Mental health and Society

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Table of Contents
1. Introduction ........................................................................................................................................... 3

2. Implications in the UK Context ............................................................................................................ 3

3. Association between Suicide and Mental Disorder .............................................................................. 4

4. Explanatory Factors and Models........................................................................................................... 6

5. Conclusion with Recommendations...................................................................................................... 8

References ................................................................................................................................................... 11
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1. Introduction

Suicide is defined by The World Health Organisation (WHO) as the delirious act of an individual
from which he or she takes own life, resulting in an injury, with an uneven degree in the
intention to die. In the United Kingdom, suicide is a major national social issue committed
mostly by female adolescents. Overall in 2017, about 5,800 deaths by suicide were registered in
the UK, equating to an average of 16 suicides on daily basis (Morrison, 2018). It is reported by
the literature that majority (90%) of suicide cases involve mental disorder, which constitutes a
significant and alarming level of public health problem. This study aims to explore and analyse
the association between mental disorders and suicidal behaviour among a social group of female
adolescents in the UK, so as to contribute to the comprehending of this major issue while
shedding light on the need to devise and enforce early care strategies.

2. Implications in the UK Context

According to Roberts et al. (2011), mental disorders such as depression, alcohol and substance
abuse disorders, violence, wars, disasters, acculturation (of indigenous peoples or displaced
persons, among others), discrimination, isolation, losses and various social environments, are
risk factors for suicide, as well as the difficulties in accessing health care, the availability of
resources to commit suicide and the sensationalism of some mass media when they report on
cases of suicide occurred.

The issues of multiple social conflicts, domestic and gender violence, sexual abuse,
mistreatment, and abuse of alcohol and psychoactive substances, trigger stress situations, self-
destructive behaviours in women, especially adolescents in the UK due to mental disorders
(Hawton and James, 2005; McIntyre et al., 2013). Among the direct causes of mental disorders
are psychosocial problems and the breakdown of the family nucleus, and indirectly the
deterioration of the social and economic situation of the population, as well as the low level of
quality of life. On the other hand, some direct effects of mental disorders on adolescents are the
increase in costs of promotion, prevention and treatment, and the reduction of work and
productive capacity; and among the indirect ones are the increase of cases of domestic violence,
sexual and gender violence, high consumption of psychoactive substances, social and economic
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deterioration (Hossain et al., 2010; Devries et al., 2011). All these phenomena, as can be seen,
constitute a vicious circle in which affectations and consequences are maintained and increased.

3. Association between Suicide and Mental Disorder

The most frequent mental disorders in both adults and adolescents (both genders) who have
attempted suicide are depression, bipolarity, personality disorder, anxiety, agoraphobia,
substance abuse (psychoactive drugs, alcohol and tobacco), schizophrenia, somatisation and
eating disorders such as anorexia nervosa (Oquendo, Currier and Mann, 2006; de Jesus Mari et
al., 2013). In adolescents, there are behavioural disorders, depression, simple phobias and
generalised anxiety (Franco, Saavedra and Silverman, 2007). There is also a relationship
between suicide and eating disorders in adolescent females, behavioural disorders in men (limit
and sociopath) and substance abuse in both sexes (Hill, Castellanos and Pettit, 2011).

There is a greater risk of suicide in the first months after being diagnosed with some affective
disorder (Arsenault-Lapierre, Kim and Turecki, 2004), psychotic depression (de Jesus Mari et
al., 2013) and bipolar disorder (Jones et al., 2006). The risk increases in the first days or weeks
of starting a pharmacological treatment since in that period the symptoms usually worsen
(Anderson et al., 2008), and in the days following hospital discharge, especially in those who
consult in the emergency department (McClure, 2001), reporting a risk 100 times greater
(Hawton and James, 2005) between the three days and the week after leaving the hospital
(Anderson et al., 2008).

In adolescents with depressive disorder, at least 27% have attempted suicide throughout their
lives (Harrington, 2001). Depression can increase the risk of suicide up to 12 times when the
despair predominates, associated with intentionality and high lethality (Harrington, 2001). The
experience of suffering in depression, evident in letters from people who have committed
suicidal acts, has been related with greater frequency and intensity of suicidal ideation and
behaviour (Glowinski et al., 2001).

Studies have shown that anxiety disorder increases the risk of suicidal ideation and attempt in
adolescents. Almost 20% of patients with an anxiety crisis disorder and social phobia make
unsuccessful suicide attempts (Nelson et al., 2000; Stein et al., 2001; Kearney, 2006; Davidson et
al., 2011). Moderate-severe anxiety disorders, transient adjustment reactions, anxiety as a
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personality trait and obsessive characteristics are considered risk factors for suicide (Davidson et
al., 2011). Assessing the severity of anxiety would help identify patients at risk of suicide
(Murray, 2018).

In a study conducted by Rodríguez-Blanco et al. (2015) it was found that female adolescents in
the UK who presented anxiety and depression were more impulsive, made more suicide
attempts, and had a family history of suicidal behaviour, sexual and emotional abuse in
childhood.

According to Murray (2018), bipolar disorder involves manic episodes, followed or preceded by
hippomanic episodes or major depression. Between 10% and 15% of adolescents with bipolar
disorder consume suicide, usually at the beginning of the disease and in the depressive phases
(Goldstein et al., 2005). McElroy and Keck (1996) identified in patients with bipolar disorder up
to a 90% tendency to suicide, and high scores on a scale of depression as the most aggravating
factor; it has also been established that the risk of suicide is 22 times greater in bipolar disorder
patients compared with the general population (McElroy and Keck, 1996).

According to the Maalouf et al. (2011) conditions classified as induced by substance use or abuse
include: intoxication, abstinence and other disorders, such as anxiety, psychotic, bipolar,
depression, sexual dysfunction, delirium, and neurocognitive). In general, the risk for all
substance-related disorders is associated with accidental and deliberate overdoses. Repeated
intoxication and abstinence may be associated with severe depressions sufficiently intense
enough to give rise to attempts and suicides. However, the available data suggest that non-fatal
accidental overdoses should not be confused with suicide attempts (Maalouf et al., 2011).

Substance abuse has high levels of comorbidity with other mental disorders (Swahn, Bossarte
and Sullivent, 2008), increasing its incidence from 19% to 45% (Landheim, Bakken and
Vaglum, 2006).

The abuse of alcohol and psychoactive substances related to deaths by suicide fluctuates between
5% and 27%, and the risk of suicide for people with diagnoses of alcoholism throughout their
lives is around 15% (Fisckenscher and Novins, 2003). Substance and alcohol abuse is an
important predictor of suicide (Frances, 2011) and depression (Stein et al., 2001) among
adolescents. The frequent comorbidity between depressive disorder and substance use is almost
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three times higher than in the general population, especially females (Ballenger, 2013), and in
the case of alcohol dependence there is up to two thirds more of association (Kim et al., 2014;
Darvishi et al., 2015).

Personality disorder is an individual’s lasting and nonflexible pattern of internal experience and
behavioural approaches deviating considerably from the individual’s culture’s expectations, and
demonstrates itself in cognition, affectivity, interpersonal functioning and impulse control. These
disorders occur up to 70% in suicidal persons (Arsenault-Lapierre, Kim and Turecki, 2004), and
traits such as poor self-esteem, impulsivity, anger and aggressiveness are involved (Nee and
Farman, 2005), the dimensions being of emotional dysregulation and impulsivity that have been
most prevalent in retrospective studies (Anestis et al., 2011; Miranda et al., 2013).

People with personality disorders have a higher risk of suicide (Schneider et al., 2008). There is
special evidence for borderline personality disorders (Pompili et al., 2005), narcissistic and
histrionic (Shahar et al., 2008), antisocial (Links, Gould and Ratnayake, 2003) and schizotypal
(Lentz, Robinson and Bolton, 2010). 56% of females who commit suicide present such disorders
in comorbidity with drug and alcohol abuse (Lieb et al., 2010), as do 65% of those who try
(González et al., 2016).

Attempted suicide is considered a diagnostic criterion of borderline personality disorder (BPD)

(Gvion and Apter, 2011). In females with this disorder, a prevalence of 60% to 80% of self-
injurious behaviours has been found (Pompili et al., 2005) and 10% of completed suicides in
children under 30 (Chapman, Specht and Cellucci, 2005), mostly women, since in the BPD there
is a strong presence of emotional instability (Pompili et al., 2005) self-destructive and impulsive
behaviours (Arsenault-Lapierre, Kim and Turecki, 2004) such as reckless driving, expenses,
theft, bingeing and purging, substance abuse, unprotected sexual encounters, self-mutilation and
suicide attempts. 46% of patients with BPD obtained high scores on a scale of hopelessness,
associated with symptoms of chronic anxiety and uncertainty about the future (Chapman, Specht
and Cellucci, 2005; Wagner et al., 2010).

4. Explanatory Factors and Models

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According to Domínguez-Martinez et al. (2016), a mental disorder by itself cannot explain

suicidal behaviour; likewise, in the literature there is ample explanatory evidence of the
association between suicide and various variables, as described below.

In the relationship between family functioning and suicidal behaviour, aspects such as
interpersonal difficulties are highlighted (Johnson et al., 2002), poor affective closeness
(Cochran, 2000), high levels of parental control, unstable family structure, family history of
suicide, domestic violence, sexual abuse in childhood (Pitman et al., 2014), and so forth, which
limit the active and adequate participation of all its members and make it difficult to satisfy basic
needs.

In post-mortem studies carried out on people who have committed suicide, we have found
neurobiological factors that may be related to the fact, such as a marker of serotonin depletion
(metabolite 5HIIA) in patients with depression (Joiner, Brown and Wingate, 2005), personality
disorders (Wagner et al., 2010), increased density of receptors (5-HT1A) (López-Figueroa et al.,
2004), and the amygdale (Costanza et al., 2014), whose structures participate in the
Experimentation of emotion, stress management and coping, adaptive capacity in the face of
difficult events, anxiety and depression.

Turecki's Integrative Model (2005) states that consummated suicide is correlated with
dimensions of impulsivity and aggressiveness, with biological factors that define an
endophenotype of suicidal behaviour, with traumatic events during childhood and adulthood, and
with accumulation of experiences negative. It is important to note that prefrontal cortical damage
generates disinhibition and impulsivity (Davidson, Putnam and Larson, 2000), associated with a
high degree of lethality (Oquendo et al., 2003) and the serotonergic alteration is also highly
associated with cultures to regulate anxiety, impulsivity and aggression (Van Heeringen, 2003).

The diathesis-stress model refers to a multi-causality of the induced risk, which occurs through
the interaction of genes and the environment (Sanchez, 2010). Mann et al. (1999) support the
hypothesis of a family transmission, mainly genetic, of a certain propensity to externalize
aggressiveness and a tendency to present suicidal behaviours. Suicide risk is not only determined
by the hereditary possibility of a certain psychiatric illness but also, and primarily, by the
tendency to experience greater suicidal ideation (Chapman, Specht and Cellucci, 2005). The
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theory of Mann (2003) is based on the medical model of predisposition for a certain disorder and
its appearance precipitated by factors such as exacerbation of mental illness, a life crisis and
psychosocial causes.

On the other hand, the trajectory model of the suicide development of Silverman and Felner
(1995) compares suicidal behaviour with the evolutionary history of a disorder, assuming the
existence of a series of processes that lead to suicide and that must unfold during a time, and
make use of the term personal vulnerability, which results from exposure to risk factors and
protectors that may be acquired during different age cycles.

Regarding psychological factors, despair is considered an important pre-contractor of suicide in

people with mental disorders, and is associated with disease awareness (insight), negative beliefs
about the disease, negative perception of the future and of oneself, based on the theory of learned
helplessness of Seligman (1975), explain that despair occurs when the person internalises
impotence or lack of control regarding behaviours or expectations that are incongruent with the
expected.

In a study conducted by Talbott (2006) with hospitalized psychiatric patients, it was found that
60.7% presented suicide risk and 70.4% presented despair. The risk of suicidal ideation and
suicide is determined by hopelessness along with negative life experiences, lack of social
support, demoralization, inability to cope with situations, isolation, conflict and neglect, loss of
control, feeling of helplessness and emptiness, despair, anxiety and panic.

Beck et al. (1990) emphasised the importance of cognitive aspects to understand suicidal
behaviour, and propose a hypothesis about the fundamental role of despair as a bridge between
depression and suicide, through a cognitive projection of the current depressive state in the
future. According to this theory, negative events, added to an internal attributional style, would
cause emotional deficit, low self-esteem, an increase in cognitive deficits and their chronicity.

5. Conclusion with Recommendations

The presence of a mental disorder is a risk factor for suicide. Within the different disorders,
depression significantly increases the risk, with despair being the most related component.
Meanwhile, in females with personality disorders, anxiety and substance use, the presence of
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impulsivity and loss of control associated with suicide predominate. On the other hand, due to its
personal, family and social implications, this problem must be addressed urgently, and because
of its tendency to increase as has been registered in the UK, this situation constitutes a problem
of public health; to which are added the conditions derived from the armed conflict, which can
exacerbate factors such as despair, family and economic problems, the consumption of
substances, etc., and increase the risk of suicide.

In the UK, mental health legislation has been in place, but it is important to bear in mind that the
prevention of suicide and mental disorders among people, especially women, in addition to the
issuance of laws and decrees, includes education, promotion of protective factors, diagnosis
early, effective treatment and even control of environmental conditions. For this reason, it is
necessary the intervention of professionals duly trained in general health and mental health
issues, which allow to provide an adequate Primary Health Care (PHC). It is also necessary to
monitor and control the treatment of patients through an adequate link between the mental health
services and general health services, so that the care is comprehensive. Likewise, it is important
not only to address the main health / risk factors and their interactions, but also the different vital
environments of each population: individual, family and community.

It is essential in the population with mental disorders and behavioural disorders, to stimulate and
strengthen communication skills, to solve problems in an adaptive manner and to seek advice
and help when difficulties arise; receptivity to other people's experiences, self-confidence,
positive attitudes and values such as respect, solidarity, cooperation, justice and friendship
(Murray, 2018); self-esteem, religious beliefs and self-regulatory capacities (Johnson et al.,
2002), self-control and recovery of balance, as well as the management of anger and sadness
(Hossain et al., 2010). In the same way, the promotion of affectionate parenting styles helps to
strengthen self-esteem, safety and generates a satisfactory social participation that prevents
depression and behavioural behaviour (Frances, 2011).

It is essential to teach and develop in specific population groups skills to identify people with
high suicide risk through education on risk factors, signs and warning signs, so that they can be
timely re-allocated for their treatment (López-Figueroa et al., 2004), supported by a model of
primary and secondary prevention in mental health, with training in coping and problem-solving
skills, restriction of access to lethal media, community screening and support groups (Pompili et
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al., 2005). It is also important to know the mental health laws that allow the community to
recognize the rights, duties and procedures to follow; in cases of suicidal ideation have an
updated list of contacts or institutions where you can go; in the event of imminent suicide, agree
with the person at risk a written and signed plan of action and preservation of life; and invite
family members and / or friends to keep in contact not only during the critical period or after it
but also when the person presents improvements.

In cases where a non-lethal attempt has been made, an immediate link to a mental health
professional contemplating treatment with medication and a psychotherapeutic process aimed at
treating the suicide attempt and the underlying mental disorder is recommended, if there is, with
constant and frequent follow-up after hospital discharge, given that it is a time of great
vulnerability. Equally, it is advisable that this discharge should not take place until the patient is
out of danger and an integral exit plan is drawn up in which the family is involved, taking into
account its great weight as a factor of risk as protection.
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