SUICIDE

 Introduction
 Epidemiology
 Etiology
 Risk factors
 Protective factors
 Common methods
 Warning signs
 Assessment and management
 Prevention
 Suicide has been defined as an act with a fatal outcome, deliberately
initiated and performed in the knowledge or expectation of its fatal
outcome.
 A suicide attempt is when someone harms themselves with the intent
to end their life, but they do not die as a result of their actions.
 Derived from Latin word
 sui = oneself , cidium = a killing
 Primary emergency for mental health professional
 Major public health problem (among the ten leading causes of death)
LEGAL PERSPECTIVE

 Legal in some countries vs illegal in many

 In Pakistan, section 325 of Pakistan Penal Code 1860 provides that “whoever
attempts to commit suicide and does any act towards the commission of such
offence, shall be punished with simple imprisonment for a term which may extend
to one year, or with fine, or with both”
 Not a criminalized act in US, UK, Egypt, India, Indonesia, Iraq, China, Iran,
Azarbijan, Bhutan any many others
Historical perspective
 Hinduism: Vedas - permit suicide for religious reasons consider that the best sacrifice
was that of one's own life - ‘sallekhana’ ,Sati, where a woman immolated herself on the
pyre of her husband rather than live the life of a widow
 Islam and Christianity considered suicide to be a sinful practice.
 In the West, in the early 17th Century, it was a belief that suicide was caused by insanity.
 In early 19th century suicide was considered to be a medical problem and could be
prevented by treatment.
 In 2014, WHO described link between suicide and mental disorders a broad
generalizations of risk factors.
“…. suicidal behaviour is a complex phenomenon that is influenced by several interacting
factors − personal, social, psychological, cultural, biological and environmental”
EPIDEMIOLOGY
 More than 800,000 people around the world die from suicide every year.
 For each suicide, there is the probability of having committed more than 20 attempts.

 75% of suicides occur in low-income and medium countries.

 Pesticide ingestion, hanging and firearms are among the most common methods of
suicide worldwide.
 Suicide is the second-leading cause of death in 15-29-year-olds globally.
 The largest number of suicides occur between ages 35 and 55, where it is the fourth
leading cause of death.
 Men commit suicides than the women, but more women attempt suicide.
ETIOLOGY

 Psychological Factors
 Hopelessness
 Lack of sense of belonging
 Desperation and guilt
 Shame and humiliation
 Impulsivity
 Dichotomous thinking
 Cognitive constriction,
 Problem-solving deficits
 Sociological theory
 Durkheim’s four social categories of suicide based on social integration and social
regulation
 Egoistic - This type of suicide occurs when the degree of social integration is
low,  isolated and lack a sense of belonging
 Altruistic - degree of social integration too high, feel that their death would
benefit society e.g. suicide bombing
 Anomic – lack of social regulation results in a failure to instill a sense of
meaning – or a failure to provide a moral framework
state of social and economic disorder
 Fatalistic - occur when social regulation is extreme and authority is
oppressive and controlling. Examples of this type could include a prisoner
who cannot tolerate prison conditions, or an unwilling young woman in a
patriarchal society who is forced into an arranged marriage.
 Biological Factors
 decreased activity of Serotonergic system: low concentration of 5-HIAA (metabolite
of serotonin) in CSF.
increased impulsivity and aggression in those with low brain 5-HT function
 Nonadrenergic system: modulates stress response, decision making and
sympathetic activity. increase in NE activity can result in insomnia, anxiety,
irritability, and hyperactivity
 HPA axis: effects brain neurotransmitters, including serotonin, noradrenaline, and
dopamine
 Genetic factors
 Molecular biology – polymorphism in TPH gene (tryptophan hydroxylase enzyme)
RISK FACTORS

Suicidal Ideation and / or Behaviour

 Prior suicidal behaviour (including suicide attempt), prior self-harm behaviour,
previous expression of suicide ideation
 Feels tired of living and/or wishes to die
 Thinks about suicide, has suicidal wishes and / or desires
 Has a suicide plan / note
Family History
 Family history of suicide, suicide ideation, mental illness
Gender
 Male > female
Mental Illness:
(90%) of those who die from suicide have some form of mental disorder at the time of death
 Major depressive disorder (4%, OR 1.8 if not seeking treatment)
 Any mood disorder
 Psychotic disorder ( Schizophrenia 5%, young men early in the course of the disorder)
 Substance misuse disorder / addictions (strong association)
 Eating disorder

4. Personality Factors
 Personality disorders (40-50%, AS/ BD)
 Emotional instability
 Rigid personality
 Poor coping skills, introversion
Medical Illness
 Pain, chronic illness e.g Epilepsy, Cancers
 Sensory impairment
 Perceived or anticipated / feared illness
Negative Life Events and Transitions
 Family discord, separation, death or other losses (increased in widowed, divorced,
single)
 Financial or legal difficulties
 Employment/retirement difficulties (higher in unemployed)
 Relocation stresses
Functional Impairment
 Loss of independence
 Problems with activities of daily living
Certain professions, with access to lethal materials
PROTECTIVE FACTORS

1. Sense of meaning and purpose in life.

2. Sense of hope, optimism.
3. Religious (or spiritual) practice.
4. Active social networks and support from family and friends.
5. Engagement in activities of personal interest.
6. Restricted access to means of suicide
7. Skills in problem solving, conflict resolution, and nonviolent handling of
disputes
8. Positive help seeking behavior and easy access to quality care for mental and
physical illnesses
Common Methods of suicide

 Pesticide poisoning/ poisoning substances (50% in Pak)

 Hanging (35%, most common in UK 53%)
 Firearms (7%)
 Drug overdose (2nd common in UK, most common in women)
 Fatal injuries
 Exsanguinations
 Suffocation
 Drowning
WARNING SIGNS

Remember “IS PATH WARM?”

 I Ideation / direct statement of intent (most obvious sign)
 S Substance Use
 P Purposelessness
 A Anxiety/Agitation
 T Trapped
 H Hopelessness/Helplessness
 W Withdrawal
 A Anger
 R Recklessness
 M Mood Changes
 ASSESSMENT OF SUICIDAL RISK
 Make direct inquiry about patient’s intentions
 Assess for risk factors/ warning sign e.g hopelessness, previous attempt, co-morb., drug
abuse etc
 Detailed history
 Current problems and patient’s reaction
 Personal, financial, status losses,
 Conflicts with other people
 Physical illness, past psychiatric illness, family hx of suicide
 Drug history
 social history
 Personality: Mood swings, impulsiveness, attitude towards religion and death etc )
 Mental state examination
 Mood
 Thoughts: Suicidal intent assessment
 Homicidal ideas
 Cognitive function
 Judgement
Suicide rating scales

 PIERCE SUICIDE RISK SCORE

 BECKS SUICIDAL INTENTION SCALE
 BECKS HOPELESSNESS SCALE
 MODIFIED SAD PERSONS SCALE
 SUICIDE PROBABILITY SCALE
 CALIFORNIA SUICIDE RISK ESTIMATION SCALE
Management of suicidal patient
 Do not leave a suicidal patient alone. Remove any potentially dangerous items
from the room.
 make a treatment plan and try to persuade the patient to accept it
 decide whether the patient should be admitted to hospital or treated as an
outpatient or day-patient
 intensity of the suicidal intention,
 the severity of any associated psychiatric illness,
 the availability of social support outside hospital

 Treatment of physical injury in case of suicide attempt

 Pharmacological treatment
ECT Evidence for short-term reduction of suicide
Benzodiazepines May reduce risk by treating anxiety
Antidepressants A mainstay treatment of suicidal patients with depressive illness /
symptoms.
Lithium Lithium has a demonstrated anti-suicide effect;
Antipsychotics Evidence for Clozapine reducing suicidality in schizophrenia and schizo-
affective disorders

 Detoxification and Rehabilitation in case of drug addiction

Psychological therapy:
 CBT,
 DBT,
 EMDR,
 Behavioral Activation Therapy
 Family therapy
 Occupational therapy
 Conflict resolution
LOW RISK/OUTPATIENT MANAGMENT
 Establish rapport and promote a trusting relationship
 Establish a clear treatment plan with the patient as to how suicidal thoughts, feelings,
and behaviors will be managed on an outpatient basis.
 Close supervision by family. Do not leave a suicidal patient alone. Remove any
potentially dangerous items from the room.
 Closely monitor and document ongoing suicidality until it resolves.
 Consider and use all appropriate modalities (e.g., various therapies: CBT, DBT,
EMDR, Behavioral Activation Therapy, journaling, exercise, couples counseling,
bibliotherapy), vocational counseling, medication, etc.
 Schedule frequent appointments e.g weekly consultations and document such.
 Document the resolution of suicidality; monitor for any future reoccurrence.
 Arrange for patient to stay with family/friends; if no one available,
hospitalization
 Weapons/pills removed by family/friends
 Encourage patient to discuss feelings
 Encourage patient to avoid decisions during crisis
 Activate links to community supports (self-help groups)
 If medication used for anxiety/depression:
 1-3 day supply only
 Monitored by family/significant other
Prevention

 Education and awareness programs for the general

public and professionals
 Screening methods for high-risk persons
 Treatment of psychiatric disorders
 Restricting access to lethal means
 Media reporting of suicide.