kill yourselves, surely God is most Merciful to you" (4:29). The same verse applies to those who are commit euthanasia, to alleviate pain and suffering due to disease.

There would also be no guilt related suicides. This is because God, the only One who matters, is forgiving, saying:

“O you servants of Mine who have transgressed against your own selves! Despair not of God’s mercy: behold, God forgives all sins - for, verily, He alone is much-forgiving, a dis­penser of grace!’” (39:53).

He or she might have done the worst sins, but He is the most kind and forgiving. Not having cultural approval or recognition could be extremely painful. There can be no doubt about that. This is how William James described it as follows:

"No more fiendish punishment could be devised, were such a thing physically possible, than that one should be turned loose in society and remain absolutely unnoticed by all the members thereof. If no one turned around when we entered, answered when we spoke, or minded what we did, but if every person we met 'cut us dead', and acted as if we were non-existing things, a kind of rage and impotent despair would be fore long well up in us, from which the cruellest bodily torture would be a relief."

Apparently, because of guilt, not so long ago, “the president of a Japanese company whose food product had accidentally poisoned some people killed himself as an acknowledgment of responsibility for his company's mistake”. In 1986, about 275 Japanese directors committed suicide for similar reasons. Of course, this is not a common reason for committing suicide in Europe or America.

Belief in God is belief in the eternal one. And with attachment to this most beautiful idea comes belief in eternal bliss, that all pain and agony is transient, that all will end well. It tells us that pain and agony are meaningful, and is merely a test. The Quran makes this no clear in so many places:

“He Who created Death and Life, that He may try which of you is best in deed, and He is the Exalted in Might, Oft-Forgiving”(67:2).

“And surely We shall try you with something of fear and hunger, and loss of wealth and lives and crops; but give glad tidings to the steadfast. Who say, when a misfortune striketh them: Lo! We belong to God and Unto Him we are returning. Such are they on whom are blessings from their Lord, and mercy. Such are the rightly guided” (2:155-7).

"God puts no burden on any person beyond what He has given him. After a difficulty, God will soon grant relief" (65:7)

“And, behold, with every hardship comes ease: Verily, with every hardship comes ease! Hence, when thou art freed [from distress], remain steadfast, and unto thy Sustainer turn with love” (94:5-8).

Similarly, with this belief in eternal bliss, there is a belief in eternal pain. Leo Tolstoy used this argument well in an essay devoted to the subject, an extract of which follows:

“The question can only be as to whether it is reasonable and moral (the reasonable and moral always coincide) to kill oneself. No, it is unreasonable; as unreasonable as to cut off the shoots of a plant which one wishes to destroy; it will not die, but will merely grow irregularly..

Life is indestructible; it is beyond time and space, therefore death can only change its form, arrest its manifestation in this world. But having arrested it in this world, I, first, do not know whether its manifestation in another world will be more pleasant to me; and, secondly, I deprive myself of the possibility of experiencing and acquiring by my ego all that could be acquired in this world.

Besides this, and above all, it is unreasonable because by arresting my life owing to its apparent unpleasantness, I hereby show that I have a perverted idea of the object of my life, assuming that its object is my pleasure - whereas its objects, on the other hand, personal perfection, and on the other, the service of that work which is being accomplished by the whole life of the Universe.

It is for the same reason that suicide is also immoral. Life in its entirety, and the possibility of living until natural death, have been given to man only on the condition that he serve the life of the Universe. But, having profited by life so long as it was pleasant, he refuses to serve the Universe as soon as life becomes unpleasant: whereas, in all probability, his service commenced precisely when life began to appear unpleasant. All work appears at first unpleasant.

In the Optin Monastery, for more than thirty years, there lay on the floor a monk smitten with paralysis, who had the use of his left hand only. The doctors said that he was sure to suffer much, but not only did he refrain from complaining of his position, but incessantly making the sign of the cross, and looking at the ikons, he smilingly expressed his gratitude to God and joy in that spark of life which flickered in him. Tens of thousands of visitors came to see him, and it is difficult to imagine all the good which flowed into the world through this man, though deprived of the possibility of any activity. Certainly he did more good than thousands and thousands of healthy people who imagine that in various institutions they are serving the world.

While there is life in man, he can perfect himself and serve the Universe. But he can serve the Universe only be perfecting himself, and perfect himself only by serving the Universe.”

With belief in God, people have a subconscious fear of Him. They do not need to reason about a purpose of life, because it has already been reasoned out for them. He or she therefore simply cannot commit suicide.

But if belief in God is such an effective prophylactic mechanism against suicide, then how is it that several God-believing philosophers believed in the permissibility of suicide. The likes of Voltaire, believed in the permissibility of suicide, saying, “Why should the suicide of a general be contrary to Christianity when killing in war is not”, a man who “defended suicide on the grounds of extreme necessity and pointed out that if suicide is a wrong against society then the homicide of war was far more harmful”, or Jean-Jacques Rousseau, who romanticised suicide, and who possibly died after a suicide (according to Russell, “his last years were spent in Paris in great poverty, and when he died suicide was suspected”), and Johann Wolfgang von Goethe, who “having experienced suicidal thoughts himself was also ready to condone it”. How do we explain this?

In addition, if one looks at the list of countries with the highest suicide rates in the world, ones sees quite a few countries where the official religion is not atheism, but Christianity. The highest rate of suicide is that of Lithuania, followed Belarus, Russia, Kazakhstan, Slovenia and Hungary. All these nations have a predominantly Christian population. Lithuania’s population in 79% Roman Catholic, while Protestant and Orthodox Lithuanians constitute another 7%. The majority of Belarusians are Orthodox. Only 16% of Russians are atheists, with the majority professing Orthodox Christianity.

The answer to this question lies in the fact that these people have a distorted view of God and religion. Many early Christians for instance, were actually not opposed to suicide, for example, the Donatists and the Catharists. Geo Stone elaborates:


“Early Christianity was strongly attracted toward suicide, perhaps because the act was often indistinguishable from martyrdom, and, "even the death of Jesus was regarded by Tertullian, one of the most fiery of the early Fathers, as a kind of suicide. He pointed out, and Origenb [another major early Christian theologian] agreed, that He voluntarily gave up the ghost, since it was unthinkable that the Godhead should be at the mercy of the flesh." While early Christianity accepted suicide, it condemned killing others through warfare, in self-defense, and by capital punishment. After all, Jesus had taught nonviolence: "Do not resist one who is evil. But if anyone strikes you on the right cheek, turn to him the other also.... I say to you, Love your enemies and pray for those who persecute you." This was taken seriously by the early church fathers, for example, Tertullian, who asked, "Can it be lawful to handle the sword, when the Lord himself has declared that he who uses the sword shall perish by it?"”

William E. Phipps, a professor of religion and philosophy at Davis and Elkins College in West Virginia also expresses the same idea, using a specific example:

“In early Christianity, suicide was sometimes regarded as a virtuous act. Eusebius, in his account of martyrs at Antioch (Ecclesiastical History, Book 8, chapter 12), tells of a mother who taught her two beautiful unmarried daughters to regard rape as the most dreadful thing that could happen to them. Eventually the mother and daughters were captured by a band of lustful soldiers. On realizing their plight, they modestly requested to be excused for a minute. They then threw themselves into a nearby river and drowned”

It was only later, at around St. Augustine’s time, that Christianity changed its beliefs. How a religion that regards itself as truthful can change itself so dramatically over what is really a short space of time, I do not know. In any case, the reason for the higher prevalence of suicide in those nations may be due to this confusion.

The other reason for the higher prevalence of suicide in those nations may be in the residual impact of many long years of state atheism that was endorsed by the communist doctrines. All of Lithuania, Belarus, Russia and Kazakhstan (and Latvia and Ukraine are not far behind either) were parts of the former USSR, the Marxist nation that believed after its founder, Vladimir Lenin, that:

“Religion is the opium of the people: this saying of Marx is the cornerstone of the entire ideology of Marxism about religion. All modern religions and churches, all and of every kind of religious organizations are always considered by Marxism as the organs of bourgeois reaction, used for the protection of the exploitation and the stupefaction of the working class.”

It is clear that only solid religion, without contradiction, is the only thing can protect someone against suicide. This, in my opinion, can only be the religion of ‘submission to God’ (Islam) or ‘deism’. And indeed, deists believe, with Muslims that:

“Suicide is a huge mistake….suicide should never be thought of as an option. It breaks the contract that was made with the Deity prior to the person's incarnation in this lifetime. It causes horrendous suffering, in most cases, among the family members that are left behind. Worst of all, it is a step backward for the deceased person on his or her path of spiritual evolution”.

Christianity is a weak faith, and cannot withstand even the mildest intellectual assault. Japan has a high suicide rate, something pointed out recently very vividly by Leo Lewis in an article in ‘The Times’ (June 19, 2008), ‘Japan gripped by suicide epidemic’. The Japanese are generally Godless, with atheist Buddhism and Shintoism common.

Voltaire, Rousseau and Goethe were all opposed to religion. Voltaire, as his biographers state, “could best be described as a deist who believed in an impersonal, possibly amoral, God. He did not believe in an afterlife, miracles, or revelation.” Rousseau, his contemporary also had similar tendencies, as did most of the men of the Enlightenment. As for Goethe, who did have a belief in an afterlife, the basis for his belief was not religion, but as he expresses somewhere that “he simply could not conceive of himself as not existing”. This is twisting life and religion in accordance with one’s wishes and desires, and failing to confront the truth, the truth that even a simple peasant knew, as Miguel de Unamuno describes in his ‘Tragic Sense of Life’:

“Talking to a peasant one day, I proposed to him the hypothesis that there might indeed be a God who governs heaven and earth, a Consciousness of the Universe, but that for all that the soul of every man may not be immortal in the traditional and concrete sense. He replied: "Then wherefore God?" So answered, in the secret tribunal of their consciousness, the man Kant and the man James. Only in their capacity as professors they were compelled to justify rationally an attitude in itself so little rational. Which does not mean, of course, that the attitude is absurd”.

It is for this reason that God did not simply say belief in Him alone is enough to get to paradise, but belief in the afterlife (and of course, good actions)is just as important:

“Lo! Those who believe, and those who are Jews, and Sabaeans, and Christians - Whosoever believeth in God and the Last Day and doeth right - there shall no fear come upon them neither shall they grieve. (5:69)”

“Lo! Those who believe (in that which is revealed unto thee, Muhammad), and those who are Jews, and Christians, and Sabaeans - whoever believeth in God and the Last Day and doeth right - surely their reward is with their Lord, and there shall no fear come upon them neither shall they grieve (2:62)”

It will be seen that all those philosophers who believed in the permissibility of suicide did not believe in God (and therefore religion). The great David Hume, for instance, writing in his posthumously published essay, ‘On Suicide’, says:

“Has not every one, of consequence, the free disposal of his own life? And may he not lawfully employ that power with which nature has endowed him? In order to destroy the evidence of this conclusion, we must shew a reason why this particular cafe is excepted; is it because human life is of such great importance, that 'tis a presumption for human prudence to dispose of it? But the life of a man is of no greater importance to the universe than that of an oyster. And were it of ever so great importance, the order of human nature has actually submitted it to human prudence, and reduced us to a necessity, in every incident, of determining concerning it. -- Were the disposal of human life so much reserved as the peculiar province of the Almighty, that it were an encroachment on his right, for men to dispose of their own lives; it would be equally criminal to act for the preservation of life as for its destruction. If I turn aside a stone which is falling upon my head, I disturb the course of nature, and I invade the peculiar province of the Almighty, by lengthening out my life beyond the period which by the general laws of matter and motion he had assigned it.”

Of no importance than that of an oyster! This same pro-suicidal philosophy was advocated later by John Stuart Mill, the father of Utilitarianism, who believed that the individual is the best guardian of his or her own interests:

“Mill uses the example of a man about to cross a broken bridge: we can forcibly stop him and warn him of the danger he faces if he continues but ultimately we should not prevent him from crossing the bridge; for only he knows the worth of his life balanced against the danger of crossing the bridge. Thus, if an individual views their life as unlivable it would appear well within their rights to end it.”

The same goes for Arthur Schopenhauer, the father of philosophical pessimism, who stated:

“They tell us that suicide is the greatest piece of cowardice... that suicide is wrong; when it is quite obvious that there is nothing in the world to which every man has a more unassailable title than to his own life and person.”

The view of his successor, Friedrich Nietzsche is a bit more complicated. Then again, one can find almost anything in his works. In his work, ‘Beyond Good and Evil’, he remarks that, “The thought of suicide is a great source of comfort: with it a calm passage is to be made across many a bad night”. However, one gets the impression overall that this man, the Champion of the Ubermensch, the Superman, would not want to concede defeat in life. He would then be the first of the anti-suicide atheists. Thomas Szasz, a pro-suicide philosopher and professor of psychiatry who is most renowned for his widely different view of psychiatric illness, wrote about him in his “Fatal Freedom: The Ethics and Politics of Suicide”:

“Nietzsche's teaching is all in the other direction. He urges, not surrender, but battle; not flight, but war to the end. His curse falls upon those "preachers of death" who counsel "an abandonment of life" - whether this abandonment be partial, as in asceticism, or actual, as in suicide. And yet Zarathustra sings the song of "free death" and says that the higher man must learn "to die at the right time." Herein an inconsistency appears, but it is on the surface only. Schopenhauer regards suicide as a means of escape, Nietzsche sees in it as a means of good riddance. It is time to die, says Zarathustra, when the purpose of life ceases to be attainable - when the fighter breaks his sword arm or falls into his enemy's hands. And it is time to die, too, when the purpose of life is attained - when the fighter triumphs and sees before him no more worlds to conquer. "He who hath a goal and an heir wisheth death to come at the right time for goal and heir." One who has "waxed too old for victories," one who is "yellow and wrinkled," one with a "toothless mouth" - for such an one a certain and speedy death. The earth has no room for cumberers and pensioners”
I conclude saying what is obvious, that a happy person will not commit suicide. A rational person will not commit suicide. A person with a sense of purpose in life will not commit suicide. Yet, every 40 seconds in this world, someone commits suicide. It can be concluded that because we are living in the saddest, most irrational of ages, the age of purposelessness, the only cure for the disease that is suicide is in bringing people back to a sense of purpose in life, to happiness, to rationality.

And that means a return to God, and a belief in an afterlife. Only God imparts true meaning to life. If one knows his or her sole purpose on earth is to worship the Everlasting God, then all that is transient takes an infinitesimal significance compared to that great purpose. Be it separation from a husband, wife or partner, the death of a loved one, or anything else. Given, one would be sad at those events, but the sadness cannot possibly overwhelm the desire to please God and attain that great goal, that of wholehearted worship.

RISK FACTORS FOR SUICIDE

There are a number of well established risk factors which should be borne in mind with every patient who presents with deliberate self harm. These are remembered as SAD PERSONS:

Sex (male)
Age > 45 / Alone
Depression or other psychiatric illness
Previous parasuicide
Excess ethanol or other drug abuse
Rational thinking loss (including psychosis)
Social support lacking (including religious, divorced, widowed, unemployed, isolation)
Organized plan (e.g. suicide note, well thought out)
No pastimes
Sickness (e.g. chronic pain) / Stated future intent to DSH

About 90% of cases involve drug overdose (e.g. paracetamol) and 10% involve self-injury (e.g. self-laceration of forearms/wrists).

The most common drugs taken are paracetamol, aspirin and other NSAIDs, as well as benzodiazepines and antidepressants, with alcohol in most instances. In younger individuals, ingestion of household items (e.g. bleach and solvents) is common.

Just a few words about those overdoses – the liver, as I mentioned before, is a quite magnificent organ, capable of withstanding much assault. But in the face of a sudden assault of 12 g of paracetamol (that’s 24 tablets– six times more than the maximal allowed intake) or 21 g of aspirin (that’s 70 tablets (300 mg)) – that’s 69 more tablets than recommended), the liver (as well as the kidneys) gives up. God has gifted the human being with just enough glutathione to protect the liver. Alas, with some cases of suicide, this may not be enough.

Paracetamol is rapidly absorbed from the stomach and upper small bowel and is metabolised by conjugation in the liver. Hepatic necrosis occurs due to the toxicity of an alkylating metabolite that is normally removed by conjugation with glutathione; glutathione is rapidly depleted with overdose and may already be low in starvation, alcoholics and, possibly, HIV disease, thus predisposing these groups to an increased risk of toxicity. Toxicity is usually asymptomatic for 1–2 days although laboratory assessment of liver function may become abnormal after 18h. Hepatic failure, if manifest, develops after 2–7 days, an earlier onset being associated with more severe toxicity.



HISTORY

The most important aspect of taking a history of a suicidal patient, once the patient is stabilised is to ask the following questions:

Who – who was with you at the time? A collateral history can be very useful, especially if the patient is drunk, drowsy or upset.

When – this is vital especially in paracetamol overdose; we check INR and paracetamol levels at least 4 hours after the event; it is unreliable before this.

Where – if patient was hiding away in a place where no one else may notice, it is considered a high suicide risk.

How – how much was taken? How did they take the drug (orally or through other routes)? With aspirin, the toxicity ranges from mild (with 150 mg a kg) to severe (>500 mg a kg). With paracetamol, 150 mg a kilogram may be fatal (or 12 g in adults).

What – what else did they take? Often patients take these things with alcohol. Ask specifically about this; hypoglycaemia resulting from alcohol and paracetamol induced hepatotoxicity could be fatal – a blood glucose (BM would do) is vital in all cases of paracetamol overdose.

Why – why did they do it & do they regret it

Assess suicide risk and do a psychiatric history if you can – the very basics are asking for symptoms of psychiatric disease, e.g. depression, psychosis.

Take the rest of the history as usual – PMH, DH, FH, SH, ROS

In the unconscious patient, a history from friends or relatives is helpful, and the diagnosis can often be inferred from tablet bottles or a suicide note brought by ambulance attendants.

PHYSICAL EXAMINATION

This aims to look for features of injury and look for signs of drug toxicity. The first thing is to look at the patient and do a general examination. Often they may be acutely unwell, or in the case of a paracetamol overdose, which takes a while to cause damage, deceptively well. A toxic dose of any drugs will cause a reduced GCS. As we explained before, consciousness, the most advanced property of man, is dependent on the integrity of all other fundamental physiological functions. The ability to maintain a normal airway, breathing and circulation, and the ability to maintain temperature, acid-base, glucose homeostasis, and to spare the brain the possibility of irritation by toxins; these are the prerequisites for consciousness. Hence, there are many possible mechanisms for a reduced GCS in poisoning attempts:

Respiratory depression – caused by opiates and benzodiazepines; an action worsened in the latter by concomitant alcohol, which acts via the same GABA receptors.
Respiratory stimulation – tachypnea can occur in poisoning due to direct respiratory centre stimulation, for instance by aspirin and salicylates, or aspiration pneumonia secondary to vomiting. It is important to nurse the patient in the semi prone position, and possibly insert an NG tube, to stop aspiration.

3. Hypertension – with cocaine and other stimulants such as amphetamines

Hypotension - all CNS depressants can depress blood pressure, such as benzodiazepines, barbiturates, alcohol). In addition, all drugs that cause a severe tachycardia may diminish cardiac output (see next).

Tachycardia with stimulants, TCAs, salbutamol and quinine.

Bradycardia – with beta blockers and other antiarrhythmics

Hypothermia - alcohol, opioid, antipsychotics (due to antihistaminergic effect) and barbiturates

Hyperthermia – with ecstasy, amphetamines, cocaine and other stimulants.

Acidosis or alkalosis – this may be due to alcohol, ethylene glycol, methanol, paracetamol, or carbon monoxide poisoning. Initially, salicylates such as aspirin cause a respiratory alkalosis, but then they cause a metabolic acidosis. This can also be mediated by causing renal failure or hepatic failure.

Hypoglycaemia – this may be caused by insulin and other anti-diabetics, as well as alcohol, salicylates and paracetamol. Salbutamol can also cause it.

Hyperglycaemia – may be caused by excess theophyllines (tea with sugar).

Thus regular observations are necessary; the ABG becomes part of general observations, as it gives both the acid-base balance and the blood sugar.

The patient may show features of JACCOL; he may be jaundiced (usually later on in paracetamol poisoning), cyanosed with opiate or carbon monoxide poisoning.

Then the patient is examined fully; chronic liver disease signs may point to a long history of alcohol abuse. Look at the eyes; remember you get ‘fat’ (dilated) pupils in stimulant overdose (amphetamines, cocaine, ecstasy, antidepressants, antipsychotics) and constricted pupils in opiate overdose. Opiates depress everything. Remember; MorPHINE: Fine. AmPHETamine: Fat:

Morphine overdose: pupils constricted (fine).
Amphetamine overdose: pupils dilated (fat).

The following diagram illustrates some common clinical features of some types of poisoning:


INVESTIGATIONS

Investigations in cases of drug overdose must include a toxicology screen – which routinely includes paracetamol and salicylate levels. Other blood or urine tests are indicated by the possibility of other drugs ingestion and index of suspicion. Other blood tests include FBC, glucose, LFTs, U&Es and clotting. Use TOXBASE to guide.

TREATMENT

Manage as you would any emergency if the patient is unstable, using ABCDEFG & MOVE. The subsequent management involves consulting TOXBASE and 5A:

Admit – if necessary use the MHA
Activated charcoal (reduce absorption) – use 50 g with water for paracetamol and salicylates, if presented within an hour of ingestion. Repeat every 4 hours if certain other drugs, e.g. theophyllines, digoxin, phenytoin.
Alkaline diuresis (severe NSAID overdose) (or other methods of increasing elimination, e.g. haemodialysis, haemofiltration)
Antidote – this depends on the toxin; only a few antidotes are available:


Assessment (full psychiatric)

With paracetamol poisoning, the mainstay of management is N-acetylcysteine, which acts to restore hepatic glutathione levels by increasing intracellular cysteine levels.

What is interesting to know about N-acetylcysteine, which is an extremely useful drug when used appropriately and within the correct time, is that it is using already endogenous mechanisms of protection. Here he is again, the physician not doing anything out of the ordinary, but exploiting what already is, what God has already bestowed man.

Glutathione is synthesized from three amino acids in a two-step process, beginning with the combination of glutamic acid and cysteine and ending with the addition of glycine. The liver (and lungs) are the primary sites of glutathione synthesis. Glycine and glutamic acid are plentiful in cells, so it is the availability of cysteine that controls the synthesis of glutathione.


A liver specialist centre should be consulted if the patient has any of the following features:

COACH

Clotting impairment (INR >3 on day 2 or >4 thereafter)
Oliguria or renal impairment
Acidosis (arterial pH < 7.3)
Consciousness impaired
Hypoglycaemia

Guidelines for liver transplantation are:

Arterial pH <7.3
PT >100, INR >6.5
Creatinine >300μmol /l
Grade 3–4 encephalopathy

High lactate levels (>3.5mmol/l at 4 and 12h) and low factor V levels are also associated with a poor outcome if not transplanted. If at 48 hours, the INR is normal, the patient may go home.

Other ways of poisoning treatment are demonstrated below:


Note that the frequency of repetitive DSH may be reduced by depot neuroleptics. Establish good rapport with the patient and follow up on a regular basis by:

GP
CPN
Social services
Samaritans


I conclude with a short comment on a discussion of ‘Prevention of Poisoning’ given byu the author of the toxicology chapter in the wonderful popular medical textbook, ‘Davidson’s Principles and Practice of Medicine’. He states that, “Preventing poisoning in the first place is much better than treating it, and a number of important measures have been taken to achieve this”. He then gives methods such as:

Addition of 'Bitrex' and other bittering agents to household products Prevents significant quantities being ingested as it tastes very bitter
Adding the antidote to the toxin, e.g. combination tablets of methionine and paracetamol Hepatic-protective glutathione remains replete and hepatocellular injury is prevented
Child-resistant containers Reduce chance of ingestion by children
Secure location, e.g. locked cupboard Reduces access
Hazard warning labels Warn of potential toxicity, routes of exposure and appropriate protective equipment
Education Warning on safe storage and handling of chemicals and drugs
Supervision The key to reduced exposure for children
Legislation, e.g. Health and Safety regulations Safeguards for the use of dangerous chemicals make a safer workplace

Little does he know of the perfect prophylaxis, belief in God and the last day, and the purpose of life – the worship of God and the service of humanity. But I do not blame Him, for who will listen to him in this age of madness. While it is true, as Voltaire said, that, “Not that suicide always comes from madness”, the prevention of suicide will never occur in the face of world madness.