IN THIS ISSUE 
Parent Corner: Talk About It
First Person: Thoughts About Suicide
In Depth: Perinatal Suicide
Research: Suicidal Ideation and Postpartum Depression
Upcoming Events and Programs

This month, we address perinatal suicide. Talking about suicide, even if it's in the abstract or in the distant past, can feel so scary. We don't know what to say about it--either when it's our experience or a loved one's--and we may have the (false) assumption that talking about it with others may lead to them acting on it.

Perhaps you wouldn't label what you're experiencing as suicidal, but are you thinking about wanting to escape, feeling hopeless, or fantasizing about dying in your sleep? In this newsletter, we use the term suicidal ideation  to describe those scenario s .  It sounds clinical, but it just means  thinking about  suicide, and it's something that needs to be treated very seriously.

Perinatal suicide and suicidal ideation can be part of the story of perinatal mood and anxiety disorders. We need to talk about this so that when parents do experience feelings of suicide around the birth of a child, they know what these thoughts are, that this has happened to other parents as well, and that  help is available.

We welcome feedback about our newsletters. Let us know what resonated with you or what you'd like to see more of. 

ParentingPARENT CORNER

Talk About It

Let's be honest: we don't like to talk about suicide. It's a taboo subject for most of us. But the reality is that some people do feel so hopeless that to them, leaving this world seems like the only way things will get better. Sometimes they think they could never feel better and that burden is hard to live with. Feeling hopeless doesn't mean you're thinking about suicide, but too many people are thinking about it and making plans. So even though it makes us uncomfortable, we have to talk about it.
 
If you are someone who is feeling hopeless, feeling like your loved ones would be better without you, like there is no other way out of this pain--tell someone right now (even if you aren't thinking about suicide): your partner, your doctor, 911, the Suicide Prevention Lifeline (1.800.273.8255). You are important and YOU CAN FEEL BETTER. Yes, this is scary (maybe the scariest thing you've ever experienced) and there are many unknowns. These feelings are not something you can fight on your own. Lean on your support people, and if you don't feel like you have support people, call the Suicide hotline (1.888.273.8255) and let them help you find support. You can even use their 24/7 chat line if you feel more comfortable asking for help that way. Help is available immediately. No shame. No stigma. By getting help, you are showing how strong you really are.
 
Maybe you're a partner or other loved one watching someone go through depression or another mood disorder. You might have seen some signs of suicidal ideation like talking about feeling like a burden, talking about dying, or a significant increase in anxiety or withdrawal. (For more common signs of suicidal ideation, you can refer to this list.) Please take her seriously. Even if she is not considering suicide, it's better to talk about it now than to wait and see. Talk openly and ask her directly, "Have you thought about hurting yourself?" Don't ask why; no judgment please. Don't tell her what she is or is not feeling. Do tell her who loves her and who needs her. Tell her she is not crazy and that with that help she can feel better. Do not take this on alone. Get help from a doctor, suicide hotline or call 911. And finally, don't forget to take care of yourself. Find your support people while you are her support. This is a tough time for you, too, and we need you to be well.

FirstPersonFIRST PERSON
Thoughts About Suicide

 
Jennifer Sumner, RN, BSN, is a public health nurse and mom of two who lives in central Washington. 

The first time the thought of death occurred to me was 4 weeks after my second baby was born. It was early in the morning and I could see the sun beginning to rise out my bedroom window. I hadn't had a good night of sleep since he was born, and hadn't slept at all in several days. Despite being more exhausted than I ever imagined possible, my brain would not shut off. I was in a constant state of panic and would alternate between pacing the floors and staring at the wall. That morning as I listened to my husband, 2-year-old, and newborn sleep, the thought of continuing on for even one more instant just seemed too much. That initial thought was fleeting, but as the days progressed and my desperation grew, I started to think about it more and more. At the time I didn't understand what had overtaken me. It felt as though something had irrevocably broken inside of me when my son was born. I didn't know what it was or how to fix it--in fact, I was quite certain it wasn't fixable. I spent my days in a daze and dreaded the nights, when I knew I wouldn't sleep. I wasn't at all interested in my baby and was completely consumed by the intensity of what was happening within me. I could see how this dramatic change affected my family, and that made it feel even worse. I whole-heartedly believed that my husband and children would be better off without me. The thoughts were non-specific initially--more like wanting to run away and escape from what I had become. Quickly I realized however that no matter how far I ran away, I couldn't escape from myself. As time progressed the thoughts became more focused. I would hear a train and think "oh, that's it--I will just walk down to the train tracks." Or I would think about all of the bridges I knew and how I could get there. Or what might happen if I took all of the medication I had. I felt entirely beyond help, and death seemed the only logical way out. 

But thankfully it wasn't. I did get help, and I did get better. I don't remember exactly when the thoughts left, but I imagine it was around the same time the depression and anxiety began to lift. For me, medication was my saving grace. I went to counseling as well but was fearful about disclosing the extent of my feelings. Truthfully, I didn't even share with my provider or family that I was having these thoughts. I was really ashamed and felt a tremendous amount of self-blame for the situation. I wish I would have understood then that I was suffering from a severe mood disorder, and that the suicidal thoughts were a result of that. When I think about those first weeks after my son was born, it's heartbreaking to know that I endured such a traumatic experience. I have such a different perspective and understanding now than I did at that time. I am so thankful that I received help and was able to get well. I am also thankful to be able to share my story so that others can have a better understanding of this very common complication of having a baby. 
 
InDepthIN DEPTH

Perinatal Suicide

We all have heard about the risks of childbirth, especially in developing countries. We know about bleeding, infections, high blood pressure during pregnancy, and birth complications. But it might surprise you that suicide is a leading cause of maternal mortality in developed nations.
 
Perinatal suicidality, which includes completed suicides, suicide attempts, suicidal ideation, and thoughts of self-harm, is considered one of the leading causes of maternal mortality in the first 12 months postpartum (Orsolini et al, 2016).
 
While suicide deaths and attempts are lower during pregnancy and the postpartum than in the general population of women, suicides account for up to 20% of postpartum deaths and is significantly greater for women in the perinatal period who are experiencing depression (Lindahl et al, 2005).
 
Self-harm ideation is more common than attempts or deaths, with thoughts of self-harm during pregnancy and the postpartum period ranging from 5 to 14% (Lindahl et al, 2005).
 
Suicide vs. Suicidal Ideation: Defining Terms
 
Suicidal Ideation
An important term to understand is "suicidal ideation." The National Institute of Mental Health (NIMH) Developing Centers for Intervention and Prevention of Suicide defines suicidal ideation as: the wish to die, thoughts of killing oneself, and the intent to kill oneself.
 
Suicidal ideation can be passive or active. Thoughts of killing oneself are thoughts, beliefs, images, voices, or other cognitions about intentionally ending one 's own life (suicide); ideation may also include the intent to act on such thoughts.
 
Suicidal ideation or thoughts are important to pay attention to because they have been found to be associated with suicide attempts and completions. Additionally, a person who is feeling this way is suffering greatly, and deserves to get relief and help. 
   
Self-Harm
Another important concept related to perinatal suicide is self-harm. The World Health Organiz ation defines self-harm as "an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences." Simply put, self-harm means hurting yourself on purpose. Common methods include cutting yourself with a knife, razor or other sharp object, burning, pulling out hair, or picking at wounds to prevent healing. Extreme injuries can result in broken bones.
 
Following an act of self-harm, the rate of suicide increases between 50 and 100 times the rate of suicide in the general population. Women who self-harm have an increased risk of suicide, which is increased with the presence of depression during pregnancy and in the postpartum period. Self-harm during pregnancy is estimated to be about half the rate for non-pregnant women (Healey et al, 2013).
 
Warning Signs for Suicide
 
According to the Mayo Clinic, warning signs for suicide include:
  • Talking about suicide, including making such statements as "I'm going to kill myself," "I wish I were dead," or "I wish I hadn't been born."
  • Getting the means to commit suicide, such as getting a gun or stockpiling pills
  • Withdrawing from social contact and wanting to be left alone
  • Having mood swings, such as being emotionally high one day and deeply discouraged the next
  • Being preoccupied with death, dying, or violence
  • Feeling trapped or hopeless about a situation
  • Increased use of alcohol or drugs
  • Changing normal routine, including eating or sleeping patterns
  • Doing risky or self-destructive things, such as using drugs or driving recklessly
  • Giving away belongings or getting affairs in order
  • Saying goodbye to people as if they won't be seen again
  • Developing personality changes, such as becoming very outgoing after being shy

The AFSP (American Foundation for Suicide Prevention) says that the signs that most directly warn of suicide are:

  • Threatening to hurt or kill oneself
  • Looking for ways to kill oneself
  • Talking or writing about suicide
  • Plans or preparations for a potentially serious attempt

 

Risk Factors for Suicide 

  • A current or prior diagnosis of Major Depressive Disorder or other affective disorder
  • Previous suicidal ideation and/or suicidal behavior
  • Family history of suicide
  • Intimate partner violence including emotional abuse, physical abuse, and/or sexual violence
  • Younger maternal age
  • Unplanned pregnancy
  • Unpartnered relationship status
  • Prior abortion
  • Severe vaginal laceration
 
References
 
Brown GK, Currier G, Stanley B. Suicide attempt registry pilot project. National Institute of Mental Health Annual Meeting of the Developing Centers for Intervention and Prevention of Suicide, September 2008. Canandaigua, NY: (2008).
 
Fuhr DC, Calvert C, Ronsmans C, Chandra PS, Sikander S, De Silva MJ, et al. Contribution of suicide and injuries to pregnancy-related mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Psychiatry (2014) 1(3):213-25.10.1016/S2215-0366(14)70282-2 [PMC free article] [PubMed] [Cross Ref]
 
Healey, C., Morriss, R., Henshaw, C., Wadoo, O., Sajjad, A., Scholefield, H., & Kinderman, P. (2013). Self-harm in postpartum depression and referrals to a perinatal mental health team: an audit study. Archives of Women 's Mental Health, 16(3), 237- 245. http://doi.org/10.1007/s00737-013-0335-1
 
Koslow SH, Ruiz P, Nemeroff CB. A Concise Guide to Understanding Suicide. Cambridge: Cambrdige University Press; (2014).
 
Lindahl V, Pearson JL, Colpe L.. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health (2005) 8(2):77-87.10.1007/s00737-005-0080-1 [PubMed] [Cross Ref]
 
Möller HJ. Suicide, suicidality and suicide prevention in affective disorders. Acta Psychiatr Scand Suppl (2003) 108(418):73-80.10.1034/j.1600-0447.108.s418.15.x [PubMed] [Cross Ref]
 
Orsolini, L., Valchera, A., Vecchiotti, R., Tomasetti, C., Iasevoli, F., Fornaro, M., ...Bellantuono, C. (2016). Suicide during Perinatal Period: Epidemiology, Risk Factors, and Clinical Correlates. Frontiers in Psychiatry, 7, 138. http://doi.org/10.3389/fpsyt.2016.00138
 
Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ.. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol (2011) 118(5):1056-63.10.1097/AOG.0b013e31823294da [PMC free article] [PubMed] [Cross Ref]
 
Posner K, Oquendo MA, Gould M, Stanley B, Davies M. Columbia Classification Algorithm of Suicide Assessment (C-CASA): classification of suicidal events in the FDA 's pediatric suicidal risk analysis of antidepressants. Am J Psychiatry (2007) 164(7):1035-43.10.1176/ajp.2007.164.7.1035 [PMC free article] [PubMed] [Cross Ref]
 
Thornton C, Schmied V, Dennis CL, Barnett B, Dahlen HG.. Maternal deaths in NSW (2000-2006) from nonmedical causes (suicide and trauma) in the first year following birth. Biomed Res Int (2013) 2013:623743.10.1155/2013/623743 [PMC free article] [PubMed] [Cross Ref]
research
RESEARCH

Suicidal Ideation and Postpartum Depression

Though uncommon, suicide is one of the leading causes of death in postpartum women. According to Massachusetts General Hospital's Center for Women's Mental Health (April 2016), a recent study explored the connection between suicidal ideation and potential risk factors in depressed postpartum women. Risk factors included childhood sexual abuse, adult abuse, sleep disturbance, and anxiety symptoms.
Researchers examined data collected from 628 depressed mothers between four and six weeks postpartum. They found that 79% of the group had "never" had thoughts of self-harm; 15.6% "hardly ever" had those thoughts; and 5.4% had them "sometimes" or "quite often." The highest association, or odds ratio (OR), was 1.68 in mothers who experienced childhood abuse. In mothers without that history, frequent thoughts of self-harm showed an OR of 1.15 to sleep disturbance, and 1.11 to anxiety symptoms.

MGH Center for Women's Health cautions that providers should not assume that these risk factors safely identify the mothers most at risk for attempting suicide, but instead should closely monitor all mothers who report suicidal ideation.
           

 
EventsUPCOMING EVENTS AND PROGRAMS
Playing Monopoly with God and Other True Stories. Join Melissa Bangs for a powerful performance of true stories full of bewilderment, chaos, and hilarity. She opens the door to talking about maternal mental health in a way that strips away shame and lets us laugh. October 26 and October 27 at Town Hall in Seattle. Click here for more information and to buy tickets. 

New Support Group in Spokane: GRIT (Growing Resilience in Transition). Megan Menard, BSN-RN, CBE, IBCLC, has started a FREE drop-in group for pregnant and postpartum moms and their babies (0-1) at CHAS Maple Clinic, 3919 N Maple Street in Spokane. The group is held every Monday from 1-2 pm and addresses topics like sleep, self-image, finding balance, feeding your baby. Water, snacks, breastfeeding pillows, and toys are provided. For more information, the flyer can be found here.
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