The aftermath of suicide effects on those involved

Bereavement counselling and practical help may be required in the immediate aftermath of the death, which will almost always be a very difficult time for relatives. In the longer term, the relatives of those who died by suicide are at high risk of psychiatric illness and social problems, and many take years to adjust, if they ever do, to a death which frequently seems like an act of aggression as well as of self-destruction. Sometimes, suicide can even seem to be an act with a violent aspect, perhaps directed toward those left behind, leaving the family almost as 'victims' of suicide. Others, however, might ultimately find their lives made easier if the dead person had been affected for many years by a severe and intractable personality disorder, mental illness, or drug/alcohol misuse.

Suicide can also exact a toll on others involved, such as train drivers, who can expect occasionally to be in the unenviable position of applying the brakes as they sight a person on the tracks ahead, knowing that it is physically impossible to stop in time. They even have their own slang expression ('one under') for these events. Mental health problems and medico-legal considerations are frequent.

The professionals involved in the care of a patient who has killed himself often react with distress and guilt, which is understandable but not always justified. A certain number of suicides are bound to occur in psychiatric practice, and it is not possible to predict exactly which patients are going to kill themselves, or when. After a suicide has taken place, review of the case may well suggest some way that management could have been improved; this should be used as a constructive opportunity to improve future standards of practice in the unit concerned, rather than a collective 'guilt trip' or, still worse, a search for a scapegoat.

Learning lessons

Some suicides, such as those resulting from an acute severe depressive illness which could almost certainly have been cured, are major tragedies. In other cases, such as those associated with chronic intractable mental or physical illness, the argument that it might have been preventable may be less strong.

The key initiative here is the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Appleby et al., 2006; Hunt et al., 2006), which is a continuing national survey. Between 1996 and 2000, there were 4859 cases of suicide in England and Wales whose victims had been in recent contact with mental health services.

1100 (23 per cent) had been discharged from psychiatric in-patient care less than 3 months before death. Post-discharge suicide was most frequent in the first 2 weeks after leaving hospital; the highest number occurred on the first day. . . .

Deaths of young patients were characterized by jumping from a height or in front of a vehicle, schizophrenia, personality disorder, unemployment, and substance misuse. In older patients, drowning, depression, living alone, physical illness, recent bereavement and suicide pacts were more common. (Appleby et al., 2006)

Hence, there should be a documented risk assessment before discharge from inpatient care, and follow-up of those on the enhanced tier of the Care Programme Approach within 7 days. All this should be straightforward in patients with a clear-cut mental illness such as schizophrenia. There is more difficulty in deciding what is appropriate for other patients who have contact with mental health services, such as 'young people with personality disorder, unemployment and substance misuse', none of which are readily treatable by medical means.

'Assisted' suicide

Recent proposals for legalizing 'medically assisted' suicide, as for those with terminal illness, have aroused much professional and public controversy, and seem unlikely to be accepted in the foreseeable future.

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