Story by Jennifer Lees

“You don’t commit suicide, you die by suicide…”

[dropcap]H[/dropcap]e was a good student in high school. He played by the rules and didn’t get into too much trouble. The “average kid” – some might say. Like most of his friends, he went on to study at university and life seemed to be on track. He got himself a girlfriend, was sailing through his classes and had a good group of friends. Life was simply peachy until – inexplicably – it wasn’t. He started partying too much, drinking much more than usual and experimenting with drugs. His sleeping patterns changed and he started missing lectures. Failing grades accompanied a 10kg weight gain in the span of just a few months. He gave up on old hobbies and became a source of great concern for his girlfriend. He knew something felt wrong, but he couldn’t put his finger on it. There was a dramatic uncontrollable change taking place and the associated discomforting feelings began seeping into every dimension of his life. Unable to corral or explain these feelings, he continued with life as usual pushing any negative thoughts to the back of his mind.

It wasn’t until he woke up confused in a hospital bed that it dawned on him that supressing his feelings was not an appropriate way to go through life. Suddenly it all came back to him, he had tried to take his life after coming home from a disappointing night out. Whilst in the hospital, he spoke to a psychiatrist about the event and everything leading up to it. He had been suffering from Borderline Personality Disorder (BPD) and would now benefit from appropriate medical treatment. Although the case presented here did not have fatal consequences, suicide continues to be a problem and every year, many people sadly decide to take their own lives.

Suicide: What’s going on?

Suicide continues to be a major public health concern all over the world, as it affects all age groups, all genders and a vast array of different cultures. Globally, suicide rates seem to be somewhat stable or even decreasing. Yet, it is still the fourth leading cause of premature death in people aged 15-49. In Sweden, suicide is the leading cause of premature death and the number of cases have been increasing in recent years (Institute of Health Metrics and Evaluation, 2013). For instance, the number of deaths per 100 000 people has risen from 10 to 14 among people aged 15-24 years old over the past 14 years. If we take a look at other countries in Scandinavia we can see that they also have higher rates of suicide than the global average. No one is sure why the rates are higher in Scandinavian countries prompting us to meet with Dr. Bo Runeson (Department of Clinical Neuroscience, Karolinska Institutet) to discuss the current increase in mental health illness among young adults.

A professor of psychiatry who specializes on suicide research, Runeson is also the Chairman of the Stockholm County Council’s regional care program for suicidal patients and works as a senior physician in the Affective Centre of Northern Stockholm Psychiatry. He has authored several books and contributed immensely to our understanding of suicide and the risk factors underlying it.

It was a cold and windy November morning when I met Professor Bo Runeson at his office in Sankt Göran’s Psychiatric Department, but that didn’t seem to dampen either of our spirits. I met him as I came out of the lift and he was rushing from one room to the other. I was early for our appointment, and I think I gave him a bit of a startle. Nevertheless, he was very welcoming and hospitable. He looked younger than I was expecting for someone with such a long list of achievements and he was much taller than I anticipated. He was very friendly and eager to share his knowledge on the topic, despite the fact that he is rarely interviewed in English.

A trained psychiatrist, Runeson made his first entry into research when he became inspired to put his clinical observations into scientific context. He started his scientific career by conducting psychological autopsies. He described these to me as “systematic interviews with people close to a suicide victim, such as friends and family members, to find out exactly what happened to the deceased and why it happened”. He would have in depth conversations with people that knew the victim in order to build up a profile of what their mental state was like before they died. “It’s almost unheard of for people to die by suicide without having a motive or underlying conditions,” he told me. Conducting these types of interviews over the years have lead Runeson to conclude that the majority of suicide victims are young adults usually presenting an undiagnosed form of mental illness.

Why is this happening?

Runeson explained that people who die by suicide are usually struggling with some form of mental illness. Depression is the most prevalent underlying mental condition in victims of suicide, which is not always severe in nature and could range between mild and moderate. However, if left undiagnosed, individuals can really suffer and may fail to cope with every day life. Other common undiagnosed mental illnesses affecting suicide victims include borderline personality disorder, schizophrenia and bipolar disorder.

The reality is that these disorders are very challenging to diagnose, especially in young adults. This is because these conditions can manifest unusual or atypical symptoms ranging from risky sexual behaviour to binge drinking and therefore can be confusing to pinpoint. Moreover, with regards to the more serious illnesses, such as bipolar disorder and schizophrenia, the symptoms begin to develop in young adulthood, around the age of 20, a period of life where a great deal of change is already going on.

Risk factors

Around 6 % of undergraduates and 4 % of graduate students in 4-year colleges report seriously considering attempting suicide in the past year and nearly half of these people did not tell anyone. (American College Health Association). This alarmingly high rate of suicidal thoughts among young adults has prompted Runeson and his team to extensively research the risk factors of suicide and mental illness. He noticed that medical and nursing students having higher rates of depression and suicidal thoughts compared to those working. It is unclear whether this pattern appears in all university students, but if it does, we are facing a huge public health problem. Runeson postulates that around 50% of all high school graduates go on to further education and 1 in 5 students report having depression. Of those who have depression, there will be a sizeable number of individuals who attempt suicide. Consequently, we could see a steady rise in the suicide rate as the number of university admissions increases.

Runeson suggests that the reasons for the high rate of depression and suicidal thoughts in students may be explained by the stress and pressure put on attainment, which plays on people’s vulnerabilities. He gives the example of medical students, which as a group, are generally high achievers so they put a lot of stress on themselves to be the best and generally struggle to accept failure. Another example is those who go to university because it is expected of them by their family and by society. After a period of time, some may come to realize that university was not meant for them, and then find themselves dealing with uncertainty and struggling to get any support from home. Another important factor may be moving from home to university, which comes with a number of changes ranging from familial separation to the challenges associated with establishing new social networks. This can lead to feelings of isolation and hopelessness, especially if one does not know where to turn to – be it for social support or for professional help.

Another risk factor for suicide is gender. Runeson has found that female students were about two times more likely to report these symptoms than their male counterparts, however, almost none actually attempted suicide. Men are more impulsive and tend to think more short term, which makes them more likely to carry through with suicide. He explained that “men are more likely to deny the situation and turn to alcohol and narcotics to ‘fix’ the problem, while women are more likely to have a supportive social network and therefore more likely to seek help”. An emerging area of research is now focusing on the risk of suicide in transgender and gender non- conforming individuals. 41% of individuals who identify as transgender have reported to have attempted suicide at some point in their lives. Compared this to general population of gender conforming individuals where 4.6% have reported attempting suicide (American Foundation of Suicide Prevention, 2014).

Getting help

Where to turn to get help and how to navigate the health care system is a very important issue. It’s not surprising that young adults are often unfamiliar with the health care system, as they have never had to deal with it before. This can make people reticent to get help, or even unaware of the help available. These observations have been documented in some of Runeson’s earlier studies. He explains that “it’s not just navigating the healthcare system what can be troubling. Having a first episode of depression or panic disorder in its own can be distressing and may not even be obvious to the person or their close family and friends”. Runeson points out that “anyone can be affected, even someone who has never had any mental health issues before. Everyone experiences pain and the pain felt varies from person to person”. There are common events that can lead to depression or anxiety, such as a break up, monetary issues, disappointment in the workplace or with university grades. It is normal to have periods of sadness that may lead to mild depression or anxiety. Unfortunately though, up to 42% of people suffering from a mental illness do not seek help, and of those half have attempted suicide at some point (Cheung & Dewa, 2007). These harrowing statistics bring home the reality of suffering from a mental illness and the importance of recognising when someone is in need of help. What is encouraging, however, is that here at Karolinska Institutet, students are invited to talk about any issues that they are experiencing with their course and programme leaders. Runeson says that both his colleagues and him welcome psychiatry students to come forward with any issues they may have be.

Changes can also be seen outside the university setting, where some important developments have genuinely aided the field of mental health. Access to mental health care has increased greatly over the recent decades and now you can even contact the psychiatric department at the hospital directly if you feel the problem is more urgent. One achievement that Runeson and his department are particularly proud of is Psykiatrisk Akut Mobilitet or PAM, which is a mobile acute emergency unit to support individuals. It looks much like an ambulance, but it deals only with mental health issues. It is staffed with a psychiatric nurse who has full real-time access to medical records so that the care is of high quality. Instead of being visited by the police, a mental distressed individual would get more appropriate attention from the PAM. In addition to helping individuals, PAM hopes to help reduce the stigma of mental illness.

Thoughts for the future

While there have been some great steps forward in the field of psychiatry in recent years, there is still work to be done. There is a shortage of physicians, psychologists and nurses in psychiatric care, which opens up a great deal of possibilities for anyone who is interested in the field. Runeson says that if you want to engage in an area where things are being improved, now it is the time to take action. There are also developing fields in psychiatric research such as epidemiology, biological research and psychological research. Runeson’s concludes that it’s a very rewarding, broad and stimulating field and encourages those who are interested to get involved.