By Elisa Gonçalves de Andrade
Trigger warning: this post discusses scientific information about suicide. If you or someone you know is in crisis, call a physician, a local hospital or a suicide prevention hotline/text line. Confidential help is available 24/7 for free. Find local help here: https://findahelpline.com/i/iasp
From the moment I opened my eyes today, I have had to make many decisions. Should I indulge and stay in bed for a few more minutes? Should I have juice or coffee for breakfast? On a typical day, the number of decisions we must make are almost endless. Ideally, our choices are guided by what is best for us, both now and in the future. But what happens when the line between the best and the worst gets blurred? What happens when we knowingly make decisions that are emotionally and physically harmful? What happens when suicide appears like an option?
At Mentally Minded, we believe information is empowering. However, we recognize that talking about suicide can be challenging. So we want to start by saying that:
What is suicide ideation?
Suicide ideation, the process in which someone considers or plans suicide, is a reality for many. In 2021, around 12.3 million adults seriously thought about suicide in the United States of America. To put this in perspective, this number is equivalent to the population of Pennsylvania. Globally, 9.2% of people experience suicide ideation at least once in their lifetime, a number almost as large as half of the population of China.
Suicide is a complex public health issue that has no single cause. People who die by suicide often have a mental health disorder. However, the reverse is also true: the majority of people with mental health disorders do not experience suicidal behaviors. Researchers suggest suicide ideation arises from a combination of psychological pain and hopelessness that can be a result of multiple causes, such as physical suffering, social isolation, and negative self-perceptions. Adding to these social and psychological components, suicide ideation is associated with changes in brain function that can affect behavior, for example, by reducing someone’s ability to make safe decisions after comparing the pros and cons.
Suicide ideation happens when your brain is not your friend
To measure an individual’s ability to make the best decisions, researchers developed a gambling task consisting of four decks of cards, called the Iowa Gambling Task. Each participant starts with a specific amount of money. The idea is to lose as little of it as possible over the course of the task. Participants must pick a card from either deck 100 times, adding or subtracting money from their original amount depending on the type of card. Decks C and D contain cards that give less rewards and less penalties, whereas decks A and B give larger rewards and larger penalties. Most participants usually notice this pattern between the 20th and 40th draw, proceeding to pick cards from only decks C and D because of their lower risk. If an individual, however, continues drawing from decks A and B, regardless of the higher risk, then it is assumed their decision-making capabilities are impaired.
Through this type of assessment, researchers have identified that adults and elderly people with a history of suicide attempts make less advantageous decisions than those without a history of attempts or major depressive disorder. Such deficit in decision-making could be caused by changes in specific areas of the brain, like the orbitofrontal cortex, which sits just above the eyes. The orbitofrontal cortex is largely responsible for learning to connect specific sensations, such as the smell of bread, with a reward or punishment. Impairments to decision-making can occur when this region is injured, for example by rupture of brain blood circulation. Similarly, individuals who have previously attempted suicide show reduced orbitofrontal cortex activation when comparing risky versus safe choices in the gambling task.
Suicide ideation is not the only context in which decision-making is impaired
Disrupted decision-making is not restricted to suicide ideation. Cognitive impairment is a reduction in brain function important for learning, memory, attention, and problem-solving that negatively impacts a person’s decision-making. Cognitive impairment affects roughly 12–18% of seniors (≥60 years of age) and is thought to be caused by changes in two parts of the brain: a region located at the very front of the brain, which contains the orbitofrontal cortex, called the prefrontal cortex, and seahorse-shaped structures that lie deep in the brain, the hippocampi.
If decision-making is disrupted in cognitive impairment and suicide ideation, do these conditions ever overlap? Yes. Researchers conducted a study with over 4500 people, all aged between 18 and 80, and found that impaired cognitive function, but not depression, was associated with the presence and frequency of suicide ideation. At the same time, people who attempt suicide are more likely to develop congitive impairment later in their life.
We don’t know what causes suicide ideation or cognitive impairment
Whether cognitive impairment predisposes suicide ideation or vice-versa is unclear. Researchers are still grappling to find the biological causes of both conditions. Many results point to an association between mental health disorders and stroke, which disrupt the functioning of cells in the brain. Moreover, since cognitive impairment and suicide ideation are both passed down through family generations, researchers think that the increased risk is shared through changes in the guidebook that cells use to function, or DNA.
In addition, early-life stress, for example, in the form of childhood abuse or parental neglect, has also been linked to increased suicide ideation and cognitive impairment. Researchers find that the body’s stress-response system can be overactivated in individuals who experience early-life stress. This overactivity disrupts the body’s ability to self-regulate and can impact how someone copes with stressful events later in life, potentially disrupting cognitive processes like decision-making and problem-solving.
There is overwhelming evidence that recovery is possible
For individuals with cognitive impairment or suicide ideation, weighing the pros and cons when making decisions may not be as easy as it might have used to be. However, there are things we can do to avoid or cope in times of crisis. To support others, an extended hand or an attentive ear can make all the difference, be it from a medical professional, therapist, friend or family. Quality health and mental care are essential to prevent suicide, as is reduced access to lethal means. On a personal level, researchers recommend activities that develop problem-solving skills, purpose, and engagement with the community. Lastly, in case your brain is not being your friend right now:
Suicide is preventable.
Help is available.
Treatment can be successful.
Recovery is possible.