Few studies have been investigated the reasons for choosing poisoning as a suicide method(15) (16), and no studies were conducted in Brazil.
The expectance of death without suffering was noticed in studies investigating self-poisoning(8), hanging(17), and the use of vehicular gas(18). In our study, the expectation of death without suffering was cited by seven participants. They expected that the chemical agents would result in a fast, painless death during sleep, as compensation for a painful life experience, as mentioned by participant 8 (P8):
“People think I took medication because I don’t want to die, called me coward, but I want to die as soon as possible. I only insist on this because I know I will not suffer, I will die in my sleep, what I suffer in my life is enough”. (P8)
The suicide method impacts the lethal outcome. Use of firearms, drowning, and suffocation/hanging present the highest lethality rates, and drug overdose, poisoning, and self-inflicted cuts present the lowest(19). Although the use of chemical agents is considered a low lethality method, in this study, seven patients cited the choice of chemicals based on their supposed high efficacy as a lethal method:
“I had read the package insert before, I saw how dangerous these drugs are, if you read the package insert before you take it, you even lose your nerve, imagine the amount I took, I was sure I would never wake up again.” (P17)
When questioned on how they reached an understanding of lethal efficacy, they cited three reasons: the consumption of large amounts of drugs expecting cardiorespiratory arrest (n = 4), information obtained on the internet (n = 2), and the risk of consumption psychotropic drugs with alcoholic beverages (n = 1).
Easy access is a leading factor in choosing a suicide method (20). In the present study, easy access was mentioned by six participants, and five stated that they used medications available in their homes.
Preserving physical appearance represents a relevant factor for choosing a suicide method (17). For three patients, the preservation of the physical appearance was justified by concern that family members participate in the wake without embarrassment:
“With medication, it just takes it and bury it, the aesthetic vision is better, without blood, without a rope. I could be buried like everyone else.” (P17)
Access to the Internet impacts suicide behavior(21). The Internet can contribute to suicidal conduct through forums that encourage suicide as a strategy to solve problems and promote meetings and pacts among people with suicidal ideation, sometimes showing examples of suicide attempts and suicides(22). Nevertheless, Internet access might support the prevention of suicidal behavior by providing information on treatment and contributing to reducing the isolation and loneliness of vulnerable people(23). In the present study, two participants cited visiting websites as an essential factor in deciding whether to choose a suicide method:
"I looked on the Internet about poisonous plants, I used the Brazilian ones. I had a second option to take medicine, but I had already done it, and it didn’t work, so I looked for something that would work better (...) I don’t like knives, cutting myself”. (P7)
Many suicide deaths can be wrongly classified as accidental, such as suffocations in people who were intoxicated or under the influence of drugs, deaths during recreational activities, car accidents or falls from heights, and many cases of exogenous poisoning. In cases of exogenous intoxication, even when large amounts of substances are found in autopsies, relatives tend to doubt suicide, as shown in a study investigating suspected suicide deaths(24). Furthermore, intoxications may simulate natural death, and some reported simulation of natural death by ingesting pentobarbital, probably to spare their relatives from the stigma of suicide(25). In our study, P7 wanted to simulate death by heart attack by ingesting plants with clonazepam to “protect relatives from the dishonor of having a suicide in the family.”
A study investigating self-poisoning showed that the desire to communicate hostility, influence people, and alleviate a painful mental state was the most relevant reason for overdosing(26). P1 wanted to “escape the unbearable pain, the pain of the soul,” and P3 wanted to convince her alcoholic husband to stop drinking.
Suicide is the leading cause of death among people with schizophrenia and psychotic disorders. The risk of suicide is considered high in this group, around 10%, resulting from concerns with the disease and the symptoms themselves, such as the influence of command voices, agitation, and behavior disorganization(27). Similarly, P14 related that self-poisoning resulted from a command hallucination.
For P4, the choice of ethanol fuel associated with crack resulted from the option of a cheap method.
Few studies have been published on the correlation between the suicide method and individual considerations of clinical damage if no lethal outcome. Brazilian research analyzing suicide attempts using fire, a method with a high potential for health injury, showed that most participants reported not considering this possibility (28). In our study, no participants considered health risks or harm if they survived. The majority (n = 12) acted on impulse, and others cited misinformation about the toxic threat of chemical agents. Paradoxically, twelve participants reported that they avoided using violent methods that could leave "broken, sequel, dependent on third parties.”
These results may reflect two possibilities: 1) they considered the chemical agents harmless and therefore did not anticipate any health risks (which could indicate low intentionality, as SIS verified in most of the sample) 2)they had the certainty of death and thus not considered the possibility of not dying.
The limitation of access to drugs results in reduced mortality from suicide attempts (6). The finding that most people who used paracetamol in suicide attempts were unaware of the liver risks changed the UK's public health strategy (8). Consequently, an extensive announcement of these risks and reducing the over-the-counter painkiller package reduced paracetamol overdose-related mortality and liver transplantation rates (29).
Thus, information on possible health damage caused by an overdose of medications can be implemented by health teams in Brazil for people at risk of suicide. In addition, digital media can leverage health literacy by redirecting search engine tools for terms like poisoning, overdose, or suicide to websites that report on health risks caused by an overdose of chemical agents.