SUICIDE DEPRESSION HELPING OTHERS

1. Dr. MOHIT BANSAL
PGT-2
Department Of Psychiatry
Katihar Medical College

2. Outline
1. Introduction
2. Demographics and
epidemiology
3. Risk factors
4. Risk assessment scale
5. Management
6. Conclusion

3. INTRODUCTION
 Suicide term was first used by Sir Thomas Browne in his
‘Religio Medici’ in 1642.
 The WHO defines ‘Suicidal Act’- “the injury with varying
degree of lethal intent & ‘Suicide’ as suicidal act with fatal
outcome.
 Among people who attempt suicide, the risk of completed
suicide is very high, about 1-2 percent, which is 100 times
that of a general population.
 In 1/3rd of attempted suicides, there is history of previous
deliberate self harm.

4.  WHO report 1 death every 40 seconds worldwide due to
suicide. Every 5 minutes, someone somewhere in India
attempts suicide, making suicide the third major cause of
death.
 Community studies show that 5 million suicide attempts
occur each year in India. Suicide rate in India is11.3 per lac
population.

5.  Glossary of Terms
 Attempted Suicide: A self-inflicted injury that has
sufficient evidence (either explicit or implicit) to allow
others to rule that the person intended to die. (Jacobs,
et al, 2003)
 Self-harm: A deliberate act of self-induced poisoning
or injury, without regard for motivation (Bilen, 2010).
 Suicide: A self-inflicted death that has sufficient
evidence (either explicit or implicit) to allow others to
rule that it was the person’s wish to die. (Jacobs, et al,
2003)
 Suicidal Ideation: Thoughts of causing one’s own
death. (Jacobs, et al, 2003)
 Suicidal Intention: Desire to cause a self-destructive
and lethal act. (Jacobs, et al, 2003)

6. Parasuicidal Behavior
 Parasuicide is a term introduced to describe patients who injure
themselves by self-mutilation (e.g., cutting the skin), but who
usually do not wish to die.
 Studies show that about 4 percent of all patients in psychiatric
hospitals have cut themselves; the female-to-male ratio is almost
3 to 1.
 Self-injury is found in about 30 percent of all abusers of oral
substances and 10 percent of all intravenous users admitted to
substance-treatment units.
 These patients are usually in their 20s and may be single or
married.
 Most are classified as having personality disorders and are
significantly more introverted, neurotic, and hostile than
controls.
 Alcohol abuse and other substance abuse are common

7. Global suicide rates
 1 million people die annually – suicide (WHO
1999)
 Globally suicide : 14-16 deaths/100 000/year
 One death by suicide every 40 seconds
 20-40 failed attempts per suicide

8.  Recently studies: younger > older (Bertolote et al., 2009).
 5-44 yrs account for 55% of suicides
 Most suicides : 35-44 yrs (Bertolote et al., 2009).
 Global incidence < 15 yrs doubled since 1960
(Malone & Yap, 2009).
• Global complete suicides rate: male > female 4 : 1
• Women are four times more likely to attempt suicide
than men.

9. Suicides in India
 The number of suicides in the country during the
decade (2002–2012) has recorded an increase of 22.7%
 The all India rate of suicides was 12 during the year
2021.( Maharashtra,tamil nadu,Madhya Pradesh)
 Youths (15-29 years) and lower middle-aged people
(30-44 years) were the prime groups taking recourse to
the path of suicides.
 Around 34.6% suicide victims were youths in the age
group of 15-29 years and 33.7% were middle aged
persons in the age group 30-44 years.

10. 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

11. Factors associated with an
increased risk of suicide
 Demographic
 Social factors
 Familial and Biological factors
 Physical illness
 Mental Illness & Psychological factors

13. Demographic
Male
Younger > Elderly
Divorced, single or widowed
Socially isolated/living alone
Certain Professionals: veterinary surgeons
pharmacists
farmers
doctors

14. Social Factors
 Social deprivation & social fragmentation
 poor economic conditions – unemployment
 Childhood adversity
 Interpersonal loss & conflict
 recent migration
 Financial difficulties.

15. Familial and Biological Factors
 Family history of suicide - genetic risk
 Non-genetic: childhood abuse or neglect
 Reduced serotonin & low concentration of 5-HIAA in
CSF are associated with suicidal behavior
 Reduced serum cholesterol (Horton et al 1995)

16. Physical illness
 Chronic and severe physical illness.
 Cancer 2x suicide rate
 Epilepsy 5X suicide rate
 Chronic pain
 HIV/AIDS

17. Mental Illnesses
 Majority suicide victims 1 or more psychiatric disorders
 22% suicides - in the first year of a mental illness
 Risk of suicide is high following discharge:
 25% of post discharge suicides in the first 3 months
most in the first 2 weeks post discharge.

18. Rates of suicide for psychiatric
disorders
 Major depression - 20 X
 Elderly depressed - 35 X
 Bipolar affective disorders - 15 X
 Personality Disorders – 7X
 Schizophrenia lifetime risk: 10% (Harris & Barraclough 1997)

19. Deliberate Self Harm
 Previously attempted suicide – Risk  38 X
 Greatest risk suicide after act of DSH is in first 3 years
especially in first 6 months
 1% DSH kill themselves in the next year.
 15% of DSH eventually kill themselves.

20. Psychological Factors
 Hopelessness
 Impulsivity
 Dichotomous thinking
 Poor problem solving skills

21. Suicide & Substance Misuse
 Opioid abusers: Risk of suicide 14 X
 Prescription drug abuse: 20 X
 Cannabis uses: 4 X
 Alcoholism: 15% risk of suicide
 Older males
 Currently drinking
 Depressive symptoms
 Poor physical health
 Unemployed with little or no social support

22. Risk Factors
for Suicide
Primary
Diagnosis
D-Graph. &
Misc Personality
Co-
Morbidities Social FactorsOther Factors
Bipolar Male Borderline Subs.abuse/de
pendence
Divorced Means avail.
Schizophrenia Older age Narcissistic Alcohol
abuse/dep
Widower Hx abuse
Major Depr.
Episode
White race Antisocial Anxiety Lives alone Few reasons
Dysthymia Prior depr. or
Sui.attempts
Conduct Dis. Axis III Dx Isolated To live
Adj. Dis. w.
Depression
Fam. Hx.
Depr/attempts
Impulsive Panic Financial
Worries
Adverse events
Delirium or
Dementia
Homosex. Other losses Change of
grades
Any psychosis Suicidal
Ideation
No religion Change of
friends
Hall/delus:
espec.poverty
Hopeless/Help
less
Giving away
possessions
Agitation/desp
eration
Guns in home

23. Evaluation of Suicide
Risk
Variable High Risk Low Risk
Demographic and Social Profile
Age Over 45 years Below 45 years
Sex Male Female
Marital status Divorced or widowed Married
Employment Unemployed Employed
Interpersonal
relationship
Conflictual Stable
Family background Chaotic or conflictual Stable
Health
Physical Chronic illness Good health
Hypochondriac Feels healthy
Excessive substance intake Low substance use
Mental Severe depression Mild depression
Psychosis Neurosis
Severe personality disorder Normal personality
Substance abuse Social drinker
Hopelessness Optimism

24. Suicidal activity
Suicidal
ideation
Frequent, intense, prolonged Infrequent, low intensity,
transient
Suicide
attempt
Multiple attempts First attempt
Planned Impulsive
Rescue unlikely Rescue inevitable
Unambiguous wish to die Primary wish for change
Communication internalized (self-blame)Communication
externalized (anger)
Method lethal and available Method of low lethality or
not readily available
Resources
Personal Poor achievement Good achievement
Poor insight Insightful
Affect unavailable or poorly controlled Affect available and
appropriately controlled
Social Poor rapport Good rapport
Socially isolated Socially integrated
Unresponsive family Concerned family

26. The “SAD PERSONS” scale
1. S Sex is male
2. A Age >45 yrs or <19 yrs
3. D Depression
4. P Previous attempts
5. E Ethanol abuse
6. R Rational thinking loss (particularly psychosis)
7. S Social support is lacking
8. O Organized plan
9. NS No spouse
Score > or equal to 5 admission is advised

27. Management of a suicidal patient
 Ensure patient is safe and medically fit
 Interview: tactful and sensitive
 Establish a rapport
 Gain the patient’s trust Collateral information
 Review previous records
 Previous psychiatric History & History of DSH
 Physical examination and Investigations
 Physical health: - chronic painful conditions

28. What to focus on in the interview
 Triggers & motives for suicide (psycho-social stressors)
 impulsive or planned
 What were the thoughts prior, during and after the act
 patient’s belief about the lethality of the method used.
 Current mental state
 symptoms of mental illness
 hopelessness & helplessness
 Psychosis e.g: command hallucinations
 current suicidal ideation, intent and plans.
 Homicidal intent.

29. A high degree of suicide intent
 The act was planned and prepared
 Precautions were taken not to be found
 A dangerous method was used
 Did not seek help after the act
 Left a will or suicide note or put affairs in order.

30. Increased risk is also associated
with:
 Recently of the previous attempt
 >1 previous attempt
 Marked hopelessness
 Social isolation
 Alcohol or drug dependency
 History of psychiatric illness - depression or
schizophrenia

31. Highest risk of suicide occurs
 The presence of suicidal thoughts
 The means to commit suicide
 The opportunity.

32. Short Term Management
 Risk assessment  management plan.
 Ensure the patient’s safety & alleviate distress
 The risk can be reduced by:
 removing the means
 reducing the opportunity
 treating any associated illnesses If the patient is high risk 
admit to hospital.
 If patient refuses  admit as an involuntary patient under the
Mental Health Care Act.

33. Outpatient Treatment
patient is less risky
good social support
Carers can provide the appropriate level of supervision
They can obtain help in case of an emergency
 Seen frequently - first follow up within the first week
 Regular reviews of the suicidal risk and mental state.
 Prescribing medication: fewer side effects
less dangerous in an overdose
smaller quantities

35. Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide
or Suicidal Behaviors*
Admission generally indicated: high risk of suicide
After a suicide attempt or aborted suicide attempt if:
Patient is psychotic
Attempt was violent, near-lethal, or premediated
Precautions were taken to avoid rescue or discovery
Persistent plan and/or intent is present
Distress is increased or patient regrets surviving
Patient is male, >45 years of age, especially with new onset of psychiatric illness or
suicidal thinking
Patient has limited family and/or social support, including lack of stable living
situation
Current impulsive behavior, severe agitation, poor judgment, or refusal of help is
evident
Patient has change in mental status with a metabolic, toxic, infectious, or other
etiology requiring further workup in a structured setting
In the presence of suicidal ideation with:
Specific plan with high lethality
High suicidal intent

36. Admission may be necessary: moderate risk of suicide
After a suicide attempt or aborted suicide attempt, except in circumstances for
which admission is generally indicated in the presence of suicidal ideation with:
Psychosis
Major psychiatric disorder
Past attempts, particularly if medically serious
Possibly contributing medical condition (e.g., acute neurological disorder, cancer,
infection)
Lack of response to or inability to cooperate with partial hospital or outpatient
treatment
Need for supervised setting for medication trial or electroconvulsive therapy
Need for skilled observation, clinical tests, or diagnostic assessments that require
a structured setting
Limited family and/or social support, including lack of stable living situation
Lack of an ongoing clinician-patient relationship or lack of access to timely
outpatient follow-up
In the absence of suicide attempts or reported suicidal ideation/plan/intent but
evidence from the psychiatric evaluation and/or history from others suggests a
high level of suicide risk and a recent acute increase in risk

37. Release from emergency department with follow-up recommendations
may be possible: lesser risk
After a suicide attempt or in the presence of suicidal ideation/plan when:
Suicidality is a reaction to precipitating events (e.g., exam failure, relationship
difficulties), particularly if the patient's view of situation has changed since
coming to emergency department
Plan/method and intent have low lethality
Patient has stable and supportive living situation
Patient is able to cooperate with recommendations for follow-up, with treater
contacted, if possible, if patient is currently in treatment
Outpatient treatment may be more beneficial than hospitalization: lesser
risk of suicide
Patient has chronic suicidal ideation and/or self-injury without prior medically
serious attempts, if a safe and supportive living situation is available and
outpatient psychiatric care is ongoing

38. Psychotherapy
Many types of psychotherapy are used with suicidal patients.
The choice should be made based on the patient's underlying
illness and on empirical documentation of a treatment's
effectiveness, not on a given therapist's particular therapeutic
bias
(For example, a patient with a borderline personality disorder
will probably be better served by being treated with both
medication and behavioral therapy (preferably DBT)
The suicidal outpatient in psychotherapy generally needs to
be seen at least weekly until he or she is no longer acutely
suicidal.

39. I. Short-term psychotherapy,
II. group psychotherapy,
III.behavioral therapy,
IV.CBT,
V. DBT,
VI.interpersonal therapy,
VII.psychoanalysis,
VIII.psychoanalytically oriented psychotherapy, and
IX.multiple other psychotherapeutic approaches
have all been employed with reported success.
Among these psychotherapies, however, CBT has
amassed by far the largest evidence base of its
effectiveness

40. Pharmacotherapy
As with psychotherapy, the primary determinant of the pharmacotherapy
is the underlying disorder.
Patients with depressions are prescribed antidepressants, mood
stabilizers, and, perhaps, atypical antipsychotics;
manic patients receive mood stabilizers and antipsychotics;
psychotic patients are treated with antipsychotics;
substance-abusing patients may receive methadone, naltrexone or
disulfiram, etc.
What is different for the suicidal patient, however, is the sense of urgency
felt by the clinician to do something quickly—before the patient harms
him- or herself.
In some cases, particularly in patients with a past history of being
refractory to medication, electroconvulsive therapy (ECT) may be elected
for the depressed and suicidal patient.

41. In selecting a SSRI or SNRI antidepressant for suicidally
depressed individuals, most psychiatrists are inclined to use
those agents or combinations of agents which seem both
more potent and rapidly acting to them.
The atypical antipsychotics are seeing much broader use for
agitation and anxiety. Undoubtedly, more effective and less
problematic pharmacological treatments will be developed
for depression, and novel agents (e.g., ketamine) will be
developed and tested.
As indicated above, the 1990 to 2003 decrease in suicide rates
made investigators suspect that better identification and
pharmacological treatment of depression was responsible
although this has not unequivocally been proven.

42. Goals to Reduce Suicide
1.Promote awareness that suicide is a public health problem that is preventable
2.Develop broad-based support for suicide prevention
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 programs
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
treatment
7.Develop and promote effective clinical and professional practices
8.Improve access to, and community linkages with, mental health and substance
abuse services
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
11.Improve and expand surveillance systems

43. Conclusion
 Suicide is a significant public health problem
 Risk factors are multifactorial & multidimensional
 High index of suspicion
 Early recognition is important to prevent suicides

44. References
 Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th Edition
 Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th
Edition
 SUICIDE RISK ASSESSMENT GUIDE REFERENCE MANUAL
 Trends in rates and methods of suicide in India Sachil Kumar a,*, Anoop K. Verma b,1,
Sandeep Bhattacharya b,2, Shiuli Rathore b,
 Suicide Risk Assessment Guide A Resource for Health Care Organizations
 Suicide Risk Assessment and Management Protocols Community Mental Health Service