2. Suicide can be prevented?
Presented by: Hani Hamed
Assist. Prof. of Psychiatry
Acting Head, Psychiatry Department,
Beni-Suef University
Supervisor of Psychiatry Department ,
El-Fayoum University
Member of American Psychiatric Association
Alex,
May, 2013

3. Agenda
 Introduction
 Risk and Protective Factors
 Suicide Warning Signs
 Suicide Prevention Programs
 Future Directions

4. World Suicide Prevention Day
 September 10 is World Suicide Prevention Day, a
day not widely celebrated or even known about.
 According to WHO, every year approximately one
million people worldwide commit suicide--almost
one death every 40 seconds.
 Suicide rates are reported to be rising steadily in
developing countries, primarily amongst those
between the ages of (15 – 44).

5. U.S. Suicide Statistics
 Average of 83 suicides per day*
 8th
leading cause of death for males, 19th
leading cause for females
 4 times more men than women die by suicide
 Highest suicide rates (73%) in the U.S. = white men over age 85
 3 times more women than men report a history of attempted suicide
 Leading method of suicide = firearms
Source: National Institute of Mental Health
*Suicide Prevention Resource Center – U.S. Suicide Prevention Fact Sheet

6. ■ 850,000 suicides per year worldwide
920,000 deaths caused by malaria
■ The suicide risk in depressed patients is up to 30-
times higher than in the general population
■ 30 to 50 % of suicide attempts are due to depression
■ Approximately 15% of severely depressed patients
die by suicide
Suicides
Challenges
Major lethal risk !
WHO 2009

7. Angst et al, 2002
Zurich Cohort, N=147 deaths
1959 -1997
Cardio-
vascularvascular
Accidents SuicideNeoplasm
p <0.01
Cerebro-
vascular
p <0.01
Other
p <0.01
All causes
p <0.01
0
5
10
15
20
25
30
35
40 p <0.01
Untreated
Treated
(%)
Challenges

8. http://nitawriter.wordpress.com , 2007

9. Suicide in Egypt
 As for Egypt, it is reported to have an annual
suicide rate of less than 6.5 per 100,000--or
fewer than 5070 deaths by suicide each year.
 Exactly how many Egyptians do commit suicide
each year? Estimates are available, but there
are no definitive statistics.

10. Introduction
 About 90% of suicides occur in persons with
a clinically diagnosable psychiatric disorder.

11. Introduction
 Evidence pertaining to potential anti-suicidal
effects of various psychotropic drugs on
suicide risk has been strikingly limited as
well as inconsistent and inconclusive.
 Particularly surprising, there is only
inconsistent evidence that antidepressants
may help prevent suicides.

12. Terminology and definitions in
suicide research
 Suicide: the act of intentionally ending one's own life.
 Nonfatal suicidal thoughts and behaviors:
– suicide ideation: thoughts of engaging in behavior
intended to end one's life
– suicide plan: the formulation of a specific method through
which one intends to die
– suicide attempt: engagement in potentially self-injurious
behavior in which there is at least some intent to die.
– Nonsuicidal self-injury : self-injury in which a person has
no intent to die

13. Suicide can be prevented
 While some suicides occur without any outward
warning, most do not.
 The most effective way to prevent suicide among
loved ones is to learn how to recognize the signs of
someone at risk, take those signs seriously and
know how to respond to them.
 The emotional crises that usually precede suicide
are most often both recognizable and treatable.

14.  Demographic factors
– Suicide: male, an adolescent or older adult, non-Hispanic
White or Native American (in the US)
– Suicidal behaviors: female, younger, unmarried, having
lower educational attainment, unemployed
 Psychiatric factors
– Mood, impulse-control, alcohol/substance use, psychotic,
personality disorders
 Psychological factors
– Hopelessness , anhedonia, impulsiveness .
Risk Factors

15.  Biologic factors
– disruptions in the functioning of serotonin
 Stressful life events
– Diathesis-stress model
– family conflicts, legal problems, child maltreatment
 Other factors: access to lethal, chronic or terminal illness,…
Risk Factors

16.  Family history of abuse, violence, or other self-
destructive behaviors place individuals at increased
risk for suicidal behaviors (Moscicki 1997, van der
Kolk 1991).
 Histories of childhood physical abuse and sexual abuse,
as well as parental neglect and separations, may be
correlated with a variety of self-destructive behaviors
in adulthood (van der Kolk 1991).
FAMILY PSYCHOPATHOLOGY

17. PSYCHOSOCIAL SITUATION:
LIFE STRESSORS
 Recent severe, stressful life events associated with
suicide in vulnerable individuals (Moscicki 1997).
 High risk stressor: humiliating events, e.g., financial
crisis, being arrested or being fired (Hirschfeld and
Davidson 1988) – can lead to impulsive suicide.
 Identify stressor in context of personality strength,
vulnerabilities, illness, and support system.

18. RISK FACTORS (Yellow= modifiable)
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; comorbidity
Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease;
hemodialysis; systemic lupus erthematosis; pain syndromes;
functional impairment; diseases of nervous system
Psychological
Dimensions
hopelessness; psychic pain/anxiety; psychological turmoil;
decreased self-esteem; fragile narcissism & perfectionism
Behavioral
Dimensions
impulsivity; aggression; severe anxiety; panic attacks; agitation;
intoxication; prior suicide attempt
Cognitive
Dimensions
thought constriction; polarized thinking
Childhood Trauma sexual/physical abuse; neglect; parental loss
Genetic & Familial family history of suicide, mental illness, or abuse

19. Protective Factors
• Children in the home, except among those with
postpartum psychosis
• Pregnancy
• Religious beliefs, religious practice, and spirituality
• Moral objections to suicide
• Life satisfaction
• Reality testing ability
• Positive coping skills
• Positive social support
• Positive therapeutic relationship

20. SUICIDE: A MULTI-FACTORIAL EVENT
Neurobiology
Severe Medical
Illness
Impulsiveness
Access To Weapons
Hopelessness
Life Stressors
Family History
Suicidal
Behavior
Personality
Disorder/Traits
Psychiatric Illness
Co-morbidity
Psychodynamics/
Psychological Vulnerability
Substance
Use/Abuse
Suicide

21. Areas to Evaluate in Suicide
Assessment
Psychiatric
Illnesses
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 / mental illness
Individual
strengths /
vulnerabilities
Coping skills; personality traits; past responses to stress; capacity
for reality testing; tolerance of psychological pain
Psychosocial
situation
Acute and chronic stressors; changes in status; quality of support;
religious beliefs
Suicidality and
Symptoms
Past and present suicidal ideation, plans, behaviors, intent;
methods; hopelessness, anhedonia, anxiety symptoms; reasons for
living; associated substance use; homicidal ideation
Adapted from APA guidelines, part A, p. 4

22. DETERMINATION OF RISK
Psychiatric Examination
Risk
Factors
Protective
Factors
Specific Suicide
Inquiry
Modifiable Risk
Factors
Risk Level:
Low, Med., High

23. DIRECT QUESTIONING ABOUT SUICIDE:
THE SPECIFIC SUICIDE INQUIRY
Ask About:
 Suicidal ideation
 Suicide plans
Give Added Consideration to:
 Suicide attempts (actual and aborted)
 First episode of suicidality (Kessler 1999)
 Hopelessness
 Ambivalence: a chance to intervene
 Psychological pain history
Jacobs (1998)

24. COMPONENTS OF SUICIDAL IDEATION
 Intent:
Subjective expectation and desire for a self-destructive
act to end in death.
 Lethality:
Objective danger to life associated with a suicide
method or action.
 Degree of ambivalence - wish to live, wish to die
 Intensity, frequency
 Rehearsal/availability of method
 Presence/absence of suicide note
 Deterrents (e.g. family, religion, positive therapeutic
relationship, positive support system - including work)
Beck et al. (1979)

25. WHAT TO DOCUMENT
IN A SUICIDE ASSESSMENT
 Document:
• The risk level
• The basis for the risk level
• The treatment plan for reducing the risk

26. Suicide Warning Signs
Depression or Paranoia
Expresses guilt/shame over offense
Statements about suicide or death
Self-harm attempts
 Each attempt should be taken seriously!

27. Suicide Warning Signs
(continued)
 Severe agitation or aggression
 Agitation often precedes suicide
 Suicide can be a possible means to relieve agitation
 Hopeless/pessimistic about future
 Extreme concern or anxiety over what will happen to
them
 Appetite and sleep changes

28. Suicide Warning Signs
(continued)
Mood/behavior changes
 May refuse treatment
 Withdraws from others, may demand to be celled alone
 Neglects personal hygiene or appearance
Preoccupied with past – doesn’t deal well with
present
Packing/giving away belongings

29. Suicide Warning Signs
(continued)
 Writes a will
 Hallucinations and Delusions
 May hear voices or see visions that tell inmate to harm self

30. MYTH OR FACT?
1. Myth: People who threaten suicide don’t go through
with it
Fact: Most people who commit suicide have made
direct or indirect statements about their suicidal
intentions
2. Myth: Suicide happens suddenly and without
warning
Fact: Most suicidal acts represent a carefully thought
out strategy for coping with their problems

31. MYTH OR FACT? (continued)
3. Myth: People who attempt suicide have gotten it
out of their system
Fact: Any individual with one or more prior suicide
attempts is at much greater risk than those who
have never attempted suicide
4. Myth: Suicidal people are intent on dying
Fact: Most suicidal people have mixed feelings
about killing themselves; they are doubtful about
living, not intent on dying. MOST WANT TO BE
SAVED!

32. MYTH OR FACT? (continued)
5. Myth: Asking offenders about suicidal thoughts or
actions will cause them to kill themselves
Fact: You cannot make someone suicidal when you are
discussing the possibilities of suicide
 Concerned, non-judgmental questions encouraging the
person to discuss his/her ideas may help relieve the
psychological pressure
6. Myth: All suicidal individuals are mentally ill
Fact: A suicidal person is extremely unhappy but not
necessarily mentally ill; a “normal” person can be
suicidal.

33.  Means-restriction programs: can decrease
suicide rates by 1.5–23%.
 Primary-care physician education and training
programs: show reductions of 22–73%.
 Although effective prevention programs exist
many people engaging in suicidal behavior do
not receive treatment of any kind.
Prevention/intervention programs

34. Suicide Prevention Training
 Increase their awareness of suicide and see
prevention opportunities they may otherwise miss.
 Become more alert to clues and communications
that someone may be thinking of suicide.
 Ask about suicide and respond in ways that show
understanding and assess risk.
 Work with persons at risk to increase their safety.
 Facilitate links with further help from family, friends
and professional helpers as needed.

35. Treating suicidal individuals
• Need to assess suicidal risk and ensure adequate
supervision of attempter
•Deal with life crisis swiftly
•Therapy focused on building protective factors and
reducing risk factors, through a variety of different
approaches
• Encourage open talk about suicidal ideation

36. Communicating With Suicidal Patients
1. Listen Patiently
 Encourage the person to talk, including about suicide plan
1. Trust Your Own Judgment
 If you believe patient is in danger of suicide, implement
suicide prevention protocols and keep the person in a safe
place

37. Is Suicide Screening Effective? Still no
Clear Answer
 Trying to separate out the large population at risk for suicide
from those who go on to die by suicide is difficult.
 Preventive Services Task Force found, there is currently a
limited evidence basis for suicide-specific screening.
 However, It is important to remember that for those primary
care practices that use collaborative care for depression-
treatment models, screening for depression is supported by
the task force.
Psychiatric News, 2013

38. Take Home Message…
Suicide Prevention Efforts
YOU form the bridge of communication with potentially
suicidal persons by:
 Observing daily behaviors
 Interacting with and listening to him
 Reporting concerns to medical/mental health staff
promptly

39. Future Directions

40. Blood Test for Suicide Risk?
 Suicidal thoughts and behavior may be uniquely
linked to inflammatory markers in patients with
major depressive disorder (MDD), new research
suggests.
 A study of 122 adults in Ireland showed that
those with MDD and high suicidal ideation had
significantly higher levels of inflammation (as
shown through blood draws) than both those
with MDD and low suicidal ideation and healthy
peers without MDD.
Depression Anxiety. 2013;30:307-314

41. Blood Test for Suicide Risk?
 A composite score comprising the
proinflammatory cytokines interleukin-6 (IL-6)
and tumor necrosis factor–alpha (TNF-α), the
anti-inflammatory cytokine interleukin-10 (IL-
10), and C-reactive protein (CRP) was used as
an inflammatory index.
 Circulating levels of adrenocorticotropic
hormone (ACTH) and cortisol were also
measured to assess hypothalamic-pituitary-
adrenal (HPA) axis abnormalities.
Depression Anxiety. 2013;30:307-314

42. Blood Test for Suicide Risk?
 Results showed higher inflammatory index
scores for the group with MDD and high suicidal
ideation compared with the group with MDD
and low suicidal ideation (P = .009) and
compared with the control group (P < .001).
 There were no significant differences between
any of the groups on ACTH or cortisol levels.
Depression Anxiety. 2013;30:307-314