Death wish or suicidal ideation: implications for management.

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