• Suicide is rarely caused by a single factor
• It results from complex interactions between multiple biological, psychological, social, and environmental factors

Suicide has been defined as an act with a fatal outcome that is deliberately initiated and carried out with the expectation or knowledge that it will result in death. For every suicide, it is estimated that there are many more episodes of non-fatal self-harm. Suicide remains a major global public health concern and is one of the leading causes of death among young people. According to data reported by the World Health Organisation (WHO), Sri Lanka's suicide rate in 2022 was approximately 15 per a population of 100,000, based on national Police statistics, with a rate of approximately 27 per 100,000 among males and five per 100,000 among females. During the mid-1990s, Sri Lanka had one of the highest recorded suicide rates in the world. Although the national suicide rate has declined substantially since then, it remains higher than the global average. Behind every suicidal crisis is a person experiencing significant psychological pain, often at a time when they feel unable to see any alternative way forward.

Distal and proximal risk factors

Suicide is rarely caused by a single factor. Rather, it results from complex interactions between multiple biological, psychological, social, and environmental factors. These factors can broadly be considered as distal and proximal risk factors. Distal factors include genetic vulnerability, certain personality characteristics such as impulsivity and aggression, restricted foetal growth and complications during the perinatal period, exposure to adverse childhood experiences, and neurobiological vulnerabilities. Proximal factors include psychiatric disorders such as depression, bipolar disorder, and schizophrenia; physical illnesses including chronic medical conditions and cancer; acute psychosocial crises such as bereavement, divorce, marital separation, imprisonment, and other major losses; and easy access to potentially lethal means, including certain pesticides and medications. The recent changes in suicide rates in Sri Lanka are likely to reflect multiple interacting factors, including socioeconomic pressures, psychological distress, mental health difficulties, and access to means. There is also concern that, in some circumstances, exposure to suicide-related events or irresponsible media reporting may contribute to contagion or imitation effects among vulnerable individuals. However, such effects should be considered as one possible contributing factor rather than assumed to be the sole explanation for changes in suicide rates. Suicide should therefore never be viewed as a sign of personality weakness or as the inevitable consequence of a single stressful event.

Every doctor and healthcare professional should have the ability to recognise and respond to suicide risk. Two essential requirements are needed. First, healthcare professionals should be willing to make direct but sensitive enquiries about suicidal thoughts, intentions, and plans. Second, they should remain alert to known risk factors and warning signs. However, it is important to recognise that suicide risk assessment has significant limitations. No assessment scale or clinical tool can predict suicidal behaviour with 100 per cent accuracy. Although researchers have identified several factors associated with increased risk, these factors cannot predict with certainty whether an individual will attempt or die by suicide. 

Suicidal thoughts or intent

One of the most important warning signs is a direct expression of suicidal thoughts or intent. However, not everyone at risk will communicate this openly. Some individuals may make indirect or subtle statements reflecting hopelessness, feeling trapped, or believing that others would be better off without them. A significant change in behaviour or emotional state should also raise concern, even when the person does not directly mention suicide. Other important risk factors include marked hopelessness, a previous history of suicide attempts, social isolation, depressive disorders, alcohol and substance use disorders, schizophrenia and other severe mental illnesses, chronic painful medical conditions, epilepsy, and certain personality disorders. A history of previous suicide attempts is particularly important, as previous suicidal behaviour is one of the strongest known risk factors for future suicidal behaviour. Everyone surrounding a person experiencing a suicidal crisis — including family members, friends, colleagues, and healthcare professionals — has an important role in suicide prevention. There is no convincing evidence that asking someone directly about suicidal thoughts increases the likelihood of suicidal behaviour. On the contrary, a person experiencing suicidal thoughts may feel relieved when someone recognises their distress and is willing to listen without judgement.

When someone appears to be experiencing a suicidal crisis, it is important to respond with compassion and without judgement. Ask directly and sensitively about their thoughts and feelings. Listen attentively without criticising, blaming, or dismissing their distress. Take any expression of suicidal thoughts seriously, even if the person appears calm or says that they do not intend to act on them. Avoid statements that minimise their suffering or suggest that they should simply "be strong" or "think positively." If there is an immediate risk, do not leave the person alone and seek urgent professional assistance. Connect the person with appropriate mental health services, and, where appropriate, involve trusted family members or other supportive individuals. When there is significant immediate risk, access to potentially harmful means should be safely reduced while urgent professional care is arranged.

Improving the ability of primary care

Identifying and supporting people at risk of suicide is not solely the responsibility of psychiatrists. It is a shared responsibility across all healthcare professionals and medical specialties. Recognising psychological distress and facilitating early referral to appropriate mental health services are vital steps in preventing distress from progressing to a suicidal crisis. Improving the ability of primary care physicians and other frontline healthcare professionals to recognise and appropriately refer people at increased risk may contribute to better suicide prevention outcomes. For individuals who have engaged in suicidal behaviour or are considered to be at significant risk, appropriate assessment, safety planning, follow-up, and access to evidence-based mental health treatment are essential. There is also accumulating evidence supporting the role of certain medications in reducing suicidal behaviour among selected patients with severe mental illnesses. Lithium, in particular, has been associated with a reduction in suicide and suicide-related outcomes in people with mood disorders. Clozapine has also demonstrated an important role in reducing suicidal behaviour among individuals with schizophrenia or schizoaffective disorder who meet the appropriate clinical criteria.

Reducing access to highly lethal means

At the community level, reducing access to highly lethal means is one of the most effective population-level strategies for suicide prevention. Families, schools, workplaces, religious organisations, community leaders, and primary healthcare workers all have pivotal roles to play. Measures such as regulating the availability and packaging of potentially harmful medications, restricting access to hazardous pesticides, reducing opportunities for suicide in high-risk locations through appropriate environmental design, and improving safety in institutional settings can contribute to reducing suicide. Improving access to timely and appropriate mental healthcare should also be an essential component of a comprehensive national suicide prevention strategy. Early identification, effective referral pathways, crisis intervention services, and the continuity of care are all important. Responsible media reporting is another critical component of suicide prevention. In some circumstances, vulnerable individuals may be influenced by the way that suicide is portrayed in the media, potentially contributing to imitation or contagion effects. Therefore, suicide should be reported with great caution, avoiding unnecessary details about the method used and avoiding sensationalised or romanticised portrayals (the Press Complaints Commission’s Editors' Code of Practice. 2007.).

Recognising distress signals

In conclusion, suicide prevention is a shared responsibility. Families, friends, colleagues, schools, workplaces, healthcare professionals, and communities all have an important role in recognising distress, offering compassionate support, and encouraging people to seek help early. Creating a culture in which emotional difficulties can be discussed openly and without shame can help people reach out before a crisis becomes overwhelming. Suicidal crises are often temporary, and with timely support, appropriate treatment, and continued care, individuals can find hope and an opportunity for recovery. By listening without judgement, taking distress seriously, connecting people with appropriate help, and creating communities where it is safe to speak about emotional suffering, we can all contribute to preventing suicide and saving lives.

The writer is a Consultant Psychiatrist attached to the Teaching Hospital, Polonnaruwa

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The views and opinions expressed in this column are those of the writer, and do not necessarily reflect those of this publication