The term suicide comes from the latin word sui (oneself) and caedere (kill). The World Health Organization defines it as a deliberated act to kill oneself, initiated, and executed by the person in complete knowledge and expectation of the final fatal outcome. It is a personal decision. ## I. INTRODUCTION Approximately one million people across the world commit suicide annually, and ten million attempt to do. The treatment and prevention of suicidal patients indicates that suicide can be prevented in most cases. Suicide is the ninth leading cause of death in the United States, with an annual incidence rate of 11.2 for every 100,000. The risk factors are divided into sociological and clinical factors. Sociological causes include male, white or native, financial problems, living alone, aged older than sixty years. Clinical risk factors may contribute to suicide completion. They include: rape, recent humiliation, bipolar disorder, panic attacks, substance abuse, schizophrenia, anhedonia, major depressive disorder and family history of suicide attempts. The presence of a major affective disorder, alcoholism, panic disorder, personality disorders, increased hopelessness, biological vulnerability, and a history of suicide attempts, indicates potential suicidal behavior in high-risk individuals. Fatigue, deterioration of cognitive abilities, unemployment, debts, social losses, life stressors, loss of economic status, sickness, defenselessness, periods of depression, access to lethal means of suicide, self-destructive behavior, $20\%$ of the suicide victims were psychotic at the time of their deaths. Without immediate intervention, a negative environment will have adverse effects on these people. Neurochemical Risk Factors: There is evidence of decreased brain stem levels of serotonin, or its principal spinal fluid metabolite. Serotonin abnormalities have been associated with potential suicidal behavior. Familial risk factors: Biological vulnerability and shared environment have adverse effects. Disrupted family environments may increase the risk for attempted suicide. The field of suicide research has expanded since Emile Durkheim published his book on suicide in France. ### National Statistics The annual incidence rate of suicides in Panamá is estimated of 3.4 for every 100,000 inhabitants. In the province of Los Santos is of 11.2 for every 100,000 persons, $85\%$ of the cases are men. Women report higher rates of attempted suicides, both in adults and adolescents. There are more cases reported of suicidal attempts in females in the whole world. The cases of women and children have increased during the pandemic. Public policies: Universal interventions, primary intervention, selective and indicated measures. Using a Hotline, exercise, activity, communication with significant others can get people to give meaning to their lives. God's presence in people's lives protects them and fills them with peace, love, and the need to be useful and help those in need: it gives meaning to our lives. Being grateful to be part of a group sustains people. Community psychiatry is very useful for suicide prevention and logotherapy, as well as spiritual life. School-based suicide prevention programs, suicide prevention centers, including parental and teacher training, student, and peer group support training and postvention as is. Identifying high risk students. One third to one half of adolescent suicides communicate in some way their suicidal ideations to friends and confidants. Community Psychiatry Approach to Suicide Prevention. Gordon's taxonomy offers new strategies. This approach refers to the broad spectrum of mental health interventions for mental disorders through preventive public health interventions. Identifying cases, treatments, and rehabilitation. Low levels of serotonin in the brain point to an increased risk of suicide. The intervention is necessary and appropriate for patients between 20 and 30 years old, but not for patients between 50 and 60 years old. Strategies of the psychosocial prevention and intervention model to be effective must offer a 24-hour emergency and crisis response service, composed of health professionals, available by telephone and in person, accessible to people during periods of highest risk. The three most studied prevention programs are: 1. Those offered in suicide prevention centers, the program in schools as a universal intervention. 2. Selective intervention. 3. Reduction in specific types of suicide. Programs in schools include parent, administrator, and teacher training, student training and access to hotlines for people with suicidal desires, gun reduction, and identifying high-risk students. One-third to one-half of suicidal adolescents confide their suicidal intentions to their loved ones. Many can be trained to identify their suicidal and very disturbed youth. Some teenagers have been influenced by the "copycat" phenomenon where they are carried away by the desire to imitate the deaths of famous people in the media especially if they are famous musicians or artists they admire. In contained populations such as prison, preventive programs have been very successful and videos have helped reduce suicide considerably, according to the team of Drs. Smialek and Spitz by $4\%$. (1978). It is reported that $90\%$ of suicides were committed by people with severe mental illness. By 1994 British doctors Gunnel and Frankel found that between one-third, to one-half, of psychiatric patients who had been discharged committed suicide within a month of leaving. The risk of suicide of psychiatric patients who have returned home is 200 times higher in men, and a hundred times higher in female patients, according to research by the group of psychiatrists Goldcare, Seagrott and Hawtton. In the United Kingdom, confinement to psychiatric hospitals increases the risk of suicide. Dr. Lester argues, "The effectiveness of individual psychiatric and psychotherapeutic treatment has not been proven as suicidal prevention." The use of substances and alcohol increases the risk of suicide by $20\%$ in depressed people. The presence of a psychiatric illness is the major risk factor in suicidal behavior, accompanied by psychosocial stressors. Suicidal risk increases with age. A high percentage of suicides visited their psychiatrist or psychologist at least a month before their deaths: a British study reflects a figure of $60\%$. Interpersonal interventions by healthcare professionals for patients in crisis situations may reduce the risk of mortality in these patients. Around 1910 at a meeting of the Vienna Psychoanalytic Society, the subject of suicide was addressed. Sigmund Freud was interested in this subject related to melancholy throughout his career and could never understand it. His most important essay on the subject was "Grief and Melancholy", written in 1929:it introduces the theme of confusion between being and the painful experience of significant loss, accompanied by mental anguish. In the background we find an unconscious identification of the being and the loved or hated person, which we have lost. The body identifies with the Other, this involves an attack on the superego. This is often accompanied by sexual fantasies, harmful sadistic feelings and a hatred of our body, intolerable anguish, and self-destructiveness. A strong desire to escape physical and mental suffering is noted. Laufer argues that teen suicide is an aggressive attack on the internalized parent. Something like: Since I cannot kill you, I kill myself. A suicide can be seen as a psychotic episode according to Schneidman. Like a hostile introjection of persecutory objects filling with hatred and organizing it around the image of another person. Suicide is seen as a neurochemical inheritance or a premorbid experience during childhood or development or adolescence. Introjection of a hostile nature makes the mind structurally fragile. D.H. Bule has observed that, in the absence of certain ego capacities, patients are vulnerable to falling into psychotic or suicidal crises. The incidence of childhood trauma, sexual abuse, cause mental illness and suicidal ideations. Behind every suicide attempt is a call to someone, God, or fate to choose a way out or a rescue. Psychoanalytic theory contemplates that there is a life force Eros, and a death force Thanatos. Karl Menninger states that suicide is the combination of three desires: the desire to kill, the taste to attack, destroy, retaliate against another. The desire to be killed, masochistic tendency of punishment. The need to feel pain and suffering. The desire to die. It includes the need to feel the essence of death and die. Baumeister's escape theory holds that suicidal behavior is the effort to escape intense and unbearable and painful psychological frustration. Scheinman's psychiatric theory holds that suicide is due to intolerable psychological pain. Most suicides are the product of frustrations in four categories: 1. Frustrated love 2. Fractured control, excessive helplessness, and frustration. 3. Self-image assaulted, avoidance of shame, failure, humiliation, and misfortune. 4. Breakdown of an important relationship and the suffering that comes with this. The psychological dimensions of every suicidal case or serious contemplation of suicide must be understood in terms of intense, unbearable psychological pain, accompanied by the thought of a way out of an unbearable situation through death. This unbearable pain has been generated by frustrations, every suicidal drama occurring in the mind. Suicide has a purpose which is, a search or exit from a crisis or situation of despair. The methods used, the suicidal note, the calculation of the effects of the survivors are oriented by disturbance and annoyance, the desire to punish others or the desire to harm those who have harmed or disappeared. In several cases of girls who have committed suicide, there has been rape by a stepfather or an adult. In 1921, Lewis Terman made a famous longitudinal study of gifted people in California, five of these men committed suicide, due to disturbing childhood experiences. The most dangerous thing we can hear is when the suicide says, "It's the only way out I have." We see cases of important men like former President Alan García of Perú, who shoot himself when the authorities went looking for him to try him for $ 250,000, he received from Odebrecht. The hanging of Judas was his only way out, when he felt the pain of his betrayal of Jesus, whom he sold for thirty pieces of silver. Cleopatra poisoned herself with an asp snake. In Egypt, suicide was seen as a disaster for body and soul. Sociological theories about suicide: The structuralist studies of the French sociologist Emile Durkheim, had a great impact on the world. Around 1897 he published Suicide: A Study in Sociology. Integration and regulation can have negative consequences if they occur excessively. This is the first and most influential theory of suicidal behavior. Social norms and rules regulate human behavior. There are social structures that, according to Durkheim, influence the lives of individuals, there are four types of suicide: Selfish suicide: Deficient social integration, this type of suicide originates from the lack of approval or acceptance of a group, little religious faith, divorce, widowhood, needs. 1. Itrustic suicide: it is when there is an excessive integration into society, it is opposed to the egoist. Suicide arises from a strong attachment or sympathy to the ideologies of a group, political or religious. The feeling is of passion, to be able to give one's life for the cause. 2. Mental suicide: Deficient social regulation, arises during extreme economic and social crises, transform the lifestyle of a person. Suicide is encouraged due to frustrations, loss of loved ones. Too little regulation encourages suicide. Economic and social imbalance. 3. Fatalistic suicide: Excessive social regulation as in authoritarian regimes where state terrorism. Euthanasia: The act of taking one's life with medical assistance based on a contract is acceptable in Scandinavian countries in older adults and with sick people. The word Euthanasia which literally means good death is a concept that appears with that name in the seventeenth century, attributed to Francis Bacon. Euthanasia as a technique of elimination of life due to various circumstances (newborns with malformations, terminally ill, elderly, insane, oligophrenic, perverts.) It has been practiced by most cultures since the earliest times. It is still widely practiced in many of the world's primitive aboriginal or native tribes and cultures. Suicidal patients may have the unconscious wish to end their lives assisted by their (savior) doctor. They don't want to be a burden to their family. Euthanasia is legal in Belgium, Luxembourg, the Netherlands, Canada, and the state of Victoria. Assisted suicide can only be done in Switzerland and several states in the United States. All these countries have different requirements to be able to carry out these practices. In most cases, the following applies: - Only the person who wishes to die can ask for it. - Neither spouses, parents nor children can do it. - It must be a free and repeated decision over time. - The ailment must be incurable and the pain unbearable. - Two doctors must verify that all these requirements are met. Most of the physicians that perform euthanasia are troubled by it afterward. When chronically ill patients attempt suicide, their families often are relieved and required assisted suicide. Euthanasia: positive, active, or direct, aimed at shortening the patient's life by radical means, either with or without the patient's consent (the so-called cases of compassion) and indirect active (alleviation of suffering by therapeutic means that necessarily shorten life). Negative euthanasia, passive or by omission, denies the patient the therapeutic means that could prolong his life, although not save him from death. The concept of dysthanasia (or therapeutic cruelty) consists in prolonging life beyond the limits of all hope, turning the sick person into reality into a dead man whose death is prolonged. #### Self-mutilation Non-suicidal self-harm, often referred to as self-harm, is the act of deliberately harming one's own body, such as cutting or burning oneself. Normally, it is not intended to be a suicide attempt. Instead, this type of self-harm is a harmful way to cope with emotional pain, intense anger, and frustration. Vincent Van Gogh mutilated his ear, was hospitalized, committed suicide to help his brother Theo from ruin. Suicide has increased in youth, in the general population, during the pandemic. Suicide is the ninth leading cause of death in the United States, responsible for about more than 30,000 deaths annually, and the third leading cause of death for young people between the ages of 15 and 24. Although it may be much more that have not been reported due to the social stigma that represents the death associated with suicide and many families try to hide the event to collect life insurance or for personal reasons. In the United States, as in the province of Los Santos (in Panamá) there is an incidence of 11.2 suicides per 100,000 people. Most suicides are preventable. As Health professionals, we must avoid misfortunes. Judas and Cleopatra were the first recorded suicides. Assisted suicide in older adults has become an outlet to end suffering. Risk factors can be divided into demographic, psychiatric, sociological, and clinical aspects. We found more cases in the male gender, in adults over 60 years of age who live alone as whites, with economic problems, without children. But suicide occurs at all levels of society and race. Among the clinical factors: people with affective disorders, manic depression, schizophrenia, substance abuse, family history, previous attempts, suicidal ideation, panic attacks, loss of pleasure, humiliation, mistreatment, and sexual abuse. The presence of fire weapons, alcohol, and drugs. Loss of work or loved ones. About $90\%$ of attempts are not made, only $7\%$ commit suicide. These behaviors are associated with suicidal behavior: cases of mental illness in the family, stories of suicidal relatives, dysfunctional families, parental separation, divorce, widowhood, family violence, incest, painful feelings, shame, and loneliness. $70\%$ of suicide victims have communicated their thoughts before death. Causes: Financial ruin, scandal, terminal painful illness. Substance abuse. Suicide in children and adolescents. Suicidal genetics. Blows to the head can alter serotonergic function, as well as monoaminergic systems. There is a great deal of evidence indicating the importance of familial transmission and genetic factors that contribute to suicidal risk. Serotonin reduction is linked to suicide. Impulsive behaviors, including targeted aggression, are more severe in those who attempt suicide. These patients attempt violent methods to take their own lives according to studies by Yates and associates. The profiles of these patients show high levels of agitation, severe anxiety, associated with psychosis. And a major loss of a loved one can led to extreme violence. Disintegration, cuts, and self-suffocation are associated with early loss and severe depression. Panic attacks and agitation lead them to a state of hopelessness and helplessness. The Recommendations are to monitor the presence of the following symptoms and the severity of anxiety. Agitation, psychosis, severe anxiety and symptoms of false illusions or hallucinations. Delirium tremens, unbearable tension, alterations in the perception of time, loss of self-control. Acts of self-mutilation are performed in private. #### Suicide in older adults For many people, religion gives meaning to their life. Suicidal behavior is found in $75\%$ of depressive patients according to research by Dr. Neeleman and associates. More than a million people commit suicide every year. Mass or religious suicides have happened throughout history. Different cultures have different ways of dealing with this event. In Japan after a disgrace seppuku is the decorous and respectable departure. The suicide of the prestigious Japanese writer, Yukio Mishima, was the culmination of a project planned, recorded, at a press conference and filmed. ## II. PREVENTIVE ACTIONS Stop mental pain, acting in time, offer psychiatric, psychological, and medical services to those suffering from an uncontrolled mental disorder, addictions, loneliness, depression, among others. Guarantee social and community support. Make sure to provide medicines. Restrict access to weapons, poisons, and drugs. Promote exercise, spiritual living. Early identification and treatment. Build, initiate a specialized health team of psychiatrists, nurses, and psychologists, and provide a helpline. # a) The Studies show that religiosity is experienced as a source of hope and trust in God. It reduces the risk of severe depression in times of crisis, facilitates recovery, and minimizes the risk of suicide. Dr. Kruijshaar and associates estimate that the risk of depression is $40\%$ in women versus $30\%$ in men. This varies across communities and countries, with $3\%$ found in Japan and $16.9\%$ in the United States. In China, Confucianists consider suicide acceptable to protect dignity and virtue. Confucius said that our bodies are derived from our parents, we should not offend or hurt them. We must understand the reasons and motives for suicide, the extreme forms of human suffering. The Hindus towards the years 3000 BC accepted mass suicides, the practice of sati self-immolation was accepted as the Jauhar or mass suicide. The belief in karma and reincarnation has been a strong factor against suicide, Hindus are more concerned with having a dignified death. Hinduism accepts and respects the decision of each person on how to live and die, the basis of the human being is the search for being and is individual. Mahaparasthana or the Long Journey is a type of suicide where the person walks towards Kailash subsisting on water and air until the body surrenders, there are religious suicides allowed as the desire to die in holy places. Sati is very common in India, when the husband dies the woman throws herself on the funeral pyre to die burned next to the corpse of her husband. ## III. INTERVENTION According to the center of investigation in UCLA's Mindfulness Awareness Research Center, expressing gratitude changes the molecular structure of the brain. It keeps gray matter working and makes us healthier, more functional, and happier. Learning to be self-compassionate strengthens us. Resilience is the process of adapting to adversity according to the American Academy of Psychology. People can learn to increase their resilience. Mindfulness allows your experience to be what it is, we must practice observing it at every moment. To Soften, soothe, allow, are strengthened with generosity and kindness. Spiritual people have a better chance of overcoming suicidal ideations. Anyone can contemplate suicide at any given time. Spiritual people have a better chance of overcoming. Case studies: a. Ernest Hemingway (Suicide with a firearm) b. Frida Kahlo. C. Vincent Van Gogh. d. Virginia Woolf. e. Violeta Parra a. Ernest Hemingway (1899-1961) Extraordinary American writer, Nobel Prize for Literature, was found dead in his residence in Ketchum, Idaho because of a shot in the mouth with a two-barreled rifle: it blew his brain. Forensic psychiatrist Dr. Andrew Farah says his tragic death was the result of neurological causes. Nine severe brain traumas, the unfortunate effects of electroconvulsive therapy (he received 15 treatments the first time, 10 the second time) obtained at the Mayo Clinic, where he was taken by his wife, for high blood pressure, erased his memory. Two days after finishing electroconvulsive therapy, his wife left the keys available to the place where he kept the weapons and he committed suicide. Mary, his fourth wife, did not warn her children of his depressive state, in order to keep his money and belongings, her marital relations were destructive, she detested his family. There is evidence of suicidal genetics in his family. His mother, whom he hated, committed suicide. Adriana, his Italian lover, hanged herself. His father committed suicide with a gun. His granddaughter Mariel and his son committed suicide. ### Psychiatric disorders Ernest Hemingway suffered from psychiatric disorders, traumatic chronic alcoholism and dementia, encephalopathy, diabetes, migraines, multiple head traumas blows to the brain and vascular dementia. In the last five years of his life he was depressed, he could not write, he could not work, he was fully aware of his cognitive decline. Many close people had taken their own lives. It is a tragedy to lose one's memory. His abilities were deteriorating, he was losing his way of life. He came to process and describe the dimension of his father's suicide, he felt that his father had betrayed him. "Man can be destroyed, but not defeated." He attacked his friends and females. He risked his life, went to fight in the Spanish Civil War, went on safaris to Africa hunting where he killed endangered animals. His mother used to dress him as a girl when he was a child. For many years he abused alcohol and drugs. He needed strong emotions; and had no limits. As a young man he was attractive, later he neglected his presence. He felt like a caricature of what he was. He became abusive, changeable. Realizing that his memory failed, he committed suicide. He had a history of various suicidal attempts, he had tried to take his own life before. # b. Frida Kahlo Magdalena Carmen Frieda Kahlo Calderón was born in Coyocan, Mexico on July 6, 1907. Her father Guillermo Kahlo, a Jew of Hungarian-German origin, was the official photographer of President Porfirio Díaz. He had a delicate health and suffered from epileptic seizures. His wife, Frida's mother had Spanish and indigenous ancestry, was conservative and very religious. At the age of seven Frida suffered from polio, leaving the rest of her life with one leg thinner than the other, she spent a lot of time alone. They called her "stick leg". From an early age she showed traits of schizophrenia, as will appear in her diary. At the age of 6 she projected a second Frida that would appear in all her work and her life. Her most famous painting is "Las dos Fridas" ("The two Fridas"), it shows the Frida that Diego loved and that he one he no longer wants. "I remember being six years old when I intensely lived an imaginary friendship with a girl... of the same age or so. In the window of what was then my room, and which was on Allende Street, on one of the first windows I sprayed mist and drew a door with my finger. Through that door I went out in my imagination, with great joy and urgency, I crossed the entire plain that could be seen arriving at a dairy called Pinzon.... Through the O of Pinzon I entered and unexpectedly descended to the interior of the earth, where my imaginary friend always waited for me. It has been 34 years since I lived that magical friendship and every time I remember it, it is enlivened and grows more and more within my world" (taken from her diary). At the age of 18, she will suffer an accident that will mark her forever and made her an invalid. All her tragedy and pain will be displayed in her works. Her love for Diego Rivera makes her forget this misfortune and she achieves a great artistic production. Her husband's infidelities fill her with insecurity and bitterness. Towards 1929 she married the great painter and muralist Diego Rivera. Later she suffered several miscarriages. A third part of her works are self-portraits. Her anxieties, pains and ghosts are reflected in her paintings. Her diary is a first-rate confidant of her life. Her desperation to live and her anguish and distress to overcome the disease were obvious. When asked why she made so many self-portraits, she replied, "I portray myself because I'm so lonely." Frida Kahlo led a tragic life. At age 7, poliomyelitis emerged. She was born with spina bifida, her sister and brother also had it, it may be one of the reasons why she did not have children. At the age of 18 she suffers the accident that will leave her invalid. Due to physical suffering, she is given morphine. Her diary shows suicidal tendencies, her anxieties and pains are reflected in her work." My leg was amputated six months ago. Centuries of torture have been done to me and at times I almost lost my mind. I still feel like killing myself. Diego is the one who stops me because of my vanity of believing I can need him. He has told me, and I believe him. But never in my life have I suffered more. I'll wait for a while." Frida was commissioned to make a painting of Dorothy Hale by Hale's family. Frida showed her committing suicide. She lived through a series of calamities, constant torture of surgical interventions, 35 operations, and had to wear 28 orthopedic girdles. On July 13, 1954, Frida Kahlo died during the early morning hours of a pulmonary embolism, according to her husband Diego Rivera. Her death could be the result of suicide or an overdose of alcohol and drugs. No autopsy was done. The last thing she wrote in her diary is an outline of a black angel, the angel of death. It said: I look forward to the departure and I hope never to return." ## c. Vincent Van Gogh (1853-1890) The famous impressionist painter Vincent Van Gogh led a stormy existence, his life reflects his art. He painted non-stop; he slept little; he drank and smoked a lot and didn't eat enough. From his youth he had a sullen, unbalanced, and taciturn spirit. Exacerbated by alcohol, malnutrition and psychosocial tensions, the fight he had with the painter Paul Gauguin led to his mutilation of the ear. Then he could suffer delirium tremens due to the forced abstinence from drinking when admitted to a sanatorium and had several severe depressive episodes with psychotic traces. On July 27, 1890, the artist shot himself. He died two days later. He was 37 years old. His best works were painted in the psychiatric hospital De Saint Remy. Vincent, suffered stages of madness, evoking his pain and sadness, during his most severe episodes of psychosis. His canvases are marked by madness, and feels a permanent claustrophobia, Vincent committed suicide to help his brother Theo, who had economic problems, Vincent's work was revalued. His last work was the Wheat Field with Crows. ## d. Virginia Woolf (1882-1941) The best English writer of the 20-th century. Virginia Woolf was an abused child, a survivor of incest, suffered from bipolar schizophrenia. She was married to Leonard Woolf, a Jewish writer, at a time when anti-Semitism reigned, the Nazis had bombed London, she and her husband had considered ways to commit suicide. An excerpt from the last letter she wrote to her husband read. "Dearest, I feel certain I am going mad again. I feel we can't go through another of those terrible times. And I shan't recover this time. I begin to hear voices, and I can't concentrate. So I am doing what seems the best thing to do. You have given me the greatest possible happiness. You have been in every way all that anyone could be. I don't think two people could have been happier till this terrible disease came. I can't fight any longer. I know that I am spoiling your life, that without me you could work. And you will I know. You see I can't even write this properly. I can't read. What I want to say is I owe all the happiness of my life to you. You have been entirely patient with me and incredibly good. I want to say that — everybody knows it. If anybody could have saved me it would have been you. Everything has gone from me but the certainty of your goodness. I can't go on spoiling your life any longer." ### e. Violeta Parra (1917-1967) Chilean Song writer famous for her song Gracias a la vida "Thanks to life, which has given me so much. It gave me two beams of light, that when open Can perfectly distinguish black from white And in the sky above, her starry backdrop, And from within the multitude. The one that I lo Violeta was going through an acute depression; she had lost the love of her life and her economic stability. Because of her work, the pressure she put on herself was greatly affected. Violeta Parra ended her life by shooting herself in the right temple with a revolver. She had twice tried to take her own life. She had various attempts before she completed her suicide, she resorted to barbiturates, then she cut her veins. ## IV. CONCLUSIONS Suicide has increased in youth and in the general population during the pandemic. Every week I find cases of suicide in my country, before this was not like that, children and young adults are taking their lives by hanging, overdose, shooting themselves, throwing themselves from high rise buildings or off the bridges to the sea, like never before. It is very sad. Suicide was the ninth leading cause of death in the United States, it was responsible for approximately 30,000 deaths annually, before the pandemic and the third leading cause of death for young people ages 15 to 24. Although the actual number may be much more, the reported number is unknown because of the social stigma that represents the death associated with suicide and many families try to hide the event in order to collect life insurance, or for personal reasons. Most suicides are preventable. $70\%$ of suicide victims have communicated their thoughts before death.

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