A short while ago, like many oth­ers, I re­ceived the hor­rif­ic news that a young ado­les­cent boy took his life in his par­ents' home dur­ing the ear­ly hours of the morn­ing while every­one slept. Even I, with so many years of ex­pe­ri­ence in med­ical and psy­chi­atric med­i­cine, still find it dif­fi­cult to ac­cept such ac­tions. The de­gree of trau­ma and pain suf­fered by the par­ents and the im­me­di­ate fam­i­ly was, as to be ex­pect­ed, enor­mous and un­bear­able. The shock and loss ex­pe­ri­enced by his peers and as­so­ciates, as judged by their re­ac­tion to the news and their com­ments in the so­cial me­dia sites, was cat­a­clysmic. Every­one searched for an­swers, and as hap­pens in these sit­u­a­tions, there was no short­age of an­swers.

But all of them were mere­ly the re­sult of spec­u­la­tion and guess­ing, and there were no, and quite like­ly, there will nev­er be any de­fin­i­tive rea­son for the tragedy. In the end a young man with so many rea­sons to live, was lost for­ev­er. To God-fear­ing so­ci­eties, sui­cide is con­sid­ered to be an abom­i­na­tion against God, and in the more ex­treme, un­ortho­dox so­ci­eties, the ac­tion is con­sid­ered to be il­le­gal or taboo. Yet de­spite every ef­fort to con­trol it, each year, over a mil­lion peo­ple the world over suc­ceed in killing them­selves. This sta­tis­tic is even more fright­en­ing when you con­sid­er that for every suc­cess­ful at­tempt there are many more who have ei­ther at­tempt­ed and failed, or se­ri­ous­ly con­sid­ered the pos­si­bil­i­ty but nev­er took any ac­tion.

Some­times I won­der whether there is some truth in the state­ment made by a col­league of mine dur­ing a dis­cus­sion on the sub­ject, "that we hu­mans are all born with the in­stinct to take our lives at any time, and for any rea­son, and ex­cept for the grace of God and a lit­tle luck, we of­ten do". Sui­cide is a world­wide scourge which, de­spite in­ten­sive at­ten­tion, con­tin­ues to in­crease at an alarm­ing rate. The World Health Or­gan­i­sa­tion es­ti­mates that by the year 2020, there will be more than 1.5 mil­lion suc­cess­ful sui­cides and be­tween 15–30 mil­lion un­suc­cess­ful at­tempts oc­cur­ring an­nu­al­ly. Each year it ranks in the top ten caus­es of death among adults and among the top three caus­es of death among ado­les­cents.

Fur­ther, al­though the records are not com­plete, the ev­i­dence points to the fact that the in­ci­dence of sui­cide in the Caribbean, par­tic­u­lar­ly Guyana and Trinidad and To­ba­go, is sur­pris­ing­ly high and get­ting high­er. This is a state of af­fairs that is un­ac­cept­able and de­mands the con­cert­ed ef­forts and un­der­stand­ing of every­one in­clud­ing par­ents, politi­cians, teach­ers and trained pro­fes­sion­als as a mat­ter of ur­gency. Apart from the trag­ic con­se­quences to the vic­tim, sui­cide is a very se­ri­ous pub­lic health is­sue that has last­ing, harm­ful ef­fects on the fam­i­ly, their as­so­ciates, and the com­mu­ni­ty, which can per­sist for gen­er­a­tions. Un­like oth­er trag­ic events such as ac­ci­dents, this ac­tion is fur­ther ag­gra­vat­ed be­cause of the un­for­tu­nate na­ture of the deed and the re­sult­ing on­go­ing "fam­i­ly em­bar­rass­ment".

It in­vari­ably re­sults in a sense of shame and with­draw­al and a gen­uine re­luc­tance to seek ap­pro­pri­ate help. When this is com­pound­ed with the in­evitable feel­ings of re­spon­si­bil­i­ty and guilt ex­pe­ri­enced by the sur­viv­ing fam­i­ly mem­bers, the re­sult is a fur­ther dis­in­te­gra­tion with­in the fam­i­ly struc­ture lead­ing to on­go­ing pain and suf­fer­ing. Sui­cide is a high­ly com­plex phe­nom­e­non, which de­spite ex­ten­sive re­search, is still not clear­ly un­der­stood and un­for­tu­nate­ly, not ad­e­quate­ly man­aged. It is a be­hav­ioral ac­tion that in­volves poor­ly un­der­stood in­ter­ac­tions among ge­net­ic, bio­chem­i­cal, psy­cho­log­i­cal, so­ci­etal, and cul­tur­al fac­tors. Re­search in­di­cates that, es­pe­cial­ly in re­gard to adult vic­tims, there are most of­ten di­ag­nos­able un­der­ly­ing psy­cho­log­i­cal con­di­tions such as de­pres­sive ill­ness­es, be­hav­ioral or per­son­al­i­ty dis­or­ders, or sub­stance abuse.

This would sug­gest that, at least in re­gard to the adult pop­u­la­tion, much more ag­gres­sive at­ten­tion should be paid to the iden­ti­fi­ca­tion of ear­ly symp­toms, the use of pub­lic ed­u­ca­tion and the easy avail­abil­i­ty of com­pe­tent re­sources in­clud­ing trained per­son­nel. This will have some ef­fect on re­duc­ing the ris­ing in­ci­dence of sui­cide. Con­trary to pre­vail­ing views, the prob­lem of ado­les­cent sui­cide is, in my view, some­what dif­fer­ent from adult sui­cide, and should be ap­proached dif­fer­ent­ly. Al­though de­pres­sion is fre­quent­ly men­tioned as a risk fac­tor in its cau­sa­tion (and some sources sug­gest that this may as high as 75 per cent of cas­es), I be­lieve that the re­al caus­es are much more com­plex, and re­late to the un­der­ly­ing de­mands of process of ado­les­cence it­self.

At best, these years are an anx­ious and un­set­tling pe­ri­od for teenagers as they face the dif­fi­cul­ties of tran­si­tion in­to adult­hood. It is the pe­ri­od in life where on the one hand much is ex­pect­ed from them, but al­so one, dur­ing which they un­der­go tu­mul­tuous changes phys­i­cal­ly, sex­u­al­ly and emo­tion­al­ly. They ex­pe­ri­ence strong feel­ings of doubt, in­ad­e­qua­cy, gen­der un­cer­tain­ty and ori­en­ta­tion, and have deep seat­ed fears of fac­ing the fu­ture and the ex­pec­ta­tions of adult­hood, while they deal with the com­pet­i­tive de­mands of the present. It is a pe­ri­od that is of­ten con­fus­ing and in­tim­i­dat­ing, caus­ing some of them to feel iso­lat­ed from fam­i­ly or au­thor­i­ty, re­luc­tant to seek guid­ance from them, and un­for­tu­nate­ly, turn­ing to their peers for help. This is a for­mu­la for tragedy.

Com­pound­ing this sit­u­a­tion, is the very re­al so­cial and en­vi­ron­men­tal risk fac­tors which we, as adults and par­ents, do not un­der­stand or have not been ed­u­cat­ed ap­pro­pri­ate­ly, and as a re­sult tend to take for grant­ed. We as­sume that "they will learn as we did when we were their age" and make lit­tle or no ef­fort to re­al­ly un­der­stand our chil­dren. We con­ve­nient­ly for­get our own pe­ri­od of un­cer­tain­ty and feel­ings of in­ad­e­qua­cy which we ex­pe­ri­enced, or wit­nessed in our time, and we try not to re­call the names of our friends or con­tem­po­raries who fell by the way­side, or chose the ul­ti­mate so­lu­tion be­cause "they could not take it any­more". I have no doubt that any one of us will have no dif­fi­cul­ty in re­mem­ber­ing sev­er­al ex­am­ples among our own peers in our day.

It is this per­ceived ap­par­ent in­ad­e­qua­cy or in­abil­i­ty of par­ents and oth­er peo­ple in au­thor­i­ty to dis­play the ap­pro­pri­ate in­ter­est or worse, ig­nore the de­vel­op­ing signs on the hori­zon, which in my mind give rise to some, if not all, of the risk fac­tors. Michelle Loubon, in her ex­cel­lent­ly writ­ten ar­ti­cle un­der the head­ing, "Youth at risk for sui­cide" in the Trinidad Guardian pub­lished on Sun­day, Sep­tem­ber 25, record­ed the fol­low­ing ob­ser­va­tion from coun­selling psy­chol­o­gist An­na Maria Mo­ra: "Up to this day, many par­ents do not han­dle their chil­dren's sex­u­al­i­ty. They do not un­der­stand chil­dren are sex­u­al be­ings. The mere fact they are go­ing through these changes will alien­ate them. No­body is ad­dress­ing that. They are all ex­pect­ing their chil­dren to get 'As' in school. The fo­cus is on aca­d­e­mics. The ex­pec­ta­tions are high."

I be­lieve Ms Mo­ra's ob­ser­va­tion high­lights some of the very fun­da­men­tal fac­tors in the cri­sis of ado­les­cence and in a sense, the rea­son for its con­tin­u­a­tion. As par­ents and adults, our ex­pec­ta­tions are di­rect­ed to per­son­al suc­cess and ad­vance­ment for our chil­dren, and we give lit­tle at­ten­tion to the storm rag­ing with­in and around them. To make mat­ters worse, the cur­rent ado­les­cent pop­u­la­tion has the added im­pact of the in­ter­net, and in par­tic­u­lar such me­dia sites as Face­book, to in­flu­ence and fur­ther ag­gra­vate their con­flicts. Not the least of which is the lin­ger­ing fear of ex­po­sure, or ridicule or hu­mil­i­a­tion that, un­like pre­vi­ous gen­er­a­tions, could oc­cur and spread rapid­ly and lead to dev­as­tat­ing con­se­quences. Par­ents must recog­nise this very re­al pos­si­bil­i­ty at all times and must take every op­por­tu­ni­ty to main­tain open com­mu­ni­ca­tion, flex­i­bil­i­ty and will­ing­ness to un­der­stand their chil­dren.

Sui­cide among ado­les­cents very rarely oc­curs on a planned, pre­med­i­tat­ed pro­gramme. Rather, it is much more an im­pul­sive re­sponse to an un­ac­cept­able sit­u­a­tion oc­cur­ring in the in­di­vid­ual's life, whether that be a failed ro­mance, bul­ly­ing, crit­i­cism, sex­u­al ori­en­ta­tion or any of the many vari­a­tions that has the po­ten­tial of caus­ing pain and em­bar­rass­ment, es­pe­cial­ly when the vic­tim feels un­able to deal with it. This is the kind of think­ing that gen­er­al­ly oc­curs in the mind of the vic­tim im­me­di­ate­ly pri­or to mak­ing the fi­nal de­ci­sion.

There may have been some pre­ced­ing thoughts or dis­cus­sion about sui­cide as the cor­rect an­swer, but the fi­nal de­ci­sion is im­pul­sive and un­planned. The fol­low­ing re­sponse of a young pa­tient af­ter a failed at­tempt is quite typ­i­cal: "I did it on a sud­den im­pulse, when I could not bear the thought that every­body will soon know about me. It seemed that this was the right thing to do es­pe­cial­ly since none of my fam­i­ly or friends re­al­ly un­der­stood."

A great deal has been writ­ten on this sub­ject and there is no re­al short­age of opin­ions and rec­om­men­da­tions of­fered. But the truth is that, in spite of the wealth of pub­lished in­for­ma­tion avail­able, we have not suc­ceed­ed in ed­u­cat­ing our par­ents, teach­ers and oth­er re­spon­si­ble adults on the dy­nam­ics of teenage sui­cide in­clud­ing the iden­ti­fi­ca­tion of ear­ly signs and cor­rec­tive in­ter­ven­tion. We need to un­der­stand that this is a very re­al and grow­ing threat to the lives and as­pi­ra­tions of many of our younger gen­er­a­tion and we must be­gin to take up our re­spon­si­bil­i­ties.

The fol­low­ing ob­ser­va­tion from a pub­li­ca­tion of the So­cial Sci­ence de­part­ment of the Uni­ver­si­ty of Am­s­ter­dam, Hol­land, is one of the most im­pres­sive de­scrip­tions of the dy­nam­ics of teenage sui­cide. We will all do well to un­der­stand that we do have a role to play: "Sui­ci­dal feel­ings should not be un­der­es­ti­mat­ed, they are re­al and pow­er­ful and im­me­di­ate. The vic­tims are dri­ven by pain not choice. Sui­cide isn't cho­sen-it hap­pens when pain ex­ceeds the re­sources for cop­ing with pain. But we do know that sui­cide is of­ten a per­ma­nent so­lu­tion to a tem­po­rary prob­lem. And we al­so know that most peo­ple who once thought about killing them­selves are now glad to be alive. They didn't want to end their lives...they just want­ed to stop the pain."

Sui­cide is clear­ly a se­ri­ous con­cern which is cry­ing out for gen­uine and con­cert­ed ac­tion from all sec­tions of so­ci­ety. The on­ly way we can hope to re­duce the in­ci­dence of at­tempt­ed and com­plet­ed episodes in our com­mu­ni­ty is by es­tab­lish­ing com­pre­hen­sive pro­grammes in­volv­ing all mem­bers of so­ci­ety. It is a well known fact that in sit­u­a­tions where mean­ing­ful ef­forts in ed­u­ca­tion, sen­si­ti­sa­tion and im­proved com­mu­ni­ca­tions among all groups have oc­curred, there has been sig­nif­i­cant im­prove­ment both in the re­duc­tion of events and in the gen­er­al wel­fare of our teenage pop­u­la­tion. But if we hope to be tru­ly suc­cess­ful we must in­clude every­one in­volved in the care and con­cern of our ado­les­cents.

Health au­thor­i­ties must pro­vide ad­e­quate pro­fes­sion­al sup­port such as So­cial and Psy­cho­log­i­cal per­son­nel to deal with the very re­al ado­les­cent prob­lems of ad­just­ment and ori­en­ta­tion and to iden­ti­fy and cor­rect the symp­toms of de­pres­sion so com­mon at that age. We can­not al­low the present pat­tern of leav­ing them to their own re­sources to con­tin­ue and not ex­pect in­creas­ing dis­as­ters. -Fam­i­lies must be ed­u­cat­ed as to their re­spon­si­bil­i­ty in the wel­fare of their chil­dren. Neg­a­tive fam­i­ly func­tion­ing is un­doubt­ed­ly a strong risk fac­tor. There is a very strong as­so­ci­a­tion of sui­ci­dal and oth­er emo­tion­al ideation among teenagers with a fam­i­ly his­to­ry of sui­cide, sub­stance abuse, phys­i­cal vi­o­lence and mar­i­tal con­flict in­clud­ing di­vorce, ne­glect or aban­don­ment.

Stud­ies sug­gest that fam­i­ly con­flicts pre­cip­i­tate at least 20 per cent of com­plet­ed sui­cides and 50 per cent of at­tempt­ed episodes. Suc­cess­ful fam­i­ly in­ter­ac­tions will go a long way in pro­vid­ing the nec­es­sary pro­tec­tive fac­tor, se­cure safe­ty net and open com­mu­ni­ca­tions that are need­ed to help over­come any chal­lenge or con­flict. -School per­son­nel play an equal­ly vi­tal role in the lives of their stu­dents. The on­go­ing con­tact in the class­room and in the hall­ways may pro­vide an op­por­tu­ni­ty for ear­ly iden­ti­fi­ca­tion and ef­fec­tive pre­ven­tion of po­ten­tial be­hav­iour. Any change in aca­d­e­m­ic per­for­mance or be­hav­iour or emo­tion­al re­sponse may her­ald an ear­ly sign of trou­ble.

This is even more im­por­tant since stu­dents are more will­ing to con­fide in their teacher than their par­ents. But for this to take place, teach­ers must make the ef­fort to be alert, be in­formed and be proac­tive in the school set­ting. In the end, the on­ly chance we have to try to curb this scourge in so­ci­ety, and to pro­tect our chil­dren from im­pul­sive­ly de­stroy­ing their sa­cred and God-giv­en life lies in our will­ing­ness, as par­ents, teach­ers, pro­fes­sion­als or sup­port per­son­nel to recog­nise our in­di­vid­ual and group re­spon­si­bil­i­ties and to take steps to fa­mil­iarise our­selves with the ap­pro­pri­ate knowl­edge.

Nor­mal, healthy ado­les­cent de­vel­op­ment oc­curs in the con­text of a lov­ing, se­cure, mu­tu­al­ly re­spect­ful set­ting, where there is re­spon­si­ble and ma­ture re­la­tion­ships. Un­til our chil­dren are com­fort­able to ex­press their con­cerns, pos­i­tive or neg­a­tive, to par­ents and teach­ers and not be afraid of ridicule or em­bar­rass­ment they are like­ly to keep them to them­selves or seek out the ad­vice of their peers or worst of all, act out im­pul­sive­ly. This is the chal­lenge we will face as we con­tin­ue to wit­ness the sense­less loss and de­struc­tion of so many of our chil­dren.

Dr Ed­ward A Moses, MRC Psych

For­mer con­sul­tant psy­chi­a­trist,

PoS Gen­er­al Hos­pi­tal