Amin A. Muhammad Gadit  ( Department of Psychiatry, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada. )

In the process of psychiatric consultation, the issue of suicidal thought, planning and attempt carry high significance in terms of management and prognosis. However, both these terms are not well understood by many mental health professionals and often the residents fail to detect whether the patient has expressed suicidal thoughts or it was merely a death wish.1 Many psychiatric admissions are done on the basis of seriousness of the issue of suicidality and that both the expression of death wish as well as suicidal thoughts is held in the same magnitude in terms of its significance. Freud has described this as "thanatos" which is a death drive representing the organic need to return to lifelessness and stasis, the ultimate calm of lifeless non-conflict attributing all aggressive and destructive activity to this notion. Death wish is a general expression when some life events assume severe proportions and start taking their toll on the mental health or it is a casual cultural expression when some social hardships cause trouble. It has been observed that some women folk would express this wish when domestic pressures becomes overwhelming, with child rearing difficulties, financial problems and turbulent relationship with the spouse. In some cultures, expression of death wish is a taboo; some religions disapprove such thoughts and expressions. However, death wishes are noted in terminally ill patients who are fed up with their long term misery. Even in these instances, assessment of psychological and social issues need to be ruled out. It has also been demonstrated that death wish in very old is likely to be associated with occurrence of a psychiatric disorder, especially major depression with negative life conditions.2 It is important that some areas should be explored like: difficulties in the patient's relationships with family, friends, and health workers, psychological disturbances, especially, grief, depression, anxiety, organic brain disorders, personality disorder, and the patient's personal orientation to the meaning of life and suffering. In a study conducted in a community on residents aged 65 and over, it was confirmed that expressed wish for death was a predictor of mortality, controlling for age, sex, and cognitive impairment.3 Thoughts of suicide may be a part of normal adolescence, and suicidal act a manifestation of pathological development specific to this stage in life, the wish to die has no age restrictions and may accompany life as a shadow, devoid of any suicidal act, for years. The imbalance between these two wishes calls for concern and need separate evaluation.4 It is said that death wish may not necessary be a feature of depression as in a study, patients expressing death wish reported less optimism, less comfort in religion, and greater hopelessness, yet the conclusion about presence of depressive illness cannot be made.5

There is a debate on whether death wish can be converted or is progressed to suicide intention, or is death wish a predictor of suicidal thought and eventual act, is the brain chemistry common, likewise, should one get alarmed and adopt preventive measures on expression of death wish to the extent of commencing biological treatment. The question arises if there were some overlapping factors in these two entities? Several psycho-social factors are associated with this, genetic factors as well as impulsive-aggressive behavior also plays a critical role in suicide predisposition.6 The role of CSF-HIAA levels7, increased density of serotonin binding sites in frontal cortex, fewer presynaptic serotonin transporter sites and upregulated levels of the 5-HT1A receptor in ventromedial prefrontal cortex, possible implication of protein kinase A and C are worth debating.8 Low cholesterol has been discussed as an important factor predisposing to suicidal behavior.9 It is a likely possibility that same biological application may be valid both for death wish and suicidal thought. Death wish can also be taken as a precursor for active suicidal thoughts and subsequent act. Those people who express death wish in clinical setting must be explored for the presence of dysthymia, chronic boredom in association with a borderline personality disorder or presence of sub threshold depression.10 From a clinical management perspective, suicidal thoughts need immediate attention whereas death wish needs detection of underlying pathology whether it is social or psychological. Presence of death wish among patients presenting to emergency department should not be dismissed as such without careful mental state examination as this may be a 'cry for help' which if ignored may result in devastation. Effective communication skills, thorough understanding of the underlying cause and knowledge of cultural background is of paramount importance as simple death wish may be a warning in disguise and a strong predictor of more serious suicide intent.

1. Lingard, L., Tallett, S., Rosenfield, J. Culture and Physician-Patient Communication: A qualitative Exploration of Residents' Experiences and Attitudes. Annals RCPSC, 2002, 35, 331-40.

2. Barnow. S, Linden M. psychosocial Risk Factors of the Wish to be Dead in the Elderly. Fortschr Neurol Psychiatr 2002, 70: 185-91.

3. Dewey ME, Davidson I A., Copeland JR. expressed wish to die and mortality in older people: a community replication. Age Ageing 1993, 22: 109-13.

4. Manor I, Vincent M, Tyano S. The wish to die and the wish to commit suicide in the adolescent: two different matters? Adolescence 2004, 39: 279-93.

5. Alber SM, Rabkin JG, Del Bene ML, Tider T, O'Sullivan I, Rowland LP, Mitsumoto H. Wish to die in end-stage ALS. Neurology 2005; 12; 65: 68-74.

6. Klempan. T, Tureki, G. Suicide: a neurobiological point of view. Rev Bras. Psiquiatr 2005, 27,3: 1-3.

7. Asberg M, Traskman L, Thoren P. 5-HIAA on the cerebrospinal fluid. A biochemical suicide predictor? Arch Gen Psychiatry 1976; 339: 1193-7.

8. Pandey GN, Dwivedi Y, Rizavi HS, Ren X, Conley RR. Decreased catalytic activity and expression of protein kinase C isozyme in teenage suicide victims: a postmortem brain study. Arch Gen Psychiatry 2004; 61: 685-93.

9. Lalovic A, Merkens L,Russell L, Arsenault-Lapierre G, Nowaczyk MJ, Porter FD, et al. Cholesterol metabolism and suicidality in Smith-Lemli-Opitz syndrome carriers. Am J Psychiatry 2004; 161: 2123-6.

10. Gadit, A. Sub threshold mental disorder. Editorial. J Pak Med Assoc 2003, 53, 42-43.