Suicide and its prevention for nursing students.

1. SUICIDE
PREPARED BY: REEJAN PAUDEL (Registered Nurse)

2. TABLE OF CONTENT
 Introduction of topic
 Epidemiology
 Etiology
 Risk factors
 Level of suicide
 Warning sign of suicide
 Suicide assessment
 Prevention and control of suicide
 Management of suicide

3. SUICIDE
 In simple, suicide means killing one self.
 Derived from Latin word: Sui = oneself, cidium = a killing.
 Is the model of psychiatric emergencies and is also the commonest cause of death
among the psychiatric patients.
 It is a type of deliberate self-harm (DSH) and is defined as a human act of self -
intentional and self - inflicted cessation (death).
 It ends with a fatal outcome. DSH is an act of intentionally injuring oneself, irrespective
of the actual outcome.

4. EPIDEMIOLOGY
 More than 700 000 people die due to suicide every year.
 Suicide is the fourth leading cause of death among 15–29-year-olds
 Ingestion of pesticide, hanging and firearms are among the most common methods of suicide
globally.
 Every year 703 000 people take their own life and there are many more people who attempt
suicide.
 Suicide does not just occur in high-income countries but is a global phenomenon in all
regions of the world.
 In fact, over 77% of global suicides occurred in low- and middle-income countries in 2019.

5.  As the largest continent in the World, Asia accounts for about 60% of World
suicides, with China, India, and Japan accounting for about 40% of the World’s
suicides .
 Suicide in Nepal has become a minor national issue highlighted by a series of
high-profile suicides in recent years.
 Ranked 126th by suicide rate globally by the 2015 World Health Organization
report, Nepal has an estimated 6,840 suicides annually, or 8.2 suicides per
100,000 people.
 Suicide is currently the leading cause of death for Nepalese women aged 15–
49.
 In Nepal, according to data provided by the police, over 19 people (7141
people in a year) committed suicide every day throughout the country in the
last fiscal year. The number was 6,252 in the fiscal year 2019-2020, police
statistics show.

6.  According to statistics, 5,124 people committed suicide in the FY
2073/74.
 In the FY 2074-75 BS, a total of 5,317 people committed suicide.
 In the FY 2075/76 BS, a total of 5,784 people committed suicide,
while in FY 2076/77 BS, 6,241 people committed suicide.
 In the FY that followed 7,117 people are found to have committed
suicide. "In the last year, the number of suicides increased from
eight to 14 percent.

7. ETIOLOGY
Some of the common causes of suicide include:
 Psychiatric disorders
 Physical disorders
 Psychosocial factors

8.  Psychiatric disorders
- Major depression
- Schizophrenia
- Drug or alcohol abuse
- Dementia
- Delirium
- Personality disorder
 Physical disorders
- Patients with incurable or painful physical disorders like cancer and AIDS.

9.  Psychosocial factors
 Failure in examination
 Dowry harassment
 Marital problems
 Loss of loved one.
 Isolation and alienation from social groups
 Financial and occupational difficulties.

11.  Age
 Males above 40 years of age
 Females above 55 years of age
 Sex
 Men have greater risk of completed suicide
 Suicide is 3 times more common in men than in women
 Women have higher rate of attempted suicide.
 Being unmarried, divorced, widowed or separated
 Having a definite suicidal plan
 History of previous suicidal attempts
 Recent loss

12. LEVELS OF SUICIDE
 Suicidal ideation
 Suicidal gesture
 Suicidal threats
 Suicidal attempts
 Suicide

13. Five levels of suicidal behavior
The following terms are used often in clinical setting to describe 5 levels of
suicidal thought or action:
 Suicidal ideation:
 Individual’s thinking about and inclination toward self -injury or self -
destruction.
 Suicidal ideation refers to thinking about or planning for the talking of one’s
own life.
 Suicidal thoughts may or may not lead to a suicide attempt.

14.  Suicidal gestures:
 Suicidal gestures are a person’s non - lethal self - injury acts,
including cutting or burning of skin areas or ingesting small
amount of drugs.
 People often see these gestures as “attention getting/seeking”
measures and do not consider them as serious problem and may
lead to suicide attempt or completion.
 Some of these people may die accidently during the act.

15.  Suicidal threats:
 Suicidal threats are a person’s verbal statements that may declare their intent to
commit suicide.
 Threats often precede an actual suicidal attempt.

16.  Suicidal attempt:
 Suicidal attempts are the actual implementation of a self -injuries
and act with the express purpose of ending the person’s life.
 An attempted suicide is an unsuccessful suicidal act with a non-
fatal outcome.
 This involve act such as taking fatal amount of medicine and
someone intervening accidently.
 It is believed that 2-10% of all persons who attempt suicide,
eventually complete suicide in the next 10 years.

17.  Suicide:
It is a type of deliberate self-harm and is defined as a human act
of self-intentioned and self-inflicted cessation (death). It ends
with a fatal outcome.

18.  Warning signs for suicide
About 80% of people who complete suicide give warning signs, although the
warnings may not be overt or obvious. These warning signs are following:
 Change in grades at school (sudden drop in school performance).
 Loss of interest, initiative.
 Sudden appearance of peacefulness in an agitated, depressed
 May become secretive
 Making a will for suicide
 Withdraws from family interactions.

19.  Change in personal hygiene.
 Talking about hopeless or having no reason to live.
 Taking about being a burden to others.
 Increasing the use of alcohol or drugs.
 Sleeping too little or too much & Isolates self from others.
 Talking directly or indirectly about committing suicide or wanting to die or to
kill oneself.
 Give thing away such as prized possessions.

20.  Writing a suicidal note.
 Talking about going away.
 Good byes such as “this is the last time you will see me” or I won’t need any
more appearances, calling people to say good bye.
 Engaging in self-destructive behavior (for example: drinking alcohol, taking
drugs, cutting hand).
 Neglect of personal appearances.
 Pre occupation with death or a lack of concern about personal safety.

21. SUICIDE ASSESSMENT
There are known risk factors and cumulatively they may offer a better accuracy of
prediction for suicidal risk. One method goes under the acronym SAD
PERSONS.
 S: Sex. Men are more likely to commit suicide than women. Males kill
themselves about 4 times more often, although females make more attempts.
 A: Age. The ages which are most dangerous for suicide vary over time. Less
than 20 or more than 40 years of age.
 D: Depression. The suicide rate for those who are clinically depressed is about
20 times greater than for the general population. Hopelessness is one aspect of
depression that has a close tie to suicide. These two issue, depression and
hopelessness, are the strongest prediction of wishes for a hastened death.

22.  P: Prior History. Roughly 80% of completed suicide were preceded by a prior
attempt.
 E: Ethanol Abuse. Alcohol and/or drug abuse increase risk.
 R: Rational thinking. Psychosis (‘I heard a voice saying I should kill myself’)
increases risk. Some estimates suggest that 20-40% of schizophrenia make an
attempt at some point, and the risk is highest early on in the illness.

23.  S: Support System Loss. Loss of support can vary tremendously. The death of
a relative, such as grandparents, can be another trigger for kids. Loss of a
spouse can be devastating to some.
Loss of a parent within the past 35 years increases risk of suicide.
Among older individuals, men who are widowed, and women who are
divorced or separated are at increased risk.
 O: Organized Plan. This speaks for itself. Having a method in mind creates
more risk.
 N: No Spouse. If divorced, widowed, separated, or single.
 S: Sickness. Terminal illness, such as cancer and AIDS, also carries with it a
20 fold increase in risk of suicide compared to the general population.

24. PREVENTION AND CONTROL
Suicides are preventable. There are a number of measures that can be taken at
population, sub- population and individual levels to prevent suicide and suicide
attempts. These include:
 Reducing access to the means of suicide(e.g. pesticides, firearms, certain
medicines)
 Introducing alcohol policies to reduce the harmful use of alcohol.
 Early identification, treatment and care of people with mental and substances use
disorders, chronic pain and acute emotional distress.
 Prevention strategic targeting vulnerable groups, persons suffering from
psychological trauma or abuse, young women of reproductive age, women who are
victim of gender based violence, and those who are bereaved by a suicide are
vulnerable sub groups for depression and suicidal behaviors.

25.  Depression precedes most suicides, early recognition of depression and
treatment through medication and psychotherapy are important ways of
preventing suicidal.
 Training of non-specialized health workers in the assessment and management
of suicidal behavior.
 Follow up care for people who attempted suicide and provision of community
support.
 Integrate mental health services into primary health-care services need to be
revised and put into action through strong programs.
 Education about suicide, including risk factors, warning signs, and the
availability of health.

26.  Reducing domestic violence and substance abuse are long term strategies to reduce
mental health problems.
 Reducing the quantity of dosage supply in packages of nonprescription medicine.
 Increase community awareness that suicide is a preventable public health problem.
 Receiving effective treatment for mental illness and emotional problems.
 Take all suicidal threats, gesture and/ or attempts seriously and notify a
psychiatrist.
 Any clue of suicide do not ignore. Research shows that 80% of people given clue
before committing suicide.

27.  Be aware of certain signs which may indicate that the individual may commit
suicide such as:
 suicidal threat (writing away treasured articles, giving away treasure articles)
 Appearing peaceful and happy after a period of depression
 Refusing to eat or drink, maintain personal hygiene, so notify a psychiatric or
prompt report to the treating team.

28.  Keep the environment free from potential dangers, such as razor, shoelace,
blades, knives, glass, bottles, belts, neckties, hanging wire, rope, matches and
lit cigarettes, drug/ poisons, chemicals etc. and also access to places whether
they can hang them up to jump to death.
 Do not leave the patient alone.
 Establish a good rapport and trusting relationship with the patient and
encourage communication.
 Spend some time with him, talk to him, and allow him to ventilate his feelings.
 Make sure that windows are locked or grill, so that the patient can’t open them.
 Patient should keep in constant observation and should never left alone.

29.  Have good vigilance (alert) especially during early morning hours.
 Educate patient and family about restriction and constant observation.
 The patient’s room should be certainly located preferably near the nursing
station and within view of the staff. Avoid placing the patient in room at the
end of a near an exit, elevator or stairwell.
 Keep him a in a room/toilet where it cannot be bolted from inside.
 Do not leave the drug tray within reach of the patient, make sure that the daily
medication is swallowed.
 Be alert to the possibility of the patient saving up his/her own medications or
obtaining medication or dangerous objects from patients.

30.  Assess patient when they leave the ward for tests/ therapy.
 Keep the ward drugs in cupboard under lock and key.
 Stay with the patient when he/she is meeting hygienic needs such as bathing,
shaving and cutting nails.
 Encourage the patient to participate in activities that he or she likes and does
well.
 Check the patient at frequent, irregular intervals during night, evening,
morning.
 Frequently check of patient’s side locker (patient belonging).

31.  Provide supportive, family therapy, individual psychotherapy.
 Provide information to family member about the careful
observation of the patient.
 Organize rehabilitation and follow up.
 Provide for maintenance of physical status: nutrition, elimination,
personal hygiene, sleep.

32.  Beware the high risks time (handover and takeover)
 Discharge is essential part of the planning aspect of care for the patient.
Perform a suicide risk assessment just before discharge to ensure that the
patient might have planned to commit suicide.
 Provide information to family member about the careful observation of the
patient.
 Organize rehabilitation and follow-up.

33. MANAGEMENT
Be aware of certain signs which may indicate that the individual may commit suicide, such
as:
 Suicidal threats
 Writing farewell letters
 Giving away treasured articles
 Making a will
 Closing bank accounts
 Appearing peaceful and happy after a period depression
 Refusing to eat or drink

34.  Monitoring the patient’s safety needs:
 Take all suicidal threats or attempts seriously and notify psychiatrist
 Search for toxic agents such as drugs/alcohol
 Do not leave the drug tray within reach of the patient, make sure that the daily
medication is swallowed.
 Remove sharp instruments such as razor blades, knives, glass bottles from his
environment.
 Remove straps and clothing such as belts, neckties.
 Do not allow the patient to bolt his door on the inside, make sure that
somebody accompanies him to the bathroom.
 Patient should be kept in constant observation and should never be left alone.
 Have good vigilance, especially during morning hours
 Spend time with him, talk to him, and allow him to ventilate his feelings.
 Encourage him to talk about his suicidal plans/methods.
 If suicidal tendencies are very severe, sedation should be given as prescribed.

35.  Encourage verbal communication of suicidal ideas as well as his/her fear and
depressive thoughts.
 A “no suicidal” pact may be signed, which is agreement between the patient
and the nurse, that patient will not act on suicidal impulses, but will approach
the nurse to talk about them.
 Enhance self-esteem of the patient by focusing on his strengths rather than
weakness.
 His positive qualities should be emphasized with realistic praise and
appreciation. This fosters a sense of self-worth and enables him to take control
of his life situation.

36.  Assess for vital signs, check airway, if necessary clear airway
 If pulse is weak, start IV fluids.
 Turn patient’s head and neck to one side to prevent regurgitation and
swallowing of vomitus.
 Emergency measures to be instituted in case of self-inflicted injuries.