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Suicide today: multiple perspectives on a complex problem

Eder Samuel Oliveira Dantas - Dantas, E.S.O - edersamuel_rn@hotmail.com - Hospital Universitário Onofre Lopes
Natal, RN
ORCID: https://orcid.org/0000-0002-6595-6105

Since the dawn of humanity, suicide has been recognized as one of the most complex and intriguing social phenomena. Considered a global public health problem, it is the cause of death of over 700,000 per year1. In the Americas and the majority of low- and medium-income countries, such as Brazil, this fatal event continues to grow year after year. In addition to the epidemiological issues, the complexity of the phenomenon stems from its multifactorial nature, which includes, but is not limited to, psychological, biological, political, social, philosophical and environmental aspects2.
In this context, the book entitled Suicídio: Complexidades e Urgências na Cena Contemporânea [Suicide: Complexities and Emergencies in the Contemporary Scene], published in 20243 by ABEPs, highlights important nuances regarding the theme. This is the Association’s first publication in this format. It is divided into three parts and written by several Brazilian authors, specialists in the Suicidology area, among whom I highlight psychoanalyst, Roosevelt Cassorla (in memoriam).
Part 1, entitled Cenas e Contracenas [Scenes and Counterscenes], comprises four chapters. In the first, the author explores the complexity of the suicidal act, mentions some pioneers in the study of the theme, and draws attention to the need to be aware of the different social scenarios that circumscribe the act in order to devise effective coping strategies. Furthemore, it points out the importance of a specific focus on suicide among Brazilian indigenous people, whose mortality rates in 2020 were two and a half times higher than those of the general population4.
The second chapter covers a psychoanalytical perspective on suicide based on the conception of narcissistic society. There is a discussion based on a young doctor’s case study, in which the author interrelates personal issues, demands and professional pressures with the incessant seeking of success, prestige and admiration. It is reflected that, for people with behavior similar to that in the case cited, frustrations of any kind can be perceived as unbearable and intolerable, to the point of resorting to self-provoked death.
The third chapter addresses suicide in Brazilian public universities. This discusses the idea that these educational spaces are places where human suffering, sometimes intense, is experienced, especially in categories whose respective public policies are still fragile, such as the LGBTQIA+, and black and low-income people. The authors reaffirm the need for universities to use their potential for collective struggle and become spaces to promote well-being, including prevention of suicide, recognizing that inequalities and suffering are preventable.
In the fourth and last chapter of Part 1, digital governance in suicide prevention is discussed. The authoress points out how information and communication technologies can be used effectively in prevention, contextualizing epidemiological data and successful programs. Furthermore, she raises ethical questions about the use of these technologies, emphasizing the need for government involvement in data protection and ensuring confidentiality of the information.
Part 2 of the book is dedicated to prevention and postvention in educational and work contexts. The first chapter deals with protection against bullying in childhood and adolescence as part of suicide prevention efforts. The authors highlight the devastating effects of physical bullying and cyberbullying on the lives of children and adolescents, pointing them out as major risk factors. They also mention that, unlike global northern countries, Brazil still lacks robust initiatives to prevent and combat these practices.
In the second chapter, the impacts news of a suicide can generate on a school environment are discussed. The authoress highlights the importance of approaching these deaths in a proper manner, integrating postvention practices - actions carried out after the event with the objective of minimizing damage to the community. She also mentions measures already recommended by the World Health Organization and other specialists in the field, such as encouraging the seeking of help, appreciation of the value of protective factors, and regarding mental health as a priority5,6.
The third chapter discusses postvention in the school context, highlighting practical actions that can be implemented, as well as proposing interventions based on the experience of the referred authors. The authoress reaffirms the role of the school in ensuring due attention to and care of the community after a suicide. The fourth chapter addresses the impacts of suicide scenes on the mental health of first responders, such as ambulance teams, firefighters, police and rescuers, who may suffer intensely through dealing with these situations. The repercussions may even include post-traumatic stress disorder.
Part 3 focuses on intervention in clinical contexts, offering a practical view on the confrontation of suicide. The first chapter explores suicide prevention within mental health care, presenting various models applicable to different scenarios. It also addresses the challenges faced during the Covid-19 pandemic, when difficulties of access to mental health care and social isolation intensified the aforementioned suicide risk factors. Besides this, it highlights the fundamental role of preventive approaches in the university environment, where due attention and psychosocial support are essential to dealing with the increasing demand for mental health care.
In the second chapter, the intersubjective relationship in clinical intervention is the theme explored. The authoress seeks to transcend intervention focused solely on restricting suicidal behavior, proposing a therapeutic alliance that values relational skills. There is emphasis on the need for continuous training for health professionals, and better working conditions in the mental health network in Brazil.
The third chapter reflects on the construction of a broader clinic for suicide, criticizing the hegemonic model of psychiatry, which directly associates psychiatric disorders with suicidal behavior. The chapter also addresses elements of the Brazilian psychiatric reform that could support a more humanizing, emancipatory clinical practice for the subjects.
The fourth chapter discusses reception groups for family members of people with self -destructive behavior. The authors explore how psychoeducation - which involves teaching about suicidal behavior and its risk factors - and collective listening become powerful tools in this mutual support process, helping family members to better understand the situation they face and deal with their own feelings. The experiences of the author in the coordination of these groups in online format, especially in, for example, a more demanding context like the recent pandemic, are detailed as practical examples of the functioning and effectiveness of this type of reception. In addition to providing a safe space for the exchange of experiences, these groups help reduce participants\' emotional isolation, promoting the strengthening and expansion of support networks.
In the fifth and last chapter, a care protocol is described for people with suicidal ideation in the hospital environment. The authors underline the importance of assertive care in this context, highlighting the need to identify risk signs and offer adequate intervention. This statement corroborates the studies of the Brazilian physician, Neury Botega7, who highlights the crucial role of health professionals in the recovery of patients with ideation or from attempted suicide.
In general, although the book covers important aspects of contemporary suicide, many chapters are short and do not deepen the themes, and there is some conceptual and epidemiological repetition. Nevertheless, I recommend reading this book, especially by those who are starting to familiarize themselves with this theme of such great social and sanitary importance. The work contributes to knowledge about suicidology in Brazil, especially by addressing the subject in educational contexts, such as schools and universities, ones still insufficiently explored in the literature.

References
1. World Health Organization (WHO). Suicide worldwide in 2019: global health estimates. Geneva: WHO [internet] 2021. [citado em 15 out 2024]. Disponível em: https://www.who.int/publications/i/item/9789240026643.
2. World Health Organization (WHO). Preventing suicide: a global imperative. Geneva: WHO [internet] 2014. [citado em 15 out 2024]. Disponível em: .
3. Salimon-Santos AV, Antoniassi RPN, D\'Oliveira CFA, Noal MHO, Gondim DSM, Sacavacini K, organizadores. Suicídio: complexidade e urgências na cena contemporânea. 1ª ed. Londrina (PR): Lucto; 2024.
4. Araujo JAP, Fialho E, Alves FJ, Cardoso AM, Orellana JDY, Naslund JÁ. Suicide among Indigenous peoples in Brazil from 2000 to 2020: a descriptive study. The Lancet Regional Health - Americas. 2023; (26):100591.
5. Dantas ESO, Bredemeier J, Amorim KPC. Sobreviventes enlutados por suicídio e as possibilidades para posvenção no contexto da saúde pública brasileira. Saude soc. 2022;31(3): e210496pt.
6. Andriessen K, Krysinska K, Hill NTM, Reifels L, Robinson J, Reavley N, et al. Effectiveness of interventions for people bereaved through suicide: a systematic review of controlled studies of grief, psychosocial and suicide-related outcomes. BMC Psychiatry. 2019;19(49):1-15.
7. Botega NJ, organizador. Prática Psiquiátrica no Hospital Geral: Interconsulta e Emergência. 4ª ed. Porto Alegre (RS): Artmed; 2017.