Suicide

1. SUICIDE
DR. RITU GUNJYAL
JUNIOR RESIDENT

2. SUICIDE derived from Latin word for “ self-murder”.
defined as ‘Self inflicted death with evidence that the person intended to die.’
 It is best viewed as a symptom rather than a disease per se and it is the underlying
cause that should be found and treated.
 Some may take days, weeks or even years before acting while others act on
them impulsively. In Psychiatry, Suicide is primary emergency.
 It is impossible to predict suicide, but numerous clues can be seen.

3. IMPORTANT TERMINOLOGY
 SUICIDE ATTEMPT :Self injurious behavior with non-fatal outcome
accompanied by explicit or implicit evidence that the person intended to
die.
 ABORTED SUICIDE ATTEMPT: Attempt stopped before any physical
damage occurred.
 SUICIDAL IDEATION: Thoughts of serving as the agent of one’s own death.
 SUICIDAL INTENT: Subjective expectation and desire for self destructive
act to end in death.
 LETHALITY OF SUICIDAL BEHAVIOUR: Objective danger to life
associated with a suicide method or action.
 DELIBERATE SELF HARM: Willful self-inflicting of painful, destructive or
injurious acts without intent to die.

4. TYPES
 EGOISTIC SUICIDE applies to those who are not strongly integrated into
any social group.
 ALTRUISTIC SUICIDE applies to those susceptible to suicide stemming
from their excessive integration into a group, with suicide being the
outgrowth of the integration.eg-sati customs
 ANOMIC SUICIDE applies to persons whose integration into society is
disturbed so that they cannot follow customary norms of behaviour.eg-
suicide after bankruptcy
 FATALISTIC SUICIDE due to overregulation of a society.eg- slave commits
suicide.
 PARASUICIDE is a term introduced to describe patients who injure

5. EPIDEMIOLOGY
 A total of 1,39,123 suicides were reported in the country during 2019 showing an
increase of 3.4% in comparison to 2018
 Majority of suicides were reported in Maharashtra (18,916 )
 U.P. only 3.9% of the total suicides reported in the country

10. ETIOLOGY
 Sociological factors
 Durkheim’s theory:
According to Emile Durkheim(French sociologist) the rate of suicide is
increased when the social bonds between people in a society are either too
strong or not strong enough. Integration and regulation are the societal
factors that contribute to suicide.
 Psychological factors
 Freud’s theory- Freud stated that suicide represents aggression turned
inward against an introjected ,ambivalently cathected love object.
 Menninger’s theory: Karl Meninger conceived suicide as inverted homicide
and described 3 components of hostility in suicide :the wish to kill, the wish
to be killed, and the wish to die.

11.  Biological factors- postmortem neurochemical studies have reported
 low conc. Of 5-HIAA(metabolite of serotonin) in CSF.
 Changes in presynaptic and postsynaptic serotonin binding sites.
 Changes in Noradrenergic system of suicide victims.
 Genetic factors-
 Twin studies have shown that concordance for suicide is significantly more
frequent in monozygotic than in dizygotic twins.
 Molecular Genetic studies- Polymorphism in THP gene (tryptophan
hydroxylase enzyme), alterations in genes controlling serotonin synthesis
and metabolism.

12. SUICIDE IN PSYCHIATRIC
DISORDERS
It has been studied that 95% of people who commit or attempt suicide have
one or the mental disorder:
 Depression 60- 70% (attempted suicide)
 Alcohol/Substance dependence upto 15%
 Schizophrenia upto 10%
 Antisocial personality disorder 5%
 Dementia & Delirium 5%
 Anxiety Disorder 20% (uncompleted suicide attempt)

13. SUICIDE IN NON-PSYCHIATRIC
DISORDERS
1. Diseases of the nervous system
1. Multiple sclerosis
2. Huntington’s disease
3. Brain and spinal cord injury
4. Seizure disorders
2. Malignant neoplasms
3. HIV/AIDS
4. Peptic ulcer disease
5. COPD
6. Chronic hemodialysis -treated renal failure
7. SLE
8. Pain syndromes
9. Functional impairment

14. ASSESSMENT
Patients history, current circumstances, mental state and direct questioning
about suicidal thinking and behaviors are asked
1. Identify specific psychiatric signs and symptoms
 Assess mood, anhedonia, hopelessness, anxiety (level of symptoms/panic
attacks), agitation, global insomnia, fearfulness, aggression, violence toward
others, and impulsiveness

15. 2. Assess past suicidal behavior, including intent of self-injurious
acts
 Obtain details about the precipitants, timing, intent, consequences as well as
well as the potential lethality of the attempt.
Also, assess patient’s thoughts about the attempt which includes:
 Ones own perception of the chosen method’s lethality
 Ambivalence toward living, visualization of death,
 Degree of premeditation
 Persistence of suicidal ideation, and reaction to the attempt

16. 3. Review past treatment history and treatment relationships
 It can help in identifying medically serious suicide attempts
 Also, about the status of past or current medical diagnoses that may be
associated with augmented suicide risk.
4. Identify family history of suicide, mental illness, and
dysfunction
 Includes details of family conflict or separation, parental legal trouble, family
family substance use, domestic violence, and physical and/or sexual abuse
 As, many aspects of family dysfunction might linked to self-destructive
behaviors

17. 5. Identify current psychosocial situation and nature of crisis
 Detect any financial or legal difficulties, interpersonal conflicts or losses,
stress related to housing problems, job loss, educational failure
 Their understanding also helps in mobilizing external supports, which can
have a protective influence on suicide risk.
6.Appreciate psychological strengths and vulnerabilities of the
individual patient
 May include factors as coping skills, personality traits, thinking style, and
developmental and psychological needs.

18. SPECIFICALLY INQUIRE ABOUT SUICIDAL
THOUGHTS, PLANS, AND BEHAVIORS
 It is essential as, the more an individual has thought about suicide, has made
specific plans for suicide, and intends to act on those plans, the greater will
be the risk
1. Elicit the presence or absence of suicidal ideation (one of
essential component )
 At enquiry, it is important to focus on the nature, frequency, extent, timing
of suicidal thoughts and to understand the interpersonal, situational, and
symptomatic context in which they are occurring

19. 2. Elicit the presence or absence of a suicide plan
 If suicidal ideation is present, then detailed information about specific
plans for suicide and any steps that have been taken toward enacting
plans
 Some suicidal acts can occur impulsively with little or no planning, more
detailed plans are generally associated with a greater suicide risk

20. 3. Assess the degree of suicidality, including suicidal intent
and lethality of plan
 Regardless of whether the patient has developed a suicide plan, the
patient’s level of suicidal intent should be explored
 In general, the greater and clearer the intent, the higher the risk for suicide
will be.

21. ESTIMATE SUICIDE RISK
 The goal is to identify factors:
 That may increase or decrease a patient’s level of suicide risk
 To estimate an overall level of suicide risk, and
 To develop a treatment plan that addresses patient safety and modifiable
contributors to suicide risk.

22. TOOLS
 Beck Scale for suicidal ideation (SSI) -19 ITEM . Each item is rated on a 3
point scale from 0 to 2, total score 38
 Columbia suicide severity rating scale (C_SSRS) – two domains of suicidal
ideation and suicidal behavior,each is rated on a 5point ordinal scale.2
 SAD PERSONS scale for assessment of suicide risk- Each risk factor is given
1 point, for a maximum 10 points.
 Becks suicidal intent scale – 20 items each scoring 1 to 3 points.
 Suicide risk assessment scale of Ducher (RSD)- It comprises of 11 ascending
levels. As the level increases, there are suicide thoughts with a desire to die

23. TREATMENT SETTINGS

25. MANAGEMENT
 Establish and maintain a therapeutic alliance
 Attend to the patient’s safety
-Strict vigilance of the suicidal patient
-No access to dangerous objects
-Medication must be monitored and given by family members
 Medical evaluation, lab tests
 Determine a treatment setting - setting that is most likely to prove safe
and effective.
 Develop a plan of treatment
- more intense follow-up in the early stages
- address substance use disorders
- review of suicidal tendencies or other symptoms
that may occur between sessions.

26.  Positive psychotic symptoms, hostility, bizarre behaviour, tension,
uncooperativeness, excitement and motor hyperactivity should be treated
aggressively
 Education regarding available treatment options will help patients make
informed decisions, anticipate side effects, and adhere to treatments.
 Psycho-educate about the role of psychosocial stressors and other
disruptions in precipitating or exacerbating suicidality or symptoms of
psychiatric disorders
 Reassess safety and suicide risk
- due to waxing and waning nature of suicidality
- if intoxicated when initially interviewed
- increase in suicide risk may occur as depressive
symptoms begin to lift.
 Monitor psychiatric status and response to treatment.

27. ANTI-DEPRESSANTS
 Mainstay of the treatment of patients suffering from anxiety and
depressive illness
 Controversial results especially regarding SSRI’ s
 Particularly close follow up to identify emerging suicidal risks
 Cover with benzodiazepines
 Non-tricyclic, non-MAOI antidepressants are relatively safe
 Although the tricyclic antidepressants and MAOIs are much more toxic in
overdose, but useful in patients not responding to SSRI

28. LITHIUM
 Strong and consistent evidence that it helps in major reductions in risk of
both suicide and suicide attempts
MOOD STABILIZING AGENTS
 No established evidence of a reduced risk of suicidal behavior with any other
other “mood-stabilizing” anticonvulsants
ANTIPSYCHOTIC AGENTS
 the antipsychotic medications have been the mainstay of somatic treatment
for suicidal patients with psychotic disorders.
 Clozapine: reduced rate of suicidal attempts
ANTI-ANXIETY MEDICATIONS
 Since anxiety is a significant and modifiable risk factor for suicide, utilization
of antianxiety agents may have the potential to decrease this risk.

29. ELECTROCONVULSIVE
THERAPY(ECT)
 ECT is used to treat patients who are acutely suicidal, considered for patients
for whom a delay in treatment response is considered life-threatening
 Efficacy of ECT is best established in patients with severe depressive illness,
manic or mixed episodes of bipolar disorder, schizoaffective disorder, or
schizophrenia

30. PSYCHOTHERAPIES
 In addition to medications and ECT, psychotherapies play a central role in
the management of suicidal behavior in clinical practice.
 Cognitive behavior therapy, dialectical behavioral therapy, psychodynamic
therapy, and interpersonal psychotherapy have been found effective in
clinical trials for the treatment of various disorders.
 By targeting deficits in specific skills, such as emotional regulation, impulse
control, anger management, and interpersonal assertiveness, these therapies
helps in reducing suicide attempts.

31. SUICIDE PREVENTION
 Measures to obtain accurate statistics regarding epidemiology.
 Creating awareness about causes and prevention to public and health care
professionals.
 Public health education through mass media.
 Identifying high risk groups.
 Creation of crisis intervention centres in vulnerable places and times

32. Suicide and MHA 2017
 Under MHA 2107 section 115,
 Presumptive of severe stress in case of attempt to commit suicide, states that
 “any person who attempts to commit suicide shall be presumed, unless
proved otherwise, to have severe stress and shall not be tried and punished.”
 “the appropriate Government shall have a duty to provide care, treatment
and rehabilitation to a person, having severe stress and who attempted to
commit suicide, to reduce the risk of occurrence of attempt to commit
suicide.”

33. 24X7 TOLL-FREE MENTAL HEALTH
REHABILITATION HELPLINE KIRAN (1800-599-0019)
LAUNCHED IN 13 LANGUAGES
 By DEPwD, Ministry of Social Justice and Empowerment to provide relief and
support to persons with Mental Illness and in view of the growing incidence of
mental illness, particularly in the wake of Pandemic COVID-19 on august 2020.
 It is backed by 660 Clinical / Rehabilitation Psychologists and 668 Psychiatrists..
 The objectives of the helpline are Early Screening; First Aid; Psychological support;
Distress management; mental well-being; preventing deviant behaviors;
Psychological crisis management and Referral to mental health experts.

34. THANK YOU