14-07-2021 | Mental health | Feature | Article

Risk for suicidal ideation: Who, when, and why?

The risk for suicide ideation, attempts, and completion is significantly increased in people with diabetes. But not all people with diabetes are at risk all of the time; instead, there is a continuum from low to high risk, which people move along according to changes in their circumstances and emotional state.

Based on discussion with Mary de Groot (Diabetes Translational Research Center, Indiana University School of Medicine, Indianapolis, USA), we briefly overview the factors that contribute to this increased risk and should raise a healthcare provider’s level of concern.

Depression, including treated depression

Bidirectional relationship with diabetes
Goes hand-in-hand with suicide risk
Treatable with antidepressants, but the early stages of recovery may represent a particular danger point in terms of suicide risk
Can co-present with diabetes distress

When people have been depressed, and very shut down, they may not be in a position to have the psychic energy to engage in behaviors that are self-harm. But it’s not uncommon for people who are starting to come out of the depression, who become more activated, but who are still experiencing high levels of emotional pain – that’s a time when people might start thinking and acting, or planning, on self-harm.

Mary de Groot

Diabetes distress

Affects up to 45% of people; the lifetime prevalence could approach 100%
No direct link to suicide, but may have an additive effect with depression
Treating depression may help to alleviate distress, and vice versa, which can improve glycemic outcomes

If we are providing people with the tools that they need to address the emotional side of diabetes, that can be the gift that keeps on giving – the tools that they keep using over time, which helps them with medical outcomes.

Mary de Groot

Family history of suicide

Suicide is a learned behavior

[People gain] a close-up understanding of how it works – what does one do, what does one need to acquire in advance, how does one make that decision?

Mary de Groot

High impulsivity

Current or historical impulsivity can contribute to the likelihood that someone will self-harm
Recreational use of drugs and/or alcohol can exacerbate the effects of impulsivity

All of us become more impulsive, we have less behavioral management, when alcohol and drug use is in place, so if people are actively using recreational drugs, misusing prescriptions, or supplementing that with alcohol we want to be very mindful of that.

Mary de Groot

High levels of emotional dysregulation

Accounts for a very small proportion of people with diabetes
Incorporates states such as borderline personality disorder, past trauma experience, and severe mental illness presentations, including severe major depression
These people experience high levels of emotional pain

This is fortunately a very small proportion of our population. But when we do encounter these kinds of presentations in patients, it’s important to think about the team approach to caring for these patients. We all need to work together to provide a safety net and appropriate sources of care for patients with these types of presentation.

Mary de Groot

Access to lethal means – including misuse of insulin

Access to weapons or medications with the potential for overdose
People with diabetes have free access to exogenous insulin – a potentially lethal medication
Under- or overdosing of insulin could indicate suicidal ideation, but also fear of hypoglycemia or hyperglycemia, or the presence of an eating disorder

For some patients, it may occur to them that omitting their insulin and going into diabetic ketoacidosis, or taking too much insulin, may be a route to address those high levels of emotional pain.
This does represent an element of risk. We have a person who’s not thinking very clearly about how they’re caring for themselves, they are in a tremendous amount of distress, and they need to have insulin in order to survive.

Mary de Groot

Transition through certain life stages

Certain life stages coincide with an increase in specific risk factors for suicide
Increased impulsivity combined with lack of life experience and under-developed emotional coping skills in teenagers and emerging adults
Adults, particularly older adults, may experience physical and emotional pain, as well as changes in their role, due to advanced complications. Older people are also more likely to be contending with loneliness and isolation

Palliative care is a very important resource for people to be able to address all sources of pain, whether that’s emotional pain, but certainly physical pain as well.

It’s very important that, as healthcare providers, we listen to how people are coping with significant changes to their life circumstances associated with diabetes complications and provide them with the emotional support that they need, including referral to behavioral health or mental health providers.

Mary de Groot

Medicine Matters Diabetes