ASSESSMENT OF SUICIDAL
DR SALMAN KAREEM
1STYR POST GRADUATE RESIDENT
Suicidal behaviour – conceptualized as a continous
ranging from suicidal ideation and communication
to suicidal attempts and complete suicide.
Suicidal process – developmental process which
leads to suicidal ideation, suicidal
communication, self destructive behaviour in some
even to suicide and consequence to survivors
Deliberate self harm – as a non fatal act whether
physical injury , drug overdosage or poisoning
carried out in the knowledge, it is potentially
harmful, and in case of drug dosage that the amount
taken was excessive.
SUICIDE: A MULTI-FACTORIAL EVENT
Access To Weapons
Durkheim’s theory – Emile Durkheim divided into 3
Egoistic – those who are not socially integrated into any
Altruistic – society which can exert a strong inflence on
an individual’s decision to sacrifice his or her own life.
Anomic – applies to person whose integration into
society is disturbed so that they cant follow customary
norms of behavior.
Fatalistic – result of strict rules in society which have
proved decisive for the destiny of an individual.
Freud’s theory ( mourning and melancholia)
Meninger’s theory – suicide as an inverted
homicide because of patient’s anger towards
Believed that suicide could be understood through
the interplay of three internal wishes:
• Wish to kill
• Wish to be killed
• Wish to die
Diminished central serotonin plays an
important role in suicide behaviour.
Decreased concentration of serotonin
metabolite in lumbar CSF is associated with
Relatives of suicidal subjects have a four-fold
increased risk compared to relatives of non-
Twin studies indicate a higher concordance of
suicidal behavior between identical rather than
Adoption studies: a greater risk of suicide among
biologic rather than adoptive relatives.
Suicide appears to be an independent,
inheritable risk factor.
Demographic male; widowed, divorced, single; increases with age; white;
Psychosocial lack of social support; unemployment; drop in socio-economic
status; firearm access
Psychiatric psychiatric diagnosis; co morbidity
Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease;
hemodialysis; systemic lupus erthematosis; pain syndromes;
functional impairment; diseases of nervous system
hopelessness; psychic pain/anxiety; psychological turmoil;
decreased self-esteem; fragile narcissism & perfectionism
impulsivity; aggression; severe anxiety; panic attacks; agitation;
intoxication; prior suicide attempt; borderline personality
thought constriction; polarized thinking
Childhood Trauma sexual/physical abuse; neglect; parental loss
Genetic & Familial family history of suicide, mental illness, or abuse
Severe anxiety and/or agitation
Depressive phase of illness
Anhedonia or hopelessness
Anxiety, agitation, or panic
Aggression or impulsivity
Global or partial insomnia
Recent sense of peace/well-being
Co-morbid alcohol abuse/dependence
• Post Partum Depression
• Co-morbid Axis I Disorder
• Mixed Drug Abuse Obsessive-Compulsive Disorder
• Paranoid or UndifferentiatedType
• Depressive State
• Command Hallucinations
• More than a high school education
• Less than 40 years old
• Personality Disorders
• Cluster B or Cluster C
• Co-morbid depression
• Co-morbid alcohol abuse/dependence
•Temporal lobe epilepsy
• Chronic Pain
• More than one psychiatric diagnosis
• Currently psychotic
• Unstable or poor therapeutic relationship
Cognitive Features that Contribute to Risk
Loss of executive function
Thought constriction (tunnel vision)
Inability to adapt to a dependent role
AFFECTIVE DISORDERS AND SUICIDE
• Suicide occurs early in the course of illness
• Psychic anxiety or panic symptoms
• Moderate alcohol abuse
• First episode of suicidality
• Hospitalized for affective disorder
secondary to suicidality
• Risk for men is four times as high as for
women except in bipolar disorder where
women are equally at risk.
Previous suicide attempt(s)
Significant depressive symptoms - hopelessness
First decade of illness – (however, rate remains elevated throughout
Poor premorbid functioning
Current substance abuse
Poor current work and social functioning
Recent hospital discharge
Suicide occurs later in the course of the illness with
communications of suicidal intent lasting several years
In completed suicides, men have higher rates of alcohol
abuse, women have higher rates of drug abuse
Increased number of substances used, rather than the type
of substance appears to be important
Most have co morbid psychiatric disorders, females have
Borderline Personality Disorder
High Risk Profile:
Recent or impending interpersonal loss
Co morbid depression
ALCOHOL / SUBSTANCE ABUSE AND SUICIDE
PERSONALITY DISORDERS AND SUICIDE
Borderline Personality Disorder
Lifetime rate of suicide - 8.5%
With alcohol problems -19%
With alcohol problems and major affective disorder -38%
A co morbid condition in over 30% of the suicides.
Nearly 75% of patients with borderline personality
disorder have made at least one suicide attempt in their
Antisocial Personality disorder
Suicide associated with narcissistic injury / impulsivity.
Areas to Evaluate in Suicide Assessment
Comorbidity, Affective Disorders, Alcohol / Substance
Abuse, Schizophrenia, Cluster B Personality disorders.
History Prior suicide attempts, aborted attempts or self harm;
Medical diagnoses, Family history of suicide / attempts /
Coping skills; personality traits; past responses to stress;
capacity for reality testing; tolerance of psychological
Acute and chronic stressors; changes in status; quality of
support; religious beliefs
Past and present suicidal ideation, plans, behaviors,
intent; methods; hopelessness, anhedonia, anxiety
symptoms; reasons for living; associated substance use;
Evaluation of suicidal
Complete psychiatric history
Thorough examination of patient’s mental
Inquiry about depressive symptoms
Suicidal thoughts, intents, plans and
Inpatient versus outpatient
Indications for hospitalization
Patient is psychotic.
Violent , near lethal or pre meditated act.
Precaution was taken to avoid rescue or discovery.
Distress is increased or patient regrets surviving
Limited family and social support.
Current impulsive behavior, severe agitation , poor
judgment and refusal to help.
Specific plan with high lethality and high suicidal
Admission may be necessary
Major psychiatric disorder
Past attempts if medically serious
Possible contributing medical condition
Lack of response or inability to cooperate with
partial hospital or outpatient department
ECT or medical trial
Limited family /social support, including lack of
stable living situation.
Lesser risk/ outpatient
Suicidality is reaction to precipitating events
particularly if the patient’s view of situation has
Plan/method has low lethality.
Patient has stable and supportive living situation
Useful measures for managing a depressed
suicidal inpatient include searching the patient's
belongings and person on arrival on the unit for
objects that might be used for suicide, and
repeating the search at times of exacerbation of
Ideally, the suicidal depressed inpatient should
be managed on a locked unit with shatterproof
windows, and the patient's room should be
located near the nursing station to maximize
observation by the nursing staff.
DETERMINE TREATMENT SETTING AND PLAN
Attend to issue of patient’s safety.
Assess treatment plan/setting/alliance.
Somatic treatment modalities:
ECT – used to treat acute suicidal behavior
Benzodiazepines – may reduce risk by treating anxiety
Antipsychotics, recent study on Clozapine
Psychotherapeutic intervention – widely viewed as helpful for
Provide education to patient and family.
Monitor psychiatric status and response to treatment.
Reassess for safety and suicide risk frequently.
ECT Evidence for short-term reduction of
suicide, but not long-term.
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
Antipsychotics Evidence for Clozapine reducing suicidality
in schizophrenia and schizo-affective
Regardless of theoretical basis, key element is a
positive and sustaining therapeutic
Recommended (primarily from clinical consensus)
To target issues
Denial of symptoms
Lack of insight
To manage high risk symptoms
Effective treatment in high risk diagnoses
Personality disorders (use of Dialectical Behaviour
Problem solving – Brief problem solving
therapy shows reduction of repetition of self
Goals to reduce suicide
1. Promote awareness that suicide is a public
health problem that is preventable
2. Develop broad based support for suicide
3. Develop and implement strategies to reduce
the stigma associated with being a
consumer of mental health , substance
abuse , and suicide prevention services.
4. Develop and implement suicide prevention
5. Promote efforts to reduce access to lethal
means and methods of self-harm.
6. Implement training for recognition of at-
risk behavior and delivery of effective
7. Develop and promote effective clinical
and professional practices.
8. Improve access to, and community and
linkages with, mental health and substance
9. Improve reporting and portrayals of suicidal
behavior, mental illness , and substance
abuse in the entertainment and news media
10. Promote and support research on suicide
and suicide prevention.