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Salud mental
versión impresa ISSN 0185-3325
Salud Ment vol.29 no.5 México sep./oct. 2006
Artículos originales
El suicidio, conceptos actuales
1Facultad de Psicología, Universidad Veracruzana. Xalapa, Veracruz.
2Laboratorio de Neurofarmacología, Instituto de Neuroetología, Universidad Veracruzana. Xalapa, Veracruz.
3Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México. Unidad Periférica Xalapa, Veracruz.
Un problema contemporáneo y creciente es el suicidio, lo que implica la necesidad de establecer definiciones precisas que lleven a la identificación de los factores de riesgo, tomando en cuenta que las bases del suicidio son multifactoriales y complejas. Los estudios epidemiológicos indican que el género masculino comete más suicidio que el femenino, en una proporción de 5:1 en todos los rangos de edad. En cambio, las mujeres realizan intentos con mayor frecuencia en la misma proporción, generalmente ingiriendo pesticidas o medicamentos. El suicidio consumado acontece frecuentemente en hombres mayores de 50 años por ahorcamiento o uso de armas de fuego. Aunque de manera alarmante, en años recientes ha ido en aumento el número de suicidios entre jóvenes de 15 a 24 años de edad, y es más común entre los de clase socioeconómica baja, con tratamiento psiquiátrico previo, con algún trastorno de la personalidad y antecedentes de abuso de substancias y de intento de suicidio.
La presencia de un trastorno psiquiátrico está íntimamente ligada al suicidio; más de 50% de los suicidios son consumados por personas con trastornos depresivos. El abuso o dependencia de alcohol está presente en alrededor de 20 a 25% de quienes se suicidan y también ocurren tasas elevadas de suicidio en la esquizofrenia. La ansiedad es otro trastorno asociado de manera rele vante con el suicidio, de modo que la comorbilidad de ansiedad con depresión multiplica el riesgo. Todo ello implica una alerta clínica que debe llevar al médico al manejo terapéutico farmacológico adecuado y a tener mayor vigilancia cuando se detecta la ideación suicida, sobre todo si hay antecedentes de depresión y de ansiedad.
Los factores de riesgo en los suicidas incluyen aislamiento, salud precaria, depresión, alcoholismo, baja autoestima, desesperanza, sentimientos de rechazo familiar y social. También es importante considerar el antecedente de daño dirigido hacia sí mismos y la incapacidad para resolver problemas, principalmente los de tipo social. Frecuentemente el suicida da indicios verbales directos e indirectos de su intención suicida. Un 60% de los suicidas que lograron su propósito había consultado al médico el mes anterior al suceso; más de la mitad había comentado con alguien su deseo de morir, y un tercio del total había hecho una amenaza declarada de suicidio. Así, la evaluación de riesgo del paciente suicida debe ser una parte fundamental en la práctica clínica diaria, ya que la detección oportuna de los factores de riesgo suicida puede permitir su prevención.
Un aspecto que no ha sido suficientemente evaluado y que hoy en día ha dado pie a una serie de controversias, es el relacionado con el impacto que el uso de antidepresivos podría tener sobre el suicidio. La Food and Drug Administration (FDA, EUA) recientemente ha documentado que no existe la suficiente información para confirmar alguna relación entre el uso de los inhibidores selectivos de la recaptura de serotonina y el suicidio entre jóvenes. En cualquier tratamiento antidepresivo, el riesgo suicida puede incrementarse significativamente durante el primer mes, particularmente durante los primeros nueve días. Entonces, el que un paciente tratado con antidepresivos se suicide al inicio del tratamiento, es atribuible a que estos medicamentos requieren de tres a cuatro semanas para empezar a producir efectos terapéuticos. Esto demuestra la necesidad del internamiento hospitalario para lograr una vigilancia estrecha.
En conclusión, el suicidio es un problema grave de salud pública y requiere atención especial. La investigación más reciente señala que la prevención del suicidio, si bien es posible, comprende una serie de actividades que incluyen, por lo menos, la provisión de las mejores condiciones posibles para la educación de los niños y los jóvenes. También se debe contar con el personal médico que permita lograr la detección y el tratamiento eficaz de los trastornos subyacentes, y tener control medioambiental de los factores de riesgo y, desde luego, la eliminación de los medios para consumarlo.
Palabras clave: Suicidio; ideación suicida; factores de riesgo; desesperanza; diátesis
One current problem in Public Health relates to suicide and the identification of the risk factors needs to be clarified accurately. The bases of suicide involve complex multiple factors. In a high proportion of nations, mainly in industry-developing countries, suicide is placed among the first three causes of death in groups aged from 15 to 34 years. In Mexico, suicide represents the ninth cause of mortality, within a wide scale of age ranging from 15 to 64 years.
Some risk factors have been identified. Epidemiological studies show that males commit suicide more frequently than females, in a proportion of 5:1. Consummate suicide occurs in men about 50 years old, mainly by hanging or fire arms. Females between 20 and 29 years old, on the contrary, carry out more frequent unsuccessful attempts in the same proportion, by using pesticides and medical drugs. However, in recent years an increase in the number of suicides among young people from 15 to 24 years old has been observed, commonly in lowincome sectors, in subjects with a previous history of psychiatric disorders, mainly personality disorders, abuse of substances and prior suicidal attempts. The risk of suicide generally increases after 45, and becomes especially serious in older people. The phenomenon of suicide in the elderly deserves special attention, due to the fact that the population over 65 years old is continuously increasing. This group displays fewer attempts than youths, but they achieve their aim more often through a silent suicide, by refusing to eat or to accept and follow medical prescriptions.
Some psychiatric disturbances are intimately related to suicide. It is considered that 50% or more of the consummate suicides are performed by people suffering from an affective disorder, mainly depression. In this sense, it is noteworthy that most of these patients had been misdiagnosed and in many cases had not received any proper treatment. In addition, the abuse of or dependence on alcohol is present in about 20% of consummate suicides, and high rates of suicide are also observed in schizophrenia. Another common disturbance associated with suicide is anxiety. The simultaneous presence of anxiety and depression must be considered as a great risk factor, since the depressed patient has a high risk of committing suicide under phases of increased anxiety. All of these observations imply an alert signal for medical care units concerning the importance of detecting signs of the presence of risk factors and suicidal ideation, and of implementing adequate therapeutic management, namely, a supervised pharmacological treatment of depression and anxiety, including hospitalization, if it were the case.
The risk factors in potential suicide include isolation, poor health, depression, alcoholism, lowered selfesteem, despair and feelings of social and family refusal. Frequently, the potential suicide directly or indirectly gives behavioral and verbal cues of his or her suicidal intention. Roughly, 60% of the victims of suicide had attended some medical care unit in the month previous to the suicide and had commented something about their desires and feelings about death at some moment, and 30% had clearly revealed their suicidal ideation. For such reason, the evaluation of risk of the potentially suicidal patient should be a common practice in medical care units. Therefore, the early detection of the presence of risk factors of suicide, including the report of self-harm and of a detectable incapacity for solving problems, mainly of social type may provide an invaluable time to permit its prevention.
Another current aspect awaiting conclusive evidence is associated with some controversial data regarding the impact that the use of antidepressants could have upon suicide. The Food and Drug Administration office (USA) pointed out that deficiencies in information do not allow to confirm any existing relation between the use of serotonin selective reuptake inhibitors (SS-RIs) and suicide in youths. The suicidal risk after initiating the treatment is similar in the patient receiving tricyclics, or seroton-in selective reuptake inhibitors. The risk of suicide can increase significantly in the first month of antidepressant treatment, especially during the first nine days. Consequently, the observation that patients receiving antidepressants attempt suicide, is due, at least partly, to the fact that for still unknown reasons, antidepres-sants require from three to four weeks of impregnation to attain clear therapeutic effects.
Therefore, it is indispensable to carry out further clinical and experimental studies to determine the variables that could be implied in this time lag in the action of antidepressants. However, fluoxetine represents a useful alternative in the management of depressive disorders; albeit as in the case of other antidepressants, it requires a strict follow-up of the patient receiving such treatments to avoid the risk of a fatal complication.
In conclusion, the suicide risk, being a serious problem of public health, requires special attention. Recent research indicates that the prevention of suicide includes a series of activities, such as educational programs for children and youths, teachers and educators, and also primary health care units for the early detection of suicide risk factors. And, of course, medical training for the management of the potential suicide.
For all of them, some relevant facts must be taken into account:
Depression can be present in children and adolescents.
Access to means of committing suicide, such as weapons, must be avoided.
People from medical care units should be on the alert when any one shows signs and symptoms of despair and impulsiveness.
Suicide, anxiety and depression have a biological basis; there-fore it is not a matter of cowardice or an act of defiance.
An inadequate and inopportune diagnosis may increase the suicidal risk.
Parents and teachers should be instructed to detect any sign of suicidal ideation and despair. Therefore, this revision intends to bring some recent data to bear upon the factors of the risk of suicide that provide the reader with information for a more effective prevention.
Key words: Suicide; ideation suicidal; risk factors; hopelessness; diathesis
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Recibido: 25 de Mayo de 2006; Aprobado: 26 de Junio de 2006
Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons
