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Point of View

Death wish or suicidal ideation: Implications for management

Amin A. Muhammad Gadit

Department of Psychiatry, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada.

In the process of psychiatric consultation, the issue of suici-

dal thought, planning and attempt carry high significance in

terms of management and prognosis. However, both these

terms are not well understood by many mental health pro-

fessionals and often the residents fail to detect whether the

patient has expressed suicidal thoughts or it was merely a

death wish.

Many psychiatric admissions are done on the

basis of seriousness of the issue of suicidality and that both

the expression of death wish as well as suicidal thoughts is

held in the same magnitude in terms of its significance.

Freud has described this as "thanatos" which is a death drive

representing the organic need to return to lifelessness and

stasis, the ultimate calm of lifeless non-conflict attributing

all aggressive and destructive activity to this notion. Death

wish is a general expression when some life events assume

severe proportions and start taking their toll on the mental

health or it is a casual cultural expression when some social

hardships cause trouble. It has been observed that some

women folk would express this wish when domestic pres-

sures becomes overwhelming, with child rearing difficul-

ties, financial problems and turbulent relationship with the

spouse. In some cultures, expression of death wish is a

taboo; some religions disapprove such thoughts and expres-

sions. However, death wishes are noted in terminally ill

patients who are fed up with their long term misery. Even in

these instances, assessment of psychological and social

issues need to be ruled out. It has also been demonstrated

that death wish in very old is likely to be associated with

occurrence of a psychiatric disorder, especially major

depression with negative life conditions.

It is important

that some areas should be explored like: difficulties in the

patient's relationships with family, friends, and health work-

ers, psychological disturbances, especially, grief, depres-

sion, anxiety, organic brain disorders, personality disorder,

and the patient's personal orientation to the meaning of life

and suffering. In a study conducted in a community on res-

idents aged 65 and over, it was confirmed that expressed

wish for death was a predictor of mortality, controlling for

age, sex, and cognitive impairment.

Thoughts of suicide

may be a part of normal adolescence, and suicidal act a

manifestation of pathological development specific to this

stage in life, the wish to die has no age restrictions and may

accompany life as a shadow, devoid of any suicidal act, for

years. The imbalance between these two wishes calls for

concern and need separate evaluation.

It is said that death

wish may not necessary be a feature of depression as in a

study, patients expressing death wish reported less opti-

mism, less comfort in religion, and greater hopelessness, yet

the conclusion about presence of depressive illness cannot

be made.

There is a debate on whether death wish can be con-

verted or is progressed to suicide intention, or is death wish

a predictor of suicidal thought and eventual act, is the brain

chemistry common, likewise, should one get alarmed and

adopt preventive measures on expression of death wish to

the extent of commencing biological treatment. The ques-

tion arises if there were some overlapping factors in these

two entities? Several psycho-social factors are associated

with this, genetic factors as well as impulsive-aggressive

behavior also plays a critical role in suicide predisposition.

The role of CSF-HIAA levels

, increased density of sero-

tonin binding sites in frontal cortex, fewer presynaptic sero-

tonin transporter sites and upregulated levels of the 5-HT1A

receptor in ventromedial prefrontal cortex, possible impli-

cation of protein kinase A and C are worth debating.

Low

cholesterol has been discussed as an important factor pre-

disposing to suicidal behavior.

It is a likely possibility that

same biological application may be valid both for death

wish and suicidal thought. Death wish can also be taken as

a precursor for active suicidal thoughts and subsequent act.

Those people who express death wish in clinical setting

must be explored for the presence of dysthymia, chronic

boredom in association with a borderline personality disor-

der or presence of sub threshold depression.

From a clini-

cal management perspective, suicidal thoughts need imme-

diate attention whereas death wish needs detection of under-

lying pathology whether it is social or psychological.

Presence of death wish among patients presenting to emer-

gency department should not be dismissed as such without

careful mental state examination as this may be a 'cry for

help' which if ignored may result in devastation. Effective

communication skills, thorough understanding of the under-

lying cause and knowledge of cultural background is of

paramount importance as simple death wish may be a warn-

ing in disguise and a strong predictor of more serious sui-

cide intent.

Vol. 57, No. 3, March 2007 156

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