How do you prevent suicide?

After all, prevention is our only medicine.

Mental health is really “whole person health”.  This is important.  Suicide and depression could be related to psychological and social factors, but there could also be physiological factors at play that happen to have mental manifestations.  Mental health disorders are multifactorial, partly a biological concern, and you cannot expect a person to “get over it” or just magically “be happy”. 

What can be done about the biology portion of this picture?  In my previous post I discussed the role of neuroinflammation.  There are many ways to help reduce inflammation, including anti-inflammatory diets.  Anti-inflammatory diets often come with recommendations for higher fat consumption.  Did you know that low serum lipid levels are associated with a 112% increased risk of suicidality, 123% increased risk of suicide attempt and 85% risk of completed suicide [1]?

And it’s not just the direct effect of the foods you eat on the optimal functioning of each cell in your body.  The foods you eat also affect the microbiome of your gut, and the gut microbiome happens to play a crucial, birectional role in mental health [2].  Therapies addressing the gut microbiota, for example through dietary changes, are valuable since the gut microbiota shape your behaviour and mental functioning [2,3]. 

What’s interesting is that it’s not even simply the bacteria in your gut.  It could also be the microbiota (or lack thereof) in your environment, which are hypothesized to help prepare your immune system for optimal functioning and modulate inflammation [4].

Another lifestyle factor to consider is exercise.  Physical activity is associated with balancing out your pro-inflammatory and anti-inflammatory cytokines to help you return to a state of lower inflammation, including neuroinflammation [5,6].

Sleep is another important part of overcoming neuroinflammation.  Whether you have insomnia or a full schedule, getting suboptimal levels of sleep increases your risk for inflammatory conditions and depression [7].  In populations with existing mental health disorders sleep disturbance was also related to increased suicidal ideation and attempt [8].  Not only is sleep important for improving health outcomes, but it is important because the night means fewer people awake and watching out for those struggling with suicidal ideation as well as fewer resources at hand [9].

There are so many factors involved that I can’t do them full justice in a single post.

Now perhaps you are trying your best to improve your life, to make yourself healthier and happier but just aren’t getting results.  For example, maybe your doctor gave you Chantix in an effort to help you quit smoking but for some reason your mental state seems to keep getting worse.  Chantix has taken a lot of heat for a rash of suicides in its users, and now carries a black box warning for depressed mood and suicidal thoughts and actions [10].

It’s important to find a physician that takes into account you as a whole person.  A doctor who will spend more than five minutes to understand what treatment is best for you.  Diet, exercise, sleep, sunshine…so many factors that you do have power over in your life.  Find a doctor who will help you make the appropriate modifications to get you back on track (see an excellent article by my good friend, “How do I select a practitioner?”).  

Being “happy” isn’t just about material things in life, it’s also about being healthy.  Imagine being a millionaire, or being famous, and still taking your own life.  Maybe you’ve heard of people saying things like “why would he do this, he had everything…”  Imagine being engulfed in flames and your only option is to jump out of the window (read David Foster Wallace’s analogy here).  If you’ve ever seen comments on news articles you know that there are people who don’t understand.  You know that there are also people who can be cruel.  Don’t worry about them – you do your part to help others or to seek those who can help you.  

It can be hard for people to understand suicide in the context of:

Beautiful people.  “They say I’m lucky to be alive.  It’s hard to figure out – when everything I feel hurts!”  Marilyn Monroe died in August of 1962 at the age of 36, despite a bright career [11,12].

Funny people.  “It lays in wait for the time when you think, ‘It’s fine now, I’m O.K.’ Then, the next thing you know, it’s not O.K.” Robin Williams died in August 2014 at the age of 63, after years of bringing laughter and entertainment into others’ lives [13].

Tough people.  "He had a huge heart and he really didn’t like for people to worry about him” [14, quote from friend, Bieksa]. August 2011 saw the death of 27-year-old Rick Rypien who scored his first goal in his very first game with the Vancouver Canucks and was known for his willingness and ability to fight players much bigger than himself [15].

People who are so beautiful they make you self-conscious, people who make you laugh, people who are physically strong, even people that seem happy on the outside… Mental health problems can affect a wide range of people. 

Whoever you are, you are worthy of help.

The staggering cost of suicide is forty-four billion dollars a year yet what is that in the face of the precious 42,773 lives that are lost in a year [16].  Watching the heartbreak of a family who has lost a child, grandchild, spouse, sister, brother, aunt, uncle, cousin to suicide is anguishing.  No amount of money can bring them back.

You are never alone, you are not the only one.  There are communities of volunteers (Suicide Watch, To Write Love on Her Arms, Active Minds, Mind Check, Living With) and programs (Vital Mind Reset, Hockey Talks) meant for support all over the world.  There are even apps for suicide prevention (My3, Jason Foundation, Ask).  If you need help or if you are concerned for a friend please reach out.  You can find local resources here or call a 24 hour helpline (click the link on the top of the page to view options).

World Suicide Prevention Day is not just today.  Suicide Prevention Day is every day.  

We all have a place in prevention.  Artists inspire, educators inform, activists create awareness, scientists seek understanding, doctors heal, friends are there when you need them…we are all part of the solution. And we all know somebody we can help look out for, even if that person is yourself.

Together, we can do this.  Dare to live.  Reach out.

(American) National Suicide Prevention Helpline: 1.800.273.TALK (273-8255)
Crisis Text Line: TEXT "TWLOHA" TO 741-741
Canadian Mental Health Crisis Line: (888) 353-2273

Visit TWLOHA for more resources and crisis lines.


References

  1. Wu S, Ding Y, Wu F, Xie G, Hou J, Mao P. Serum lipid levels and suicidality: a meta-analysis of 65 epidemiological studies. J Psychiatry Neurosci. 2016;41(1):56-69.

  2. Rogers GB, Keating DJ, Young RL, Wong ML, Licinio J, Wesselingh S. From gut dysbiosis to altered brain function and mental illness: mechanisms and pathways. Mol Psychiatry. 2016;21(6):738-48.

  3. Logan AC, Jacka FN, Craig JM, Prescott SL. The Microbiome and Mental Health: Looking Back, Moving Forward with Lessons from Allergic Diseases. Clin Psychopharmacol Neurosci. 2016;14(2):131-47.

  4. Lowry CA, Smith DG, Siebler PH, et al. The Microbiota, Immunoregulation, and Mental Health: Implications for Public Health. Curr Environ Health Rep. 2016;

  5. Barry A, Cronin O, Ryan AM, et al. Impact of Exercise on Innate Immunity in Multiple Sclerosis Progression and Symptomatology. Front Physiol. 2016;7:194.

  6. Spielman LJ, Little JP, Klegeris A. Physical activity and exercise attenuate neuroinflammation in neurological diseases. Brain Res Bull. 2016;125:19-29.

  7. Irwin MR, Opp MR. Sleep Health: Reciprocal Regulation of Sleep and Innate Immunity. Neuropsychopharmacology. 2016

  8. Stubbs B, Wu YT, Prina AM, Leng Y, Cosco TD. A population study of the association between sleep disturbance and suicidal behaviour in people with mental illness. J Psychiatr Res. 2016;82:149-154.

  9. Littlewood DL, Gooding P, Kyle SD, Pratt D, Peters S. Understanding the role of sleep in suicide risk: qualitative interview study. BMJ Open. 2016;6(8):e012113.

  10. Available at: http://www.chantix.com

  11. Available at: http://marilynmonroe.com

  12. “Marilyn Monroe”. Available at: http://www.biography.com/people/marilyn-monroe-9412123#famed-career

  13. Itzkoff, D. (2014). “Robin Williams, Oscar-winning comedian, dies at age 63”. The New York Times. Available at: http://www.nytimes.com/2014/08/12/movies/robin-williams-oscar-winning-comedian-dies-at-63.html?_r=0

  14. “Brothers forever: The Bieksa-Rypien story from last year. (2011). The Vancouver Sun. Available at: http://vancouversun.com/news/staff-blogs/brothers-forever-the-bieksa-rypien-story-from-last-year

  15. “The quiet hero”. Available at: https://mindcheck.ca/quiet-hero

  16. https://afsp.org/about-suicide/suicide-statistics/

Copyright of Beyond20Questions.

How do inflammatory conditions affect suicide risk?

For all the hidden stories and all the hidden hurt you are not seeing – seize this opportunity to learn more, to understand better.  If you have ever lost a loved one to suicide, you will understand the significance, the weight of this topic.  If you do not have a mental health problem and are struggling to understand what someone you love is going through, let me offer this quotation from David Foster Wallace:

The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.

A mental disorder is not something that is “all in your head”.  It’s not something you can “snap out of” or fix by “changing your attitude”.  This is a serious medical condition with real biological underpinnings.  We cannot be afraid to speak up, because silence kills.  We should not be any more ashamed of asking for help with our mental well being than we are to ask for help with infections, cuts, burns, cancer...

The biology is real.  New research demonstrates that inflammation and the immune system play a prominent role in mental health disorders and that’s just the tip of the iceberg [2,3,10,12,14].   A point brought up by one team of researchers was that even the perceived “threat” that triggered the suicidal contemplation could activate inflammatory pathways and further increase the risk [4].

Did you know that interferon treatment (read that as increasing inflammation) for certain cancers and multiple sclerosis is linked to depression, suicidal ideation and suicide attempts in otherwise psychiatrically healthy patients [3]?  What about other conditions involving inflammatory immune responses such as allergies (5, 6 to read more about seasonal allergens and increased spring time suicides), asthma, multiple sclerosis, systemic lupus erythematosus, and celiac disease?  Yep, also linked to suicidal ideation and attempt [3,5].  For the sake of perspective, consider studies that have found these rates in people with the following conditions compared to the rates in the general population

"Psychiatric" Disorders
Major Depressive Disorder
Schizophrenia

"Biological" Disorders
Celiac disease
Diabetes mellitus

Heart attacks
Multiple sclerosis
Systemic lupus erythematosus
Traumatic brain injury
 
20x increased suicide risk [3]
4.9-10% lifetime suicide risk [17]


2x increased suicide risk [3]
13.3-26.4% increased suicide risk [3]
3x increased risk of psychiatric disorder [20]
3x increased suicide risk [18]
2x increased suicide risk [3]
40% develop depression [3]
3x increased suicide risk [3]

 Let’s take a quick look at how this can happen from the perspective of immune and inflammatory pathways.

Your immune system has these wonderful messengers called cytokines and these cytokines can affect neurotransmission in the brain [3].  Analysis of cytokine levels in those who attempt suicide reveals centrally increased cytokine levels in the orbitofrontal cortex (IL-4, IL-13), the anterior prefrontal cortex (IL-1β, TNF-α, and IL-6), and in cerebrospinal fluid (most notably IL-6) [3,4].  

We may also be able to use markers of peripheral inflammation to detect suicide risk [3].  For example, it’s been found that S100B levels also correspond with suicidal ideation intensity, and can lead to inflammation-derived glial dysfunction in patients with schizophrenia [3,7].  CRP might be a more familiar marker of inflammation to you.  Last month a research team in Arkansas published a study concluding that there is a gradient in CRP levels in those who attempted suicide (highest), had suicidal ideation or were an inpatient psychiatric control [12].  

You may well wonder whether the inflammation was caused by the method of attempted suicide or existed aside from that.  Follow up and longitudinal studies have shown the inflammation to be related to depression and suicidal behaviour rather than simply a result of it [3,10,16].

So what happens when we have all this inflammation and how does it affect suicide risk?  This can occur through the kynurenine pathway, designed to break down tryptophan.  Tryptophan is used to make neurotransmitters like serotonin.  However, when there is significant inflammation (such as in the form of cytokines), there is a shift from making serotonin to activating enzymes for tryptophan breakdown instead [11].  This results in increased blood levels of kynurenine, and relates to increased IL-6 in cerebrospinal fluid [3].  This pathway can then produce picolinic acid, quinolinic acid or kynurenic acid.  Kynurenic acid has some neuroprotective function (although you don’t want excessive amounts of it) but quinolinic acid causes neuroinflammation [10,11].  Increased quinolinic acid relative to picolinic acid and kynurenic acid is associated with increased suicide risk [10,11].  

How do genetic factors fit in?  Just last month genetic variation in the SNP rs2121337, responsible for a key enzyme involved in the kynurenine pathway, was found to be associated with neuroinflammation and suicide attempts [10].  This enzyme allows the kynurenine pathway to produce the neuroprotective picolinic acid, and without its proper function the pathway will create more of the neuroinflammatory quinolinic acid [10].

So it’s not a basic matter of your brain being on fire with CNS-derived inflammation.  Pro-inflammatory cytokines from elsewhere in the body can trigger inflammation in the brain, and having this genetic variation can further compound matters, increasing risk for suicide [10,11].  Additionally, neuroinflammation may increase permeability of the blood brain barrier [13].

What about learned helplessness, hopelessness, impulsivity, aggression, thought patterns and all those other psychological concepts we’ve associated with mental health disorders like depression?  Turns out cytokines like IL-6 affect these traits too [3, see 15 for a more in-depth view of the complex IL-6 story].

And inflammation isn’t even the entirety of the different biological processes involved.  It’s just a small sample to demonstrate the relevance of biology rather than just psychology.

In the next post we’ll discuss how mental health problems do not have to be a death sentence - there is hope.

References

1.    https://afsp.org/about-suicide/suicide-statistics/
2.    Brundin L, Bryleva EY, Thirtamara rajamani K. Role of Inflammation in Suicide: From Mechanisms to Treatment. Neuropsychopharmacology. 2016.
3.    Brundin L, Erhardt S, Bryleva EY, Achtyes ED, Postolache TT. The role of inflammation in suicidal behaviour. Acta Psychiatr Scand. 2015;132(3):192-203. 
4.    Courtet P, Giner L, Seneque M, Guillaume S, Olie E, Ducasse D. Neuroinflammation in suicide: Toward a comprehensive model. World J Biol Psychiatry. 2015;:1-23.
5.    Christodoulou C, Douzenis A, Papadopoulos FC, et al. Suicide and seasonality. Acta Psychiatr Scand. 2012;125(2):127-46.
6.    Makris GD, Reutfors J, Ösby U, et al. Suicide seasonality and antidepressants: a register-based study in Sweden. Acta Psychiatr Scand. 2013;127(2):117-25.
7.    Hong W, Zhao M, Li H, et al. Higher Plasma S100B Concentrations in Schizophrenia Patients, and Dependently Associated with Inflammatory Markers. Sci Rep. 2016;6:27584.
8.    Winerman, L. (2005). “Helping men to help themselves”. American Psychological Association. Available at: http://www.apa.org/monitor/jun05/helping.aspx. Accessed September 5, 2016.
9.    Kersting, K. (2005). “Men and depression: battling stigma through public education”. American Psychological Association. Available at: http://www.apa.org/monitor/jun05/stigma.aspx
10.    Brundin L, Sellgren CM, Kim CK, Grit J, Palsson E, Landen M, Samuelsson M, Lundgren K, Brundin P, Fuchs D, Postolache TT, Traskman-Bendz L, Guillemin GJ, & Erhardt S. (2016). An enzyme in the kynurenine pathway that governs vulnerability to suicidal behavior by regulating excitotoxicity and neuroinflammation. Translational Psychiatry. 2016;6(8):e865.
11.    Richter CB, Linderholm, KR, Lim, CK, Samuelsson M, Traskman-Bendz L, Guillemin GJ, Erhardt S, & Brundin L. (2015). A role for inflammatory metabolites as modulators of the glutamate N-methyl-D-aspartate receptor in depression and suicidality. Brain, Behaviour, and Immunity. 2015;43:110-7. 
12.    Gibbs HM, Davis L, Han X, Clothier J, Eads LA, Cáceda R. Association between C-reactive protein and suicidal behavior in an adult inpatient population. J Psychiatr Res. 2016;79:28-33.
13.    Ventorp F, Barzilay R, Erhardt S, et al. The CD44 ligand hyaluronic acid is elevated in the cerebrospinal fluid of suicide attempters and is associated with increased blood-brain barrier permeability. J Affect Disord. 2016;193:349-54.
14.    Priya PK, Rajappa M, Kattimani S, Mohanraj PS, Revathy G. Association of neurotrophins, inflammation and stress with suicide risk in young adults. Clin Chim Acta. 2016;457:41-5.
15.    Isung J, Aeinehband S, Mobarrez F, et al. High interleukin-6 and impulsivity: determining the role of endophenotypes in attempted suicide. Transl Psychiatry. 2014;4:e470.
16.    Khandaker GM, Pearson RM, Zammit S, Lewis G, Jones PB. Association of serum interleukin 6 and C-reactive protein in childhood with depression and psychosis in young adult life: a population-based longitudinal study. JAMA Psychiatry. 2014;71(10):1121-8.
17.    Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol (Oxford). 2010;24(4 Suppl):81-90.
18.    Rettner, R. (2010). “Heart attack patients at higher risk for suicide”. Live Science. Available at: http://www.livescience.com/35251-heart-attack-suicide-101210.html. Accessed September 6, 2016.
19.    Sarkar S, Balhara YP. Diabetes mellitus and suicide. Indian J Endocrinol Metab. 2014;18(4):468-74.
20.    Butwicka A, Frisén L, Almqvist C, Zethelius B, Lichtenstein P. Risks of psychiatric disorders and suicide attempts in children and adolescents with type 1 diabetes: a population-based cohort study. Diabetes Care. 2015;38(3):453-9.