An interview with guest-editor professor Vsevolod Rosanov

Posted: 08.09.2022

Vsevolod Rozanov is a professor at the St. Petersburg State University, chief scientist at the V.M. Bekhterev National  Medical Research Center for Psychiatry and Neurology and a co-chair of the suicidology section of the World Psychiatric Association (WPA).

MD: Hello! Once again, thank you very much for agreeing to this interview. It's very nice to finally meet you.

VR: Hello! Nice to meet you too.

MD: Today you are invited as Guest Editor of the Consortium Psychiatricum Special Issue on Suicide and Emergencies. You are co-chairman of the Section on Suicidology in the World Psychiatric Association, you teach at St. Petersburg State University, and you work at the Bekhterev Scientific Center. What else should we know about you?

VR: You stated everything correctly, there is nothing to add.

MD: As someone who studied the humanities, I find the issue of suicide very philosophical and very paradoxical. This is something at the junction of various disciplines. I remember how at the university we read the French sociologist Émile Durkheim, who believed that suicides have social causes rather than psychological or personal ones. There is also the gender paradox of suicide. I always thought suicide was a fait accompli. But after reading the articles in the Special Issue, I realized that this topic is much broader. Scientists and psychiatrists work primarily with people who have not actually committed suicide. There were thoughts, intentions, certain behavior, maybe attempts. How can all this be comprehended and measured from a scientific point of view? Could you tell us a little about suicidology and what suicidologists do?

VR: You know, suicidology is really a science in its own right. And some people consider themselves suicidologists, although this is not officially recorded anywhere. There is a journal of the same name in Russia: Suicidology.

The point is that suicide is indeed a very versatile phenomenon. In the same way, a person cannot be understood only from one side. A person is a member of its biological species, which is subject to some biological, neurobiological and other mechanisms and laws; and on the other hand, there is a whole world of philosophical views, opinions, values and religious beliefs, which interacts with all this basis. You were right saying that if you look only from a sociological standpoint, we have an accomplished phenomenon, we see statistics on how many suicides occurred this year or last year, in which countries, and so on. But the fact is that you need to take a broader view. If we talk about suicidal behavior, we already have a much larger issue on our hands, since suicide is the very tip of the metaphorical iceberg, you know? The iceberg model is quite fitting: under suicide as such, an accomplished event, there is a huge number of suicidal attempts, and you still need to carefully study these phenomena in order to understand how to properly qualify them based on the degree of intentionality. Then come suicidal thoughts, suicidal experiences, suicidal communication. Then there are cases of so-called non-suicidal self-harm that we encounter, for example, among young people, but they are actually associated with suicidal behavior. Thus, this is a very multifaceted issue, and therefore, naturally, it concerns specialists of a purely medical profile, neurobiologists, geneticists, and, of course, sociologists, psychologists, and even philosophers.

MD: Thank you. This brings us to your article, which you provided specifically for the issue. It's called "Psychosocial and Psychiatric Factors Associated with Expected Fatality during Suicide Attempt in Men and Women."

I was particularly impressed by the phrase “We have built the whole study around the question What did you think were the chances that you would die as a result of your act?”. Very interesting wording for further reasoning. Please tell us about the context and what is unique about this study and this research question.

VR: That’s exactly right. This is a question that interested me greatly as well. I cannot say that I dealt with this issue all my life. I was once a clinical biochemist, a neurochemist, I was mainly studying some extreme states, the biochemistry of the nervous system, but about 25 years ago the life itself pushed me to this issue. I participated in a very large genetic project, which was devoted precisely to the search for possible markers of a suicide attempt, and a particularly high case-fatality of such an attempt. When a person inflicts various kinds of harm on themselves, they, roughly speaking, can achieve different results, depending on what they originally wanted and were able to do in the end, as far as they understood what would come of it. We are well aware that sometimes there are some difficult experiences, there is an intention to die, but due to certain circumstances it is not possible to carry it out, only long-term troubles remain. For example, let's say young people know that you can poison yourself with paracetamol. But not severely. Because it is sold for general use by pharmacies. In fact, by swallowing paracetamol, you can get a non-fatal, but very serious lifelong disorder. And vice versa: hoping, perhaps, only to have some impact on other people, you can unexpectedly do something that will end very sadly, including death.

In the course of this study, we used one tool that was developed by one of the eminent American suicidologists, Aaron Beck. By the way, his real surname was Byck, not Beck, and he was born either in Belarus, or in Ukraine, or in Russia. Much can sometimes be found out about scientists abroad. He was from a Jewish family that had moved abroad very early. Aaron Beck spent his life developing different ways to understand what people really want to do when they do these things. He used a tool called the Suicidal Intent Scale. The concept of intent was introduced. We never know until we ask, you know? The intent remains hidden. Even for a person who survived a suicidal attempt. There are really a lot of such people. They end up in general hospitals, brought by ambulance, and they are treated there, brought to their senses. Finding out all the circumstances, what is behind this, is of great interest. We are going to discharge this person from the hospital. We need to understand, firstly, the degree of his psychological issues, how mentally healthy he is now. This is easily achieved: a psychiatrist comes to talk to him. But for future, we want to know: what was the degree of his intent? What was he actually going to do? This is how we noticed this interesting question. It was a major international project in which I was the responsible executor. Sweden was the leading country. The basis was, of course, genetics, because we were looking for markers. But psychology also yielded a huge amount of data: each person answered 1,440 questions. It had to be the person who made the attempt, along with his parents, dad and mom. That's why it was mostly young people. When we looked at the answers to our question, we suddenly noticed that people are divided into three groups that are quite close in size: those who did not think about it at all; those who thought death was possible but unlikely; and those who really thought they were going to die. And then we decided to see what was behind it. Behind this feeling. A person can be asked a lot of questions. You probably can imagine what psychological questionnaires are: there will be different scales, methods, assessments, or you can ask one direct question, point-blank. Then a mental activity begins, he starts to remember what it was. It seemed to me that this question is of particular importance in relation to young people who are just starting out in life. What drives them? This is what started it all. We developed this approach, analyzed it, made presentations at conferences several times, and we produced a full-fledged article.

MD: As far as I understand, some differences between men and women who attempted suicide were detected. They had a different set of stressful events in their lives, in their childhood, that influenced their decision. What is the reason, in your opinion? Maybe cultural context?

VR: Yes, exactly. When we analyzed this issue and started to compare all three groups in terms of statistics, we began to investigate how the degree of expectation of death is associated with some other (psychological, psychosocial etc.) characteristics of these people, at the statistical level. There were a lot of things: depression, of course, detected using the same Beck questionnaire, a tendency to violent actions, hopelessness (also the Beck questionnaire), some other parameters. But the most interesting thing is that we had a very large questionnaire which asked people about what troubles, what difficult events happened to them in life. There were 32 potentially severe events. This is very interesting: it is difficult to think of more than 30 troubles. Starting from the most insignificant, ending with the most tragic. And so, people told us what happened to them, and how often it happened.

Naturally, these were people whom we found after a suicide attempt, that is, they were probably in a crisis or post-crisis state. We really hoped that what they told us was more or less objective. We are convinced that this was the case in at least 80 per cent of cases.

When we began to look at the associations, we discovered a lot of interesting things: for men and women, the same feeling of really wanting to die turned out to be associated with different life circumstances. Men, for example, had more pronounced depression. This is despite the fact that depression is generally believed to be more pronounced in women.  The next thing we were very interested in was the actual events. Moreover, these were not just any events, we specifically asked about what happened in childhood, before the age of 18. So, formally, the set of these events for men and women turned out to be different, and this also interested us very much. For men, this was a lack of parental warmth and care. And the second parameter, in my opinion, which was associated with this is their pessimism, hopelessness. For women, it turned out to be a strong feeling of hatred for one of her parents, and also strong frustration due to the fact that they could not achieve something, could not achieve some goal, and in general the total severity of these negative stressful events which they encountered. Nowadays we often think that much of what happens to people in life is somehow rooted in the early period of development, in childhood, in the conditions in which the personality was formed, some important events took place that form the attitude towards oneself, to the world, to one’s future. And the different sets of these events in men and women made us think too. Having identified this pattern on a large statistical sample, we can come closer to understanding what dangerous factors exist for young men and women during childhood development. This material, in my opinion, is important for understanding, for prevention, maybe even just to talk to people who come with some kind of psychological experiences, including suicidal ideation, to a psychotherapist, a psychologist, a consultant.

MD: This, of course, is extremely interesting. According to gender stereotypes, such things as achieving goals are more significant in the male worldview. Or, for example, such strong emotions as hatred are more clearly manifested. But it turns out, the opposite is true: men are more influenced by close relationships and care, something sensual.

You have already touched a little on the practical application of your study. How can you further use what you have discovered? Maybe in post-crisis counselling, to prevent further attempts.

VR: You see, when it comes to post-crisis counselling, the question is, do we have the capacity and time to do it? Imagine, a person has done something to himself. It became noticeable, an ambulance arrived, if necessary, he was taken to the hospital, he spent several days there, then he was consulted by a psychiatrist, maybe a psychologist talked to him. They, in fact, do not have sufficient budget and time to talk to each such patient. Moreover, there are people in the same intensive care unit who are being saved from some other serious diseases, and very often the staff and doctors think like this, for example: “this girl swallowed something, and now we have to deal with her.” And her problems, as often happens, may seem insignificant to adults. These are also things to keep in mind. If an experienced specialist visits this patient, he will find the right words. Counselling psychiatrist or clinical psychologist. But very often these people first encounter a nurse, a paramedic who takes them in an ambulance, an intensive care doctor who will run in, look, make a prescription and, at best, say a few more words.

We have discovered a pattern that is characteristic, by the way, of our culture. We were expecting one thing, but it turned out that other things mattered. Do not forget that we are talking about the period of early development, about childhood. And I thought about using this question wording in the future. Instead of asking a lot of questions, just ask in the context of the conversation: what did you really think to do? Were you planning to die? Or you didn't think about it at all. Having received one answer or another, you can roughly imagine what drove this teenager or young person. And this, in my opinion, is very useful for further prevention. And prevention is the most important thing. No one in the whole world can say that he can one hundred percent predict further suicidal behavior or prevent all suicides without exception. At the same time, there is a great deal of evidence that what works best in such a situation is essentially a simple psychosocial procedure: maintaining contact for some time with the person who made the suicide attempt. This also, of course, requires some effort. But we may think about how to implement such a practice. The strongest predictor of a possible suicide is a previous suicide attempt. And there are a lot of them, by the way. When we interview teenagers or students, it turns out that about 10% of young people have already attempted suicide. The numbers may be different: 6%, 8%, 10%, depending on where the study is conducted.

It is important to understand what motives, what circumstances may be in the minds of men and women, what significant negative impact they had in their youth. And then in a week or two, I would call this person who made the attempt. And then again in a month, and then in 5-6 months. And I would just ask how he feels, what is happening now, and so on. Thus, repeated attempts and the suicide itself could be prevented. This, by the way, has been verified in serious randomized controlled studies. Today it is one of the best methods. And with today's opportunities (e-mail, instant messengers, mobile phones), it costs virtually nothing.

MD: It's like investigating crimes. Sometimes it seems to come out of nowhere, but in fact, if you really pay proper attention to some signs, a lot can be prevented.

Now I would like to ask you about your role as a Guest Editor and your experience working with the editorial team of the Consortium Psychiatricum to create the Special Issue. What was it like?

VR: First of all, I was very flattered and grateful to Georgy Petrovich for the invitation. He seems to have conveyed this invitation through Nikolai Grigorievich Neznanov. Indeed, I am constantly actively engaged in this topic at the Bekhterev Institute and at St. Petersburg University, I lecture a lot, and, perhaps, this played a role. What does this experience mean to me? I immersed myself in editorial work, saw what it was like to make one volume of a journal. A journal which is still only taking its position, but already has a certain presentation. It always presents different opinions, different countries, and the range of topics is usually very wide: it combines organizational issues, for example, organization of psychiatric care, and, in a sense, issues related to humanities, to psychology, arguments about how to deal with psychiatric patients from a depth psychology perspective. This is a very multifaceted journal. The idea to dedicate an issue to suicidology is an important step. Many psychiatric journals publish articles related to suicidal behavior in one way or another. In addition, there is a specialized Suicidology journal. But it has a different fate. The main thing there is that the topic should be related to suicide. And all studies are published, including, say, those of the suicidal potential of inert gases such as helium and questions, for example, “is it possible to get poisoned by helium?” or “do people often get poisoned with helium?”. Therefore, chemists or, for example, toxicologists can act as experts in the journal. Here the journal is a psychiatric one, but suicidology was chosen specifically as the topic, so it also kind of expanded the range of its approaches. There were a variety of opinions. And immediately there was an idea to connect it with extreme situations, with crisis states. At first it seemed to me that this was too much for one journal, two such topics. But I was wrong, it turned out very well. The editorial team was very professional. I had a chance to work a lot with a translator and with editorial corrections, and review several articles. I think we have done an excellent job. The end result was a massive and interesting volume. What is the purpose of a journal? To attract more readers. And I believe that this task has been completed.

MD: So, you believe that this special issue has every chance to bring the attention of the scientific community and doctors to the problem, and that it really has a global goal?

VR: Definitely. The journal contains case reports and reviews on, say, the prevention of suicidal behavior; there are very specialized articles, as narrowly focused as ours; on the contrary, there are more comprehensive ones, for example, dedicated to ways to provide mental health care in crisis situations or help certain categories, such as vulnerable groups, refugees, and so on. These are relevant, hot topics for general psychiatry in our changing world, which has yet to go through many crises. And of course, mental health issues and helping large groups of people are definitely on the agenda. I got an impression of the journal as an ambitious project with far-reaching goals. It happens in different ways: a good idea arises, and a journal is immediately created, I have seen this. I am on the editorial board of several journals. But here I see some well-thought-out strategy with a plan to reach a fairly high level. This is very commendable.

MD: Finally, I would like to refer to your editorial note, in which you write: “Suicide is a serious public health problem worldwide; therefore, suicide prevention is imperative for any individual.” 

In this regard, I wanted to ask a perhaps somewhat provocative question about suicide prevention: why is it even important? It would seem that if a person has already made such a decision, why stop them? Why do we need to think about it, spend resources on it?

VR: Yes, it's very good that you raised this question, because it is asked very often. I teach at the university, at a humanities faculty, the Faculty of Psychology, and this question always pops up: Why are you, in fact, making a fuss about all this? After all, there is freedom of the individual. Of course, this is all true. But if we take this position, we, in a sense, completely relieve ourselves of responsibility. Like, go ahead! The right to die instead of the obligation to live. That's the problem. We need to take action, to teach that suicide prevention is an imperative. Because the actions of a person who really already wants to die are in fact always ambivalent: he wants and does not want at the same time. “Why and how” is a difficult question.

Very often it happens that after the person is stopped, nothing like this ever happens in their life. The World Health Organization and, in fact, the whole suicidology, which is guided by certain principles, take the correct position in this regard. And the first principle is: suicide is preventable. We know that there are many different ways and approaches. Everyone can personally take part in suicide prevention. In this regard, we need to talk more about suicide, disseminate objective knowledge, fight myths about suicidal behavior. For example, that this is a kind of sword of Damocles: if a person has already made the decision, we cannot stop them. Not at all. We absolutely can. And they will be grateful for the rest of their life. In fact, this is done for the sake of society as a whole. Any program of suicide prevention works, for example, at the level of some federal subject. For example, in Tuva, where the suicide rate is high, they decided to create an interdepartmental, interdisciplinary program of suicide prevention. This is preceded by a discussion, people meet at the level of representatives of healthcare, education, the Ministry of Internal Affairs, the Ministry of Emergencies, maybe some other structures, the army, the police. They discuss this problem, then the working group writes something, formulates, then it's all published, some kind of event is held, and this should be visible to the whole society, you know? If the state takes measures to reduce the number of people dying on the roads - creates road markings, compels drivers not to exceed the speed limit - then why shouldn't it also take measures so that other deviant forms of behavior are also somehow limited?

Suicide prevention is such a broad task, from the highest level to the level of an individual, especially since each of us, if you think about it, at some time in our lives faced this issue, if not personally, then at least heard about it. Today, with the help of the media, information about suicide is spreading at a tremendous speed. This certainly has an impact, especially on young people. Thus, we must work with the media in this regard, so that they inform the society about suicides, so that these messages are accompanied at the end with links to help resources, helplines, words that suicides can be prevented. 

This, of course, does not cancel any ideas about the freedom of the individual. Let these freedoms also exist, but there must be some social measures that help create an appropriate moral and psychological attitude towards this problem.

MD: This is also true from a personal, human point of view: it is rightly said that there is nothing worse than stepping off a roof and changing your mind the next moment. Perhaps it is very important to give people a chance to change their minds.

Maybe you have some advice for everyone on a personal level, what they can do, what they should pay attention to? Even some appeals, instructions, warnings?

VR: In fact, a lot of the right things have already been said, there are various lists of what you need to pay attention to in relation to teenagers, adults.

I would say that the most important thing is paying more attention to each other. To some signs. Anyone understands the signals that usually come from a person who is in a severe life crisis or is currently thinking about suicide and issuing so-called suicidal communications. In principle, the main recommendation is to treat this carefully enough, seriously, not to shock your, so to speak, counterpart. Sometimes there are such provocateurs: “You said you would jump, so go ahead and try!” This, perhaps, should not be done: you never know how it can end. And to show empathy, to try to understand what is behind it, and maybe even to just give advice; if you don’t know what to do, contact someone, this is very important, up to the point that you really call the helpline, which everyone knows, every federal subject has one. In addition, there are national hotlines. There are trained people there who know how to talk. There are websites for teenagers. If you do not want to contact the teenager directly, you can advise him to contact the relevant organizations, like Your Territory and a number of others. There are also trained psychologists there. The general idea is to really pay more attention to people around you. At home, at work, in a higher educational institution, at school - for teachers, not necessarily psychologists. This is a very broad question that concerns everyone without exception.

MD: Once again, thank you for today's meeting and, from the entire editorial team, for preparing the Special Issue.  And I think we will meet again?

VR: Thank you very much! It was very nice to talk and work in this direction. Life experience is cumulative.



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