Suicide and attempted suicide

Self-poisoning among girls aged 15–19 has increased by 250% in the last 20 years, with annual incidence rates in this population group exceeding 1% in some regions. Most self-poisonings are not usually fatal. Self-poisonings account for 4.7% of all admissions to general hospitals among people aged 12–20.

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Reasons for suicide attempts

Most often, the preceding event is a quarrel with someone very close (usually a girl with a young man).

In recent decades, the breakdown of sexual relationships has become typical for an even earlier age, i.e., when the partners have not yet acquired experience in overcoming such situations - stress. With the modern reduction of family ties, the serious support that is necessary at such a time for those in love in families is very insufficient. Another important factor in suicides may be the weakening of religious feelings. The availability of drugs on the market is also significant (especially psychotropic drugs - these drugs are most popular for self-poisoning). The desire to imitate often plays a role - if, for example, a celebrity has attempted suicide. This is especially true for the USA and Japan, where complicated suicide is the cause of death of more than 600 children a year. Often the cause of suicide is lagging behind in studies. Relate this to your own bad mood after endlessly overcoming hundreds of pages of thick reference books, so for God's sake, slam these books shut and allow yourself a good rest.

There are six steps (stages) in an attempt to help survive in such a situation:

• Assessing the condition of the victim.
• Establishing contact with the victim and offering him help.
• Discussing with the victim's family how the problems they are facing can be overcome.
• Problem solving: Help the survivor understand the predicament he/she is in and help him/her remember how he/she overcame similar situations in the past. The goal of this type of conversation is to help resolve personal and social problems and to restore the survivor's ability to cope with difficulties in the future.
• Warning: It is important that psychotherapeutic assistance be available; if necessary, the patient should be hospitalized in an appropriate clinic or provided with 24-hour access to a telephone service (“helpline”).
• Follow-up: Follow-up contact either with the family as a whole or with the victim only.

Assessing the victim's condition

Imagine that you are at a shooting range and there is a target in front of you, surrounded by three circles (rings). The inner "ring" is the circumstances that led to this attempt at self-poisoning. Find out the following: what happened on that day itself? Was everything normal in the morning? When, in fact, did the events and moods arise that led to the thought of the inevitability of self-poisoning? Find out everything down to the smallest detail. What was the final motivating stimulus (for example, a newspaper article about a suicide)? What were the actions of the victim after he attempted self-poisoning? How did he imagine the events unfolding after his attempt at self-poisoning? The middle "ring" in the "target" circle is the definition of the background against which these sad events developed, i.e. how were things going in general in the months preceding the event? Perhaps the attempt at self-poisoning could have been committed at almost any time during the last months? What relationships (with the people around the victim) seem most important to the victim during this time? The outer "ring" around the "target" is the characteristics of the patient's family and the victim's medical history. After you have passed through all three of these "rings", you find yourself directly at the "target" point - what are the intentions behind the attempt at self-poisoning, what are the feelings and intentions of the victim at this moment? Perhaps this attempt itself is an expression of the desire to die (this is a grim symptom that should not be ignored)? Or was the main desire to notify someone about what happened or the desire to somehow change the circumstances of life that are no longer bearable? Ask the victim: "If you were discharged from the hospital today, how would you cope with your difficulties?"

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"Contract" with the victim

• The therapist promises to listen to the victim and help him if the latter agrees to be completely frank and tell the doctor about any suicidal thoughts and plans that arise in him.
• An agreement with the patient that the issues discussed will be presented in great detail and clearly.
• An agreement is established with the victim regarding the nature of the exchange of information to achieve the goal.
• The question of who else will be involved in the treatment of the victim (for example, other family members, friends, the general practitioner observing the patient) is discussed.
• The time and place of meetings between the doctor and the patient are established.
• The patient's responsibility to the doctor and the promise to work with him effectively and complete any "homework" are discussed.

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Treatment with tricyclic antidepressants and related compounds

Patients who are agitated and obsessed with fears should be prescribed

• sedative antidepressants, such as amitriptyline (50 mg every 8-24 hours orally, starting with 25-50 mg at night); dothiepin (50 mg every 8-24 hours, orally, starting with 50-75 mg at night);
• Doxepin (75 mg every 8-12 hours orally, starting with a dose of 10-50 mg at night);
• Mianserin (30 mg every 8-24 hours orally, starting with a dose of 30 mg at night);
• Trimipramine (25-50 mg every 8 hours orally, starting with a dose of 50 mg 2 hours before bedtime).

Less sedating antidepressants include clomipramine (50 mg orally every 8-24 hours, starting with 10 mg daily; this drug is especially effective in cases of phobias and obsessive-compulsive disorders); desipramine (25 mg orally every 8-24 hours, increasing the dose slowly to no more than 200 mg daily); imipramine (10-25 mg orally every 8-24 hours, increasing the dose to 8 tablets of 25 mg daily); lofepramine (70 mg orally every 8-12 hours, starting with 70 mg daily); nortriptyline (25 mg orally every 6-24 hours, starting with 10 mg every 12 hours); protriptyline (5-10 mg orally in the morning, at noon, and at 4 p.m. to avoid insomnia, no more than 6 tablets of 10 mg per day; this drug also has a stimulating effect).

Elderly people are prescribed smaller doses.

Side effects

Convulsions (dose-dependent effect), arrhythmia, cardiac arrest is possible (especially when treated with amitriptyline, which is contraindicated for several weeks after myocardial infarction and is especially dangerous in case of overdose; therefore, this drug should be prescribed in small doses and the patient's condition should be regularly monitored, especially for suicidal intentions).

Anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention, drowsiness, and sweating) may occur with any of the above tricyclics and their derivatives, especially nortriptyline, amitriptyline, and imipramine. All of this should be explained to the patient. Also tell him or her that these side effects will subside over time and that driving or operating machinery should be avoided while taking these medications. Intraocular pressure should be monitored.

Adverse reactions from the liver and blood system may also be observed, especially with mianserin. Agranulocytosis may occur soon after the start of treatment, so clinical analysis of peripheral blood should be performed monthly.

Interactions with other medicinal products

Contraceptive steroids inhibit the action of tricyclic antidepressants. The side effects of antidepressant drugs may be aggravated by the simultaneous use of phenothiazines. The effect of some antihypertensive drugs (for example, clonidine, but not beta-blockers) may be weakened.

Insufficient therapeutic efficacy of antidepressants

Before you think about it, make sure that the patient has been taking the prescribed drug in full and for at least a month. (The point is that one should not expect a therapeutic effect before this period.) Then make sure that the patient has been following the doctor's instructions correctly, and if so, reconsider whether the diagnosis is correct. Shouldn't ECT (electroconvulsive therapy) be used, or low doses of Flupenthixol (0.5-1 mg orally in the morning), or tryptophan (0.5-2 g every 8 hours orally after meals), or a monoamine oxidase inhibitor (MAOI), but not together with tricyclics (they should not be used for 21 days after using MAOIs)? In such cases, phenelzine (Phenelzine) 15 mg every 8 hours orally can be prescribed. However, there is a risk of hypertensive crisis, provoked by some foods and medications, such as cheese, pickled herring, drugs, yeast preparations [Marmite], commonly used cold medicines, levodopa, tricyclic antidepressants. Hypertensive crisis can occur even almost 2 weeks after the end of treatment with MAO inhibitors. Therefore, such a patient should carry a card stating that he is taking MAO inhibitors and listing the foods that he should not eat. But, of course, this does not mean that these products should be completely excluded from consumption: the frequency of hypertensive crises is only about 17 cases per 98,000 patients per year. At the same time, the benefits of using MAO inhibitors can be very noticeable, especially when the patient experiences increased sensitivity to the cool attitude of friends, slight short-term improvement in mood depending on the environment, bulimia, severe drowsiness, rapid fatigue, a tendency to panic fears, irritability, anger, or hypochondria.