Suicide, it’s importance, global burden, burden of suicide in India, theories of suicide, it’s prevention, psychiatric co-morbidities associated with suicide, its treatment

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DR.ASHWATHI.J
FINAL YEAR PSYCHIATRY POSTGRADUATE
SSIMS & RC
DAVANGERE

3. Some myths
Talking about suicide is a bad idea and
can be interpreted as encouragement
 Given the widespread stigma around suicide, most people who are
contemplating suicide do not know who to speak to.
 Rather than encouraging suicidal behaviour, talking openly can give an
individual other options or the time to rethink his/her decision, thereby
preventing suicide.
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4. Some myths
Only people with mental disorders are
suicidal
 Suicidal behaviour indicates deep unhappiness but not necessarily
mental disorder however 90% of them are found to have mental
disorders as reported by WHO survey.
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5. Some myths
Most suicides happen suddenly without
warning
 The majority of suicides have been preceded by warning signs,
whether verbal or behavioural.
 Of course there are some suicides that occur without warning
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6. Some myths
Someone who is suicidal is determined
to die
 On the contrary, suicidal people are often ambivalent about living
or dying
 Someone may act impulsively by drinking pesticides, and die a few
days later, even though they would have liked to live on
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7. Some myths
People who talks about suicide do not
mean to do it
 People who talk about suicide may be reaching out for help or
support to discuss their difficulties / issues bothering them.
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8. CONTENTS
 Definition of suicide
 Related terms
 Historical background
 Global burden and suicide in India
 Etiology
 Risk factors
 Protective factors
 Common methods of suicide
 Suicide process model
 Treatment
 Prevention
 Laws related to suicide
 References
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9. DEFINITION OF SUICIDE
 Derived from Latin language
 sui = oneself , cidium = killing
A fatal act of self-injury undertaken with more or less conscious
self-destructive intent, however vague and ambiguous.
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10. RELATED TERMS
 SUICIDE ATTEMPT : self- injurious behaviour with a nonfatal outcome
accompanied by explicit or implicit evidence that the person
intended to die.
 SUICIDAL INTENT : subjective expectation and desire for a self-
destructive act to end in death.
 SUICIDAL IDEATION : thought of serving as the agent of one’s own
death; seriousness vary depending upon the specificity of suicidal
plans and the degree of suicidal intent.
 DELIBERATE SELF-HARM : will ful self-inflicting of painful, destructive, or
injurious acts without intent to die.
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11. RELATED TERMS (contd)
 PARASUICIDAL BEHAVIOUR : describe patients who injure themselves
by self-mutilation but who usually do not wish to die.
 CYBER-SUICIDE : suicide pact made between individuals who meet
on the internet
 COPYCAT SUICIDE : a suicide within a peer group/publicized suicide
can serve as a model for next suicide in absence of sufficient
protective factors (Werther effect)
 ANNIVERSARY SUICIDE: persons take their lives on the day a member
of their family did
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12. ADD-ONS 12

13. HISTORICAL BACKGROUND
 The story of suicide is probably as old as that of man himself.
 Suicide has variously been glorified, bemoaned and even
condemned.
 Ancient Athens - a person who committed suicide without the
approval of the state was denied the honours of a normal burial.
 Ancient Greece & Rome - suicide was deemed to be an
acceptable method to deal with military defeat.
 ISLAM: suicide is prohibited
 CHRISTIANITY: suicide is considered a sin
 In 19th-century, in Europe, the act of suicide shifted from being
viewed as caused by sin to being caused by insanity.
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14. HISTORICAL BACKGROUND (contd)
 Hinduism: When Lord Sri Ram died, there was an epidemic of suicide
in his kingdom, Ayodhya
 The Bhagavad Gita - condemns suicide
 Upanishads, the Holy Scriptures - condemn suicide ‘he who takes his
own life will enter the sunless areas covered by impenetrable
darkness after death’
 Vedas - permit suicide for religious reasons consider that the best
sacrifice was that of one's own life - ‘sallekhana’
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15. GLOBAL BURDEN
 Primary emergency for mental health professional
 Major public health problem
 Over 8,00,000 people die by suicide and more than 20 million attempt suicide each
year.
 Every 40 seconds a person dies by suicide somewhere on the globe.
 Every 15 seconds someone will attempt to take his or her own life.
 Globally, suicides account for 52% and 71% of all violent deaths in men and women
respectively.
 15th leading cause of death.
 Second leading cause of death in young people (15-29 years) globally after traffic
accidents.
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16. SUICIDE IN INDIA
 India ranks 43rd in descending order of rates of suicide with a rate of
10.6/100,000 reported in 2009
 About one-third of suicides over the world happen in India.
 Seven of the 12 surveyed states recorded suicide rates higher than
the national average [Assam (11.1), Chhattisgarh, Gujarat and
Kerala (22.4 each), Madhya Pradesh (11.9), Tamil Nadu (23.4) and
West Bengal (15.5)].
 Suicide rates were the lowest in Uttar Pradesh (1.7) and Manipur
(2.0) [ interpreted with caution considering the role of under
reporting and other contextual factors ]
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17. ADD-ONS 17

18. ETIOLOGY
 Sociological factors
 Psychological factors
 Biological factors
 Genetic factors
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19. SOCIOLOGICAL FACTORS
 EMILE DURKHEIM’S CONCEPT OF SUICIDE (French sociologist) –
described 4 basic types of suicide:
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Applies to persons
whose integration into
society is disturbed so
that they cannot follow
customary norms of
behaviour. Anomie
explains why a drastic
change in economic
situation makes persons
more vulnerable than
they were before their
change in fortune.
Applies to those who
are not strongly
integrated into any
social group. The lack
of family integration
explains why unmarried
persons are more
vulnerable to suicide
than married ones and
why couples with
children are the best
protected group
ANOMIC
SUICIDE
ALTRUISTIC
SUICIDE
EGOISTIC
SUICIDE
FATALISTIC
SUICIDE
a result of strict rules
in a society which
have proved
decisive for
the destiny of an
individual (the
suicide of a person
held as a slave)
Applies to those
susceptible to
suicide stemming
from their excessive
integration into a
group, with suicide
being the outgrowth
of the integration
(soldier who
sacrifices his life in
battle)

20. PSYCHOLOGICAL FACTORS
 Freud’s theory:
1) In his paper ‘Mourning and Melancholia’ – self-destructive
behaviour in depression represents aggression directed against a part of
the self that has incorporated a loss or rejection of a love object.
2) Freud doubted that there would be a suicide without an
earlier repressed desire to kill someone else.
 Menninger’s theory:
1) In Man against Himself, described suicide as inverted
homicide because of a person’s anger toward another person; this
retroflexed murder is either turned inward or used as a excuse for
punishment.
 Aaron Beck :
hopelessness – most accurate indicators of long-term suicidal
risk.
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21. BIOLOGICAL FACTORS
 Diminished serotonin plays a role in suicidal behaviour.
 Low concentrations of 5-HIAA in CSF predict future suicidal
behaviour.
 Recent studies report some changes in the noradrenergic system of
suicide victims
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22. GENETIC FACTORS
 Polymorphism in the TPH1 gene on chromosome 11 – associated
with an increased risk of suicidal behaviour.
 Polymorphism in the serotonin transporter gene is associated with
impulsive-aggressive personality traits.
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23. RISK FACTORS - SOCIO-DEMOGRAPHIC VARIABLES
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24. CLINICAL DETERMINANTS OF
SUICIDE
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25. PROTECTIVE FACTORS
 Strong connections to family and community support
 Skills in problem solving, conflict resolution, and nonviolent handling
of disputes
 Personal, social, cultural and religious beliefs that discourage suicide
and support self-preservation
 Restricted access to means of suicide
 Seeking help and easy access to quality care for mental and
physical illnesses
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26. COMMON METHODS OF SUICIDE 26

27. SUICIDE PROCESS MODEL
RISK AND PROTECTIVE
FACTORS (genetic,
social, psychological
and biological)
SITUATIONAL
FACTORS (recent
stressors, availability
and lethality of
methods)
INTENT TO COMMIT
SUICIDE
SUICIDE ATTEMPTDEATH OR SURVIVALAFTER EFFECTS
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28. TREATMENT
 Most suicides among psychiatric patients are preventable, because evidence
indicates that inadequate assessment or treatment is often associated with suicide.
 Evaluation for suicide potential involves:
1) A complete psychiatric history
2) A thorough examination of the patient’s mental state
3) An inquiry about depressive symptoms, suicidal thoughts, intents, plans and
attempts.
 Usage of scales to assess the risk of suicide
1) SAD PERSONS Scale (low sensitivity and high specificity)
2) Manchester Self-Harm Rule (MSHR) scale ( low specificity and high sensitivity)
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29. TREATMENT (contd)
 Treatment of suicide attempters:
❖ For every completed case of suicide there are about 20 non fatal
attempts
❖ Repetition – 15-25% within a year
❖ Poor problem solving skills – most commonly seen.
❖ Psychosocial therapy – mainstay of treatment.
❖ Pharmacological treatment to treat the associated psychiatric
conditions
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30. TREATMENT (contd)
 A lack of future plans, giving away property, making a will and
having recently experienced a loss – imply an increased risk of
suicide.
 INPATIENT VERSUS OUTPATIENT TREATMENT :
whether to hospitalize a patient with suicidal ideation is the most
important clinical decision to be made.
 INDICATIONS FOR HOSPITALIZATION :
1) Absence of strong social support
2) History of impulsive behaviour
3) A suicidal plan of action
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31. TREATMENT (contd)
 Outpatient treatment may be more beneficial than hospitalization in patients with
chronic suicidal ideation and / or self-injury without prior medically serious attempts, if a
safe and supportive living situation is available
 Psychosocial treatment
a) Problem-solving
b) Psychotherapy – individual and group therapy.
c) Distress-tolerance skills
d) Family therapy
 Pharmacological treatment
a) Antidepressants
b) Antipsychotics combined with other therapies
c) Mood stabilizers
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32. PREVENTION
 General principles
✓ Population strategies
✓ High-risk strategies
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33. PREVENTION (contd)
Population strategies
 Intervention at community level:
1. Increasing public awareness
2. Campaign to reduce stigma
3. Guidelines for the mass media
4. Regulating formulations, packaging and sale of pesticides
5. Regulation of over-the-counter medication
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34. PREVENTION (contd)
 Interventions at institutional and organizational levels:
i. Establishing sentinel centres and developing an information system
ii. Training of personnel working in high risk settings
iii. Establishing crisis intervention and counselling centres and
telephone hotlines
iv. Increase in specific clinical training programmes for lay counsellors
v. Redesigning the curriculum for medical and nursing personnel
vi. Intervention programmes for high schools
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35. PREVENTION (contd)
High-risk strategies
 Patients with psychiatric disorder
1) Risk identification
2) Preventive strategies- active treatment of underlying condition and
psychological therapy
 Elderly people- care and support
 High-risk occupational groups- all these groups have easy access to
methods of suicide – removing the access
 Prisoners- Ensuring that prison cells are safe in terms of absence of
structures favourable for suicide
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36. ADDITIONAL POINTS
 The Section 309 in the Indian Penal Code lays down the punishment
for attempted suicide.
 309 IPC - 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.
 Attempted suicide was decriminalized with the passage of the Mental
Healthcare Bill.
 The relevant provision of the Mental Healthcare Act, 2017 states,
"Notwithstanding anything contained in section 309 of the Indian Penal
Code any person who attempts to commit suicide shall be presumed,
unless proved otherwise, to have severe stress and shall not be tried
and punished under the said Code.“ The act commenced in July 2018.
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Theme of 2019 :
WORKING
TOGETHER TO
PREVENT
SUICIDE

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39. REFERENCES
 New Oxford textbook of Psychiatry
 Kaplan & Sadock’s Synopsis of Psychiatry
 Kaplan & Sadock’s – COMPREHENSIVE TEXTBOOK OF PSYCHIATRY
 National Mental Health Survey 2015-16
 Gazette of India
 Google search
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THANK YOU ☺