Suicide in adolescents: A case study

Suicidal behavior is the most violent behavior that a person commits against himself. Suicidal behavior is a complex form of behavior in which biological, psychological, cultural, environmental and social factors are effective together, which deeply affect the individual, his environment, society and subsequent generations. The etiology of suicidal behavior in adolescents includes problems such as psychiatric illness, domestic violence and restlessness, mental disorders, social events, previous suicide attempts, loss of family relatives, parental divorce, physical and/or sexual abuse


INTRODUCTION
Violence is one of the most common public health problems we encounter, which negatively affects the society in general.The World Health Organization (WHO) defines violence as "any act of intentionally committed by a person against a group, himself or herself or others to the extent that it causes permanent physical or mental health problems or even death" (WHO, 2002).Suicide is the most violent behavior that a person has committed against himself (Polat, 2021).The World Health Organization (WHO) defines suicidal behavior as "self-injury with a perception of purpose and varying degrees of lethal intent".Suicide and suicide attempt are an important public health problem because this feeling has a profound effect on the individual's relatives and environment (Polat, 2016).According to Emile Durkheim (2002), who made important researches on this subject, death, which is the direct or indirect result of positive or negative actions of the deceased even though he knew that it would result in death, is called suicide.If the person dies as a result of suicide, these cases are called completed suicide, and cases that are stopped before death are called suicide attempts (Polat, 2001).Suicide is the second or third leading cause of death among adolescents in Western countries, and one of the leading causes of death among youth in Turkey (WHO, 2021).Suicide represents the highest degree of violence a person can inflict on himself.There are many methods of suicide.Sevently percent of people who attempted suicide preferred to use overdose of drugs, and 63% of those who committed suicide preferred to use firearms.Self-poisoning, hanging, cutting, burning, jumping in the middle of traffic and firearms are among the methods most frequently used by adolescents (Jacobs, et al., 2010).
According to the WHO (2019), an estimated 703,000 people worldwide died due to suicide, and suicide was the fourth cause of death between the ages of 15-29, and it is estimated that suicide attempts are 20 times the average rate of suicides resulting in death.According to the WHO suicide rates by country in 2019, the male/ female sex ratio in suicides in Turkey was found to be 3/1.According to the 2019 data of the Turkish Statistical Institute (TUIK), the suicide rate is 4.12 per hundred thousand, and the male/female gender ratio is 3.36/1.
The most preferred suicide methods in Turkey are as follows; ace, firearms, and high jumping.When the cause-related suicides table of the Turkish Statistical Institute in 2019 is examined, it is seen that the cause of only one third of the suicides is known, and the three most common causes are illness (not specified separately as general medical illness or psychiatric disorder), financial difficulties and family conflict, respectively.
People want to end their lives for various reasons.Suicide is a preventable cause of death.There are many reasons and factors for making this decision.This action is usually caused by a combination of factors.Suicide has both a personal and a social dimension.The frequency of suicide varies according to age groups and gender (Czyc et al, 2019).According to studies, gender is an important demographic variable in suicide.In many countries, the suicide rate for men is 2-3 times higher than for women (Beautrais, 2006).In our country, the suicide rate resulting in death in men is about twice that of women (TUIK Statistics, 2019).In non-fatal suicide attempts, this rate is reversed, with women attempting approximately twice as much as men (Zhang et al., 2005).Suicidal behavior in childhood is rare, but increases during adolescence (Miller et al., 2013).Suicide is one of the most important causes of death, especially in adolescents between the ages of 15-24.
The total number of suicides from 2015 to 2019 was found to be 16,355 in the suicide rate obtained through the Turkish Statistical Institute.According to these data, the total number of people under the age of 19 who committed suicide is in 2011 (TUIK, 2022).These figures show that the suicide rate among youth cannot be underestimated.
In this study, it was aimed to investigate the risk factors of suicidal behavior in adolescents and to examine a case sample.

ADOLESCENT AND SUICIDE
Adolescence is the period when emotionality is at its strongest.Hormonal changes cause teens to separate adulthood from childhood, making them overly sensitive and fragile when it comes to self-esteem.They are very sensitive to criticism, vulnerable, react very harshly to rejection and feel anger, joy and sadness (Hawton et al., 2020).
Adolescent suicide is a multifaceted behavior influenced by sociocultural factors, genetic and biological predispositions, psychiatric disorders and symptoms, stress, difficult living conditions and lack of social support (King et al., 2018).In this bustling, lively and active period; Situations such as parental separation, loss of loved ones, group humiliation, separation from family, unsuccessful exams and resulting inadequacies cause great sadness and despair in adolescents (Abraham, 2019).They may think that the only solution is to die; that is, suicide.Suicide is the third leading cause of death in adolescents after accidents and homicides.Suicidal ideation and attempts are more common in adolescents, but although it is more common, suicidal ideation is denied when asked and there are misconceptions about the methods used to cause death (Lee et al. ,2018).With the increase in suicide rates in adolescence, we should also focus on the suicidal behavior of male and female adolescents in this period.Boys are more likely to engage in suicidal behavior than girls (Glen et al. , 2020;Doğan et al., 2018).However, girls are more likely to attempt non-lethal suicide (boys use more deadly methods such as weapons or hanging, while girls use less dangerous methods such as poisoning or slashing their wrists).Rather, this difference reflects the nature of suicidal intent.It has been determined that girls have more suicidal thoughts than boys, make plans and start to realize them (Alpay, 2015).Although completed suicide is rare in children, destructive thoughts and behaviors are common in this age group (Alptekin and Duyan, 2021).

SUICIDE RISK FACTORS IN ADO-LESCENTS
When we examine the risk factors for suicide in adolescents, we most frequently encounter the following risk factors (Erdoğan et al., 2021): • Psychiatric disorders (especially depression, bipolar disorder (manic depression), alcohol or substance abuse, schizophrenia, borderline personality disorder, behavioral disorders (adolescents), psychotic disorders, anxiety disorders, other psychiatric disorders associated with impulsivity and aggression) • Alcohol or substance use • Family history of suicide or exposure to suicide • Serious illness or chronic pain • Relationship problems, • Prolonged exposure to stress such as harassment or bullying • Social isolation and loneliness

• History of trauma or abuse
Causes of suicide are often different in younger and older people.The causes of suicide are very diverse.Some conditions increase the risk of suicide (Turecki et al., 2019).

Psychiatric Diseases:
The most important problem leading to suicide is depression.In various studies on this subject, depression was found in 30-64% of those who were injured as a result of suicide and in 90% of those who died as a result of suicide (Martinen-go et al., 2019).15% of people with depression die as a result of suicide attempts (Orsonlini et al., 2020).Men with depression have higher suicide and suicide-related death rates than women (Güleç, 2016).As a result of psychological autopsy studies performed on adolescents who committed suicide, psychiatric disorders were found to be the most important factor in the causes of suicidal behavior.Among these psychiatric disorders, depressive disorders and substance use are in the first place (Narayanan, 2020).
Other psychiatric disorders related to suicide during adolescence include emotional disorders, communication disorders, and personality disorders (Paulus et al., 2021).Similarly, in a study conducted in Turkey, a psychiatric disorder was found in 73.68% of adolescents who attempted suicide, and these disorders are conversion disorder, adjustment disorder, panic disorder, enuresis, major depression, automutilation, schizophrenia and mental disability, respectively ( Gijzen et al., 2021;Siyez, 2006).According to the results of a study conducted on 521 high school students, a significant relationship was found between depression and suicide risk, although it differs according to gender (Metha, 1998).In the same study, depression increased the risk of substance use and subsequent suicide in men; states that depression directly increases the risk of suicide in girls.In another study, they observed that the incidence of suicidal ideation and suicidal behavior is 4-5 times higher in adolescents with affective disorder than in adolescents with other psychiatric disorders (San Too et al., 2019).Communication in terms of adolescents attempting suicide.disorders are also among the most common psychiatric disorders (Van Meter et al., 2019).Antisocial behavior disorders are observed in 70% of adolescents who commit suicide, while this rate remains at 35% in the control group (Ecevit, 2019).He states that although less common than other disorders, anxiety disorders are also a risk factor for adolescents who attempt suicide (Satinsky et al., 2021)

Social Reasons:
Suicide rates vary from country to country, depending on the social composition and social cohesion of a society.People with weaker family ties and less social interaction seem to be more likely to commit suicide (Self-selling suicide) (Yağdıran, 2019).Social and economic crises increase the suicide rate (anomic suicide) in the society (Hossen, 2022).
Durkheim defines unusual suicide as: 'We observed that there were changes in the social structure after the Industrial Revolution in Western societies and that the risk of suicide increased in people who could not maintain strong family, religious beliefs and relationships.Suicide often manifests itself as a social norm rather than an individual norm (Durkheim,2002;Hossen, 2022).
Egoistic suicides (selfish suicides) occur in organized societies with criminals and misfits (Hossen, 2022).Taking social realities into account cannot explain why one person is in the same situation and the other does not commit suicide.
According to Adler, although suicide has sociological causes and consequences, suicide can only be understood individually (Steggals et al, 2022).All suicides are personal and should be evaluated individually.Psychiatric disorders such as depression and schizophrenia are among the causes of suicide, but the suicide rate in these patients is not as high as it is thought.This highrisk group includes high-risk patients.

Biological Predisposition:
Decreased serotonin in the brain increases the likelihood of suicide.For this reason, many researchers suggest that low serotonin levels are an important factor in subsequent suicides, especially in young people who are considering suicide.The vast majority of researchers similarly state that low serotonin levels, especially in adolescents who attempt suicide, are an important factor for the completion of subsequent suicide.Similarly, the vast majority of researchers state that low serotonin levels, especially in adolescents who attempt suicide, are an important factor for the completion of later suicide.

Genetic susceptibility / Familial Predisposition:
It has been determined that if a family member has committed suicide in the past, the probability of suicide increases.The high suicide rate in some families is striking.Having a blood relative with a history of suicide in the family increases the likelihood of committing suicide (Brenth and Melhem, 2008) Economic distress, conflicts and losses in the family, separation of parents, remarriage, previous suicide attempt by a family member, depression and substance use in family members are among the risk factors.(Roy et al., 1997;Lengveynte et al., 2021 ) Many studies have shown that adolescents experience intense family conflicts before attempting suicide (Scully et al., 2020).A family history of suicide and family medical and psychiatric disorders also increase the risk of suicide.It has been observed that the families of adolescents with suicidal ideation are indifferent, rejecting and unsupportive individuals (Palabıyıkoğlu, 1993;Consoli et al., 2013;King et al., 2018).In another study, the importance of family was emphasized and they stated that suicide attempts were mostly seen in children of families with mental problems and diffuse alcoholism (Siyez, 2006).The family factor is considered the most important of the risk factors that cause adolescent suicide.Among the life problems of adolescents, the most important are family problems.Domestic violence, mental illness, or suicide attempts can also create a negative situation.The presence of the patient or patient's family in need of psychiatric treatment is an important factor contributing to suicide (Kabasakal, 2007).Psychiatric disorders in the family may contribute to suicide among young people in many ways (Beautrais, 2000;Scully et al., 2020).
It should be emphasized here that suicides are not committed only because of family problems.However, family ties or intra-family communication, interaction, etc. are also extremely important.This is closely related to the attitudes of troubled adolescents or young people towards their family members.If there is a high level of love and respect in family communication and interaction, the adolescent or young person may be influenced by the problems he/she is experiencing and the sadness of his/her family in order not to upset the family members he/she loves very much, and may avoid committing suicide.
Here, an important preventive role of the family's communication and interaction pattern and the duty of social support also emerges.Since family culture and social culture are in interaction, changes or deviations that may occur in this institution affect the individual.Since the individual performs a significant part of his/her socialization within the family, he/she tries to solve many negative problems such as alienation, incompatibility and deviation in relationships within this institution.Sometimes the family is the source of a positive solution, but sometimes it can also be the source of an unsolvable problem.The rapid social change that has taken place in our society in recent years has also affected our family structure and cultural characteristics in the direction of change; it has confronted the youth with problems that are very difficult to face in many areas, from identity problems to intergenerational conflict.The family system, the socialization and individuality of individuals and younger generations.It is the only element of social structure that provides and expresses many social values such as culture, customs and traditions.Family turmoil has a significant impact on suicide.Authoritarian family structures where there is no family authority, love, discrimination or democratic relations deeply affect young people and youth.It is accepted as the category in which individuals experience the most serious problems both in adolescence and adulthood.In other words, it can be said that suicide begins in adolescence, when social and psychological problems become serious, reaches high levels in adulthood, and then gradually decreases in the later stages of life.

Physical Predisposition:
People with serious diseases such as cancer, epilepsy, heart disease, dementia and AIDS are more likely to commit suicide than others (Yağdıran, 2019;Gürhan et al., 2019).Predictors of suicidal behavior risk in individuals with physical illness:depression, anxiety, pre-existing suicidal behavior, suicidal ideation, feelings of hopelessness, pain, crisis, reactive behavior, substance use, family, work and finance-related social problems, and illness during stressful times (Stenager et al. 2000).

Situational Risk Factors:
There is no single cause of suicide, but when combined with other risk factors, people may be more prone to suicide (Beautrais, 2000;Bilsen, 2018).Rejection, unwanted pregnancy, poor school performance, fights, break-ups, and family problems are risk factors for adolescent suicide.Traumatic experiences, losses, economic problems, inadequate social support systems and disciplinary crises are among the most important stresses during adolescence (Consoli, 2013).

CASE
Z.D. is a 15-year-old female high school student.Z.D.'s parents are divorced.Her father is in prison, her mother has been through 3 marriages and currently has a boyfriend whom she is about to marry.Z.D. has a brother who is 8 years younger than her and lives with a different mother and father.The socioeconomic status of the family is low and there is no financial income because the father is in prison.The mother earns money from her daily cleaning work.Z.D.'s communication with her family is disconnected and weak.Z.D. is a student who does not make many friends at school, has a boyfriend and has low academic achievement.Z.D. is also reluctant to attend school and has a high absenteeism rate.Z.D. was previously diagnosed with depression and bipolar by a psychiatrist.After breaking up with her boyfriend, Z.D. fell into a great emptiness and attempted suicide by taking pills.This was not Z.D.'s first attempt.She had attempted before for different reasons.Z.D.'s aunt also died by suicide.She is often afraid that people will leave her, so sometimes she acts too happy to be in tune with her feelings and thoughts so as not to be alone.When his friends make negative comments, he feels unloved and unappreciated and withdraws from those people.He/she wants his/her friends to never leave him/her alone and to understand what he/she is saying.When this does not happen, She experiences events that can end his relationship with those people.
In the first mental examination of Z.D., She was a regular person with good self-care and general appearance.In the interviews with Z.D., her thoughts were intense that her boyfriend had been unfair to her and that she did not want to break up with her.In her mental examination, her mood was mildly depressed.Z.D. was diagnosed with major depression according to DSM-5 diagnostic criteria.As a result of family interviews, it was observed that Z.D. had intense thoughts of inadequacy and dislike, and when she tried to cope, she felt inadequacy and when she could not, depression prevailed.Being in adolescence, parental neglect and absence of the father, thoughts of loneliness and increased fears of being abandoned after her boyfriend.In her family history, her aunt's death as a result of suicide and her difficulties in coping with separation, suicide was the only solution for Z.D. Presence of existing depressive symptoms before suicide attempt, previous suicide attempt, being in adolescence, having acute stresses etc.Although there are risk factors such as suicide, not mentioning suicidal thoughts in the follow-ups before the loss, choosing a similar method with her aunt for her suicide and repeating similar situations, losing her boyfriend, parental neglect and feeling of loneliness are risk factors for Z.D.'s suicide attempt.In her family history, her aunt's death as a result of suicide and her difficulties in coping with separation, suicide was the only solution for Z.D. Presence of existing depressive symptoms before suicide attempt, previous suicide attempt, being in adolescence, having acute stresses etc.Although there are risk factors such as suicide, not mentioning suicidal thoughts in the follow-ups before the loss, choosing a similar method with her aunt for her suicide and repeating similar situations, losing her boyfriend, parental neglect and feeling of loneliness are risk factors for Z.D.'s suicide attempt.In her family history, her aunt's death as a result of suicide and her difficulties in coping with separation, suicide was the only solution for Z.D. Presence of existing depressive symptoms before suicide attempt, previous suicide attempt, being in adolescence, having acute stresses etc.Although there are risk factors such as suicide, not mentioning suicidal thoughts in the follow-ups before the loss, choosing a similar method with her aunt for her suicide and repeating similar situations, losing her boyfriend, parental neglect and feeling of loneliness are risk factors for Z.D.'s suicide at-tempt.having acute stresses, etc.Although there are risk factors such as suicide, not mentioning suicidal thoughts in the follow-ups before the loss, choosing a similar method with her aunt for her suicide and repeating similar situations, losing her boyfriend, parental neglect and feeling of loneliness are risk factors for Z.D.'s suicide attempt.having acute stresses, etc.Although there are risk factors such as suicide, not mentioning suicidal thoughts in the follow-ups before the loss, choosing a similar method with her aunt for her suicide and repeating similar situations, losing her boyfriend, parental neglect and feeling of loneliness are risk factors for Z.D.'s suicide attempt.
With an holistic evaluation, the case, presence of depressive symptoms before the suicide attempt, previous suicide attempts, being in adolescence, having acute stresses, intense loneliness and unloved thoughts, separation from her boyfriend, having a family history of suicide suggested that Z.D. was the trigger of suicide in the suicide attempt.In the presence of risk factors that increase the risk of suicide, of risk factors and an intervention plan are important.

DISCUSSION
Suicide is a complex behavior that requires a biopsychosocial approach.Research has comprehensively addressed risk factors for suicide under biological, psychological and social dimensions: age, gender, mental disorders, familial and genetic factors, physical illness, childhood, early experience, psychosocial support systems, negative cognitive structures and access to lethal weapons have been associated as risk factors for suicidal behavior.(Czyc et al,, 2019;Gijzen et al., 2021).Although Z.D. had risk factors related to suicide such as the presence of depressive symptoms before the suicide attempt, previous suicide attempts, being in adolescence, having acute stresses, etc., the fact that Z.D. did not mention suicidal thoughts in the follow-ups before losing her boyfriend and the fact that Z.D. was alone during the suicide attempt suggest that it was a trigger.
Psychiatric disorders constitute the most important risk factor in suicidal behaviors (Martinen-go et al., 2019).In the literature, the psychiatric disorder with the highest prevalence of suicide in adolescents has been reported as a depression-related disorder, and major depression in female adolescents has been reported as the most important risk factor for suicide attempts in adolescence (Orsonlini, et al., 2020;Güleç, 2016).As seen in the case of Z.D., the presence of depressive symptoms before the suicide attempt and being in adolescence constitute risk factors for suicide attempt.Regarding suicide attempts, it was found that girls attempted suicide more than boys.However, it is observed that girls resort to less lethal methods compared to boys (San Too et al., 2019).According to studies in the literature, the most common suicide method is drug overdose.Subsequently, it is seen that various methods such as wounding with a firearm, hanging oneself, and jumping in front of traffic vehicles can be used (Glen et al., 2020;Doğan et al., 2018).Z.D.'s suicide attempt was using high doses of medication, which is less lethal.The prevalence of suicidal behavior in children and adolescents with a family history of suicide was higher than in children and adolescents without a family history of suicide.
In addition, family history of mental disorders is also reported to be a factor that increases the risk of suicide in adolescents.When the family history of Z.D. was analyzed, it was found that her own aunt had lost her life due to suicide.It has been found that helplessness is stronger and suicidal ideation is more common in people who have difficulty coping with difficult life events.If there are risk factors that increase the risk of suicide, it is important to identify triggers and plan interventions in advance.

CONCLUSION
As a conclsion, it is important for families to pay attention when dealing with adolescents and young people who are associated with suicide.In some cases, young people may share their thoughts with their friends that they cannot share with their families.It is important to keep track of your child's school situation and friends.It is also important for parents to share with adolescents and young people, learn to communicate well with them, get to know their children and listen to family stories.You should ask yourself the question and take responsibility for solving the problem.Allowing children to express themselves helps them to feel authentic and safe.Spending time on cognitive skills such as age-appropriate coping and avoiding abstract explanations is an important factor.