The relationship between visual impairment and suicide
Summary
Studies analyzing the intersection between suicidal behavior and visual impairment are still scarce in Spain, although there is a greater number of investigations internationally. Before reviewing some data from these studies, it is important to consider two premises that serve as a contextual framework in this first quarter of the 21st century:
- The preamble to the constitution of the World Health Organization (WHO) defines the concept of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
- In line with this definition, a social approach to disability—or biopsychosocial model—is also being promoted, driven by the emancipatory movements that emerged at the end of the last century and by the political responses stemming from them. A turning point in this process was the 2006 Convention on the Rights of Persons with Disabilities , which resulted in an international legal instrument ratified by numerous countries. In this new paradigm, concepts such as universal accessibility, inclusion, and functional diversity are fundamental to understanding disability.
Under this new approach and context, we understand suicide and disability as public health problems . The perspective is social, and strategies are proposed from a community-based perspective. Based on these two premises, the plans and programs designed and implemented by countries in general, and ours in particular, are developed around selective and structural measures . These measures are based on risk and protective factors , and their primary objective is to identify social groups or communities at higher risk of suicidal ideation and behavior. Among these is the visually impaired population.
The risk of suicide in people with visual impairment
Suicide remains a taboo subject in our modern society. This is one of the reasons why statistical data on social groups and subgroups is not collected, even though overall data indicates that the number of deaths by suicide far exceeds that of other causes of mortality, such as accidents and homicides. If we consider that an average of eleven people commit suicide every day in Spain, it is clear that we have "the elephant in the room." And if we link suicidal behavior to disability, we find another social taboo. Now we can speak of "two elephants in the room."
To statistically illustrate the correlation between visual impairment and suicide, we will rely on the systematic review published by Kim et al. (2024), which examines 31 international studies and analyzes 5.6 million cases. The general conclusions are as follows:
- Suicidal behavior: People with visual impairment are 2.5 times more likely to engage in suicidal behavior.
- Suicidal ideation: People with visual impairments have recurrent suicidal thoughts twice as often as the general population.
The study also identifies some particularly high-risk subgroups within people with visual impairments:
- Adolescents. This is the most vulnerable group. Visual loss at a critical stage of developmental, social, and educational growth exacerbates feelings of isolation, hopelessness, and fear of facing future situations.
- Adults in their active years. Acquired family and socioeconomic responsibilities are the main cause of mental health problems in this subgroup, although they can act as both a risk and a protective factor, in one direction or the other.
- Older adults. In this group, suicidal ideation is associated with comorbidity with other diseases and also with the loss of autonomy and personal independence.
- People with severe and sudden vision loss experience greater and more intense stress due to coping with the loss and the adaptive effort, aspects that do not occur in people with congenital or childhood blindness.
Both quantitative and qualitative data help us explain why the visually impaired community is vulnerable to both suicidal ideation and behavior . It is the latter, the qualitative aspects, that bring us closer to identifying the risk factors in this correlation.
Risk factors for suicidal behavior
Visual impairment is not, in itself, a risk factor; rather, it appears alongside a series of mediating elements that arise during a person's interaction with social environments and life contexts . In disability, its conceptualization, and the repercussions it may have on each individual and situation, accessibility and inclusion always act as modulating factors. Some risk factors are:
- Mental health. The likelihood of suffering from a depressive or anxiety disorder is three times higher for people with visual impairment. Coping with vision loss involves a period of mourning and intense stress due to the adaptive effort. Adaptation to new life circumstances is required, and when the desired adjustment is not achieved, the stress can become chronic and lead to symptoms of anxiety and depression (in clinical psychology terms, an adjustment disorder).
- Inhibition and social isolation. Problems with transportation and difficulties in accessibility can generate or accentuate isolation and feelings of loneliness, one of the personal factors most linked to suicidal behavior.
- Socioeconomic status. Employment and economic difficulties are greater than in the general population and can generate socioeconomic stress. Some studies evaluate and confirm a significant gap in academic and employment access for people with visual impairments compared to the general population and indicate that this difference may be at the root of the problems in carrying out each person's life project, as well as greater economic insecurity (Trott et al., 2022).
People with visual impairments are 2.5 times more likely to engage in suicidal behavior and have recurrent suicidal thoughts twice as often as the general population.
- Personality traits. Some more static personal traits and others more variable, such as self-esteem, self-efficacy perception, social and communication skills, are closely related to suicidal ideation and can be a predictor of suicidal behavior.
- The feeling of being a burden to others or of dependence is identified as a key factor in many cases. The lack of accessibility in education, employment, leisure activities, sports, and, in general, social participation, impacts each person's autonomy and capabilities. Even if the individual maintains a positive attitude, willingness, initiative, and generally suitable skills, without an accessible and inclusive environment that enables adaptation, risk factors will increase.
- Social stigma is the psychosocial construct by which individuals in a general population hold negative thoughts, beliefs, and attitudes toward specific groups, for example, people with low vision or blindness. We must remember that human barriers are often more devastating than material ones. And we must also consider, in this case, self-stigma, which is the internalized negativity experienced by those who suffer from stigma.
In other words, vision loss always causes a greater or lesser emotional impact, mediated by personal factors such as personality traits and socio-familial support, as well as external factors such as the sociodemographic environment and the inclusive policies of each region. The adjustment or maladjustment of a person who acquires a significant visual impairment will determine the presence of risk factors that can also predict suicidal ideation and behavior, with the context in which the person lives their daily life always being key.
Trauma and hopelessness, two key factors in suicidal behavior
Protective factors against suicidal behavior
Addressing the mental health of people with visual impairments requires a perspective that goes beyond the sensory deficit and focuses on internal resilience resources and external resources that promote adaptive adjustment , acting as protective shields against suicidal behavior. We detail the main protective factors here:
- Social support and a network of belonging are crucial. It's not just about having people around and enjoying their functional and emotional support, but also about the quality of those relationships, which should avoid overprotection and foster autonomy. Beyond the immediate family and social environment, we will give special attention to peer support. Sharing experiences with other people with visual impairments allows for the validation of emotions, facilitates the development of more adaptive resources, and reduces feelings of alienation.
- Personal autonomy and independent living . Self-perception of ability, effectiveness, and competence is an antidote to hopelessness. Learning and using skills and tools for orientation and mobility, as well as using technical devices for accessing information, leisure, culture, etc., should be considered important resources for carrying out the life project of people with severe visual impairments. When a person feels they can move around, work, or manage their home independently, their self-esteem is strengthened, and functional autonomy is directly related to a lower rate of depressive symptoms.
- Psychological skills. Internal resources such as adaptive psychological traits (cognitive flexibility and resilience) will make it easier for us to accept the consequences of vision loss. The ability to adapt plans, interests, and goals to the new circumstances will prevent future frustrations.
Problems with transportation and difficulties with accessibility can generate or accentuate isolation and feelings of loneliness, one of the personal factors most linked to suicidal behavior.
- Access to specialized mental health services is essential. It is necessary to eliminate the architectural, digital, and human barriers that still persist. When considering accessibility in healthcare services, it is crucial that mental health professionals understand the common barriers faced by people with disabilities and are aware of the appropriate resources available. Early intervention is crucial for detecting signs of depression that may appear during ophthalmological evaluations. It also allows for intervention before the psychological condition worsens and suicidal ideation develops. Therefore, collaboration between ophthalmologists and mental health professionals, as well as with organizations that can provide psychosocial resources, will always be valuable.
- And as a final protective factor, implement reasonable accessibility adjustments in each of the social environments , as well as the necessary inclusive policies in all areas of a person's life: academic, work, cultural, leisure, sports, etc., to promote social participation and the development of life projects for people with visual disabilities.
In short, as we can see, the protective factors align with the WHO's concept of health and with the current model of disability, as we mentioned at the beginning of this article. A community-based approach to public health should always consider both the individual and their social environment. The empowerment theorists, such as community psychologists Rapaport and Zimmerman, already pointed out that empowerment always correlates positively across different levels: individual, family, community, and institutional.
Prevention recommendations
Based on the review by Kim et al. (2024) and the clinical guidelines that typically accompany these studies, the recommendations are divided into specific actions for clinical and social settings. The goal is to focus on the person rather than the eye or visual function. Some of these recommendations are:
- Integrating mental health screening into ophthalmology consultations. Since ophthalmology is often the only specialty a person visits, it is recommended to implement brief tools such as the PHQ-9 for possible use in medical check-ups, normalize the conversation in consultations, and ask how vision loss affects their daily life, while simultaneously reducing the stigma surrounding mental health.
- Identifying critical risk moments. Professionals must be vigilant, especially at two times: at the time of diagnosis, particularly in rapidly progressing diseases with a serious prognosis; and during functional transitions in basic daily living tasks, such as ceasing to drive or being unable to read independently.
- Promoting early basic rehabilitation. Studies on basic rehabilitation suggest that learning and using adaptive tools such as walking sticks or optical and technological tools helps maintain social connection, thus becoming adaptive resources and, at the same time, protective factors for mental health.
- Restoring autonomy. When we improve mobility and access to leisure, culture, sports, academic or work environments, we reduce the feeling of burden or dependence, one of the main predictors of suicidal ideation.
- Referral to support networks and peer groups . It is essential not to work in isolation: ophthalmology professionals should be connected with other health services, with psychology, social work, with associations, and be able to offer specialized human and material resources for visual impairment.
- Education for families and caregivers . Instructing family members about the warning signs and alarm bells of suicide.
- Helping to prevent social isolation and inactivity are crucial. These are likely risks for people with significant visual impairments and, therefore, become risk factors for suicidal behavior.
Keys to preventing suicidal behavior
In conclusion, we must reiterate that the correlation between visual impairment and suicide, along with its risk and protective factors, constitutes a complex public health problem . Both risks and protective factors must be identified within the interaction between different social levels, from the individual to institutional policies, including the family, social groups, and the community. This must always take into account the individual's physiological, functional, and psychological aspects , as well as accessibility adjustments in their environments and social inclusion in various spheres.
Loss of vision always causes a greater or lesser emotional impact, mediated by some personal aspects, such as personality traits or socio-family support, and other external aspects, such as the socio-demographic environment and the inclusive policies of each territory.
The stigma towards people and groups who are different , who deviate from the social norm, persists. It is clear that the rights of people with disabilities have advanced in recent decades. Although some eugenic policies from almost a century ago, or the realities of segregated social groups at any point in our history, are now distant memories, achieving inclusive social environments for all remains a public health project.
We can see and we can not see, just as we can hear and we can not hear, we can walk and we can not walk. Some of the latest data tells us that 50% of people will have a disability at some point in their lives, so we would do well to normalize this condition.
A community-based vision of social realities implies the creation of inclusive policies and their implementation in all areas. But it also implies changes in people's perspectives and in the social imaginary. Each and every one of us, in our daily roles—family, community, work, etc.—is an agent of inclusion. We can all contribute from our own position to make each day a kinder and more inclusive society, one that embraces all its abilities, contributions, and needs.
