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Presenter:Dr.Santhosh Goud 
DNB Resident 
Chairperson:Dr.P.Krishna mohan 
MD DPM
 Suicide(Latin suicidium, from sui caedere, "to kill 
oneself") 
 Suicide attempted/DSH/para suicide 
Unsuccessful but potentially lethal action 
 Suicide cluster/Copycat suicide 
Individuals or groups committing suicide after 
publicity about suicide of acquaintances or 
public figures 
 Suicide pact 
agreement or pledge between two or more 
persons to take their own lives simultaneously
 Suicidal ideation is any self-reported thoughts 
of engaging in suicide-related behavior 
 To have suicidal intent is to have suicide or 
deliberate self-killing as one's purpose. 
 This is contrasted with suicidal motivation, or 
the driving force behind ideation or intent, 
which need not be conscious.
 Suicide-suicide is conscious act of self induced 
annihilation, best understood as a multi-dimensional 
malaise in a needful individual, 
who defines an issue for which suicide is 
perceived as the best solution(Shneidman) 
 Suicide is the intentional act of self destruction 
committed by someone knowing what he is 
doing and knowing the probable consequences 
of his action. The verdict of suicide should be 
supported with evidence. It can never be 
presumed(Legal)
 Suicidal act is the injury with varying degrees of lethal 
intent, and suicide is defined as a suicidal act with fatal 
outcome(WHO,1968) 
 Suicide -Death caused by self-directed injurious 
behavior with any intent to die as a result of the 
behavior(CDC). 
 The Government of India classifies a death as suicide 
if it meets the following three criteria: 
 It is an unnatural death, 
 the intent to die originated within the person, 
 there is a reason for the person to end his or her life. 
The reason may have been specified in a suicide note 
or unspecified
 Males>Females 
 Men 10 years earlier than females(45-55) 
 Whites>Black(India north<south) 
 Protestants>Catholics (orthodoxy is a protecting factor) 
 Divorced>never married>married(children are protecting factor) 
 Higher social status 
 Sexual orientation-elevated suicide risk among gay and lesbian 
people 
 Physical Illness-Psychosomatic illness 
 Occupation- Physicians >other professions 
 Retirement and unemployment 
 Season- greatest during the late spring and early summer 
months, despite the common belief that suicide rates peak during 
the cold and dark months of the winter season
 According to the World Health Organization, 
approximately one million people die by 
suicide worldwide every year, 
 The global suicide rate is 16 per 100,000 
population 
 The suicide rate varies from 0.5/100,000 in 
Jamaica to 75.6/100,000 in Lithuania for men 
and from 0.2/100,000 in Jamaica to 
16.8/100,000 in Sri Lanka for women
 The number of suicides in the country during the 
decade (2002–2012) has recorded an increase of 
22.7% (1,35,445 in 2012 -1,10,417 in 2002). 
 India in 2012 had nearly 2.6 lakh suicides, 
dwarfing China's 1.2 lakh. 
 The rate of suicides has shown a declining trend 
since 2002 to 2003 and thereafter an increasing 
trend is observed during 2005 to 2010. However, it 
was declined in 2011(from 11.4 in 2010 to 11.2 in 
2011) and remained static in 2012. 
 South Indians accounting for a rate above 15 and 
North Indians below 3
 Puducherry reported the highest suicide rate at 36.8 
per 100,000 people, followed by Sikkim, Tamil Nadu 
and Kerala 
 The lowest suicide rates were reported in Bihar (0.8 per 
100,000), followed by Nagaland, then Manipur. 
 In India, about 46,000 suicides occurred each in 15-29 
and 30-44 age groups in 2012 - or about 34% each of all 
suicides 
 Poisoning (33%), hanging (31%) and self-immolation 
(9%) were the primary methods used to commit suicide 
in 2012 
 80% of the suicide victims were literate, higher than the 
national average literacy rate of 74%
 In the year 2012, Chennai reported the highest total 
number of suicides at 2,183, followed by Bengaluru 
(1,989), Delhi (1,397) and Mumbai (1,296). 
 Jabalpur (Madhya Pradesh) followed by Kollam 
(Kerala) reported the highest rate of suicides 45.1 
and 40.5 per 100,000 people respectively, about 4 
times higher than national average rate. 
 West Bengal reported 6,277 female suicides, the 
highest amongst all states of India, and a ratio of 
male to female suicides at 4:3
 In 2012, family problems and illness were the 
two major reasons for suicides, together 
accounting for 46% of all suicides. Drug abuse 
addiction (3.3%), love affairs (3.2%), 
bankruptcy or sudden change in economic 
status (2.0%), poverty (1.9%) and dowry 
dispute (1.6%) were the other causes of suicides
 Sociological approach 
 Psychological approach 
 Biological aspects 
 Psychiatric approach
• Emile Durkheim (1867) 
Le Suicide. Etude de 
Sociologie 
• Each society has a specific 
tendency toward suicide 
• Refuted contribution of 
individual factors 
• Social integration / 
Social regulation
 Aaron T. Beck – Cognitive Theory 
 Cognitions = Mental processes that are involved 
in information gathering, thinking, remembering 
etc and exists in three forms: 
- Dysfunctional automatic thoughts skew 
perceptions of self, others and future 
- Schemas: framework or concept that helps 
organize the information gathered
 Post-mortem studies have shown changes in 
central neurotransmission of serotonin, nor-adrenaline 
and post-synaptic signal transduction 
 Dysfunction of Hypothalamic-pituitary-adrenal 
axis (stress response) predicts suicide in depressed 
patients 
 Increased suicide risk associated with low 
cholesterol levels 
 Reduced 5-HIAA levels in CSF of depressed 
patients who suicide
 Family history of suicide increases the risk two-fold especially in 
women and children independent of family psychiatric history 
 Concordance rates of suicide higher among monozygotic twins 
 Adoption studies: a greater risk of suicide among biologic rather 
than adoptive relatives. 
 Genetic factors account for 45% of suicidal thoughts and behaviors: 
7 types of genes have been focused on serotonin transporter(SERT), 
tryptophan hydroxylase (TPH) 1 and 2, three serotonin receptors (5- 
HTR1A, 5-HTR2A, and 5-HTR1B), and the monoamine oxidase 
promoter(MAOA)
Combines psychological and biological factors 
Holmes & Rahe 1967
Holmes & Rahe 1967 
STRESS DIATHESIS 
 A force that disrupts the 
equilibrium or normal 
functioning of an individual’s 
mental or physical state. 
Different types of stressors may 
precipitate suicidal behavior. 
Negative Life events 
Acute substance intoxication 
Acute psychiatric condition 
 Innate vulnerability or 
predisposition (in the form of 
traits) for developing the 
suicidal state 
Familial / genetic influences 
Chronic multiple psychiatric problems 
Hopelessness 
Being male / loneliness
 Study by S.Gupta and C.L. Pradhan more 
family conflicts and broken love affairs in 
suicide attempters vs financial issues and death 
of close family member in people having only 
suicidal ideations 
(Indian journal of preventive and social medicine 
vol.38 no.3&4, 2007)
 The primary and necessary mental state called 
'idiozimia' by Federico Sanchez (from 
idios=self and zimia=loss) followed by suicidal 
thoughts, hopelessness, loss of will power, 
hippocampal damage due to stress hormones, 
and finally either the activation of a suicidal 
belief system, or in the case of panic or anxiety 
attacks the switching over to an anger attack, 
are the converging reasons for a suicide to 
occur
 90% of suicides can be traced to depression, 
linked either to manic-depression (bipolar), 
major depression (unipolar), schizophrenia or 
personality disorders, particularly borderline 
personality disorder 
 Anorexia nervosa has a particularly strong 
association with suicide: the rate of suicide is 
forty times greater than the general population
 Mental state 
 affective state of hopelessness, 
 severe anger and hostility, or with agitation, 
anxiety, fearfulness, or apprehension 
 Specific psychotic symptoms, such as 
grandiose delusions, delusions of thought 
insertion and mind reading 
 Command hallucinations??
Predictors of risk 
 Direct statement 
 Plan 
 Past attempts 
 Indirect behaviors and gestures 
 Depression
 Helps in short-term management of problematic emotions 
 Stress-relieving function 
 Consequences – disapproval by others and a sense of inability to 
solve problems 
 Regulation of unpleasant self-states (eg. depersonalization) 
common to people experiencing trauma 
 Sense of mastery and control for people who feel powerless or out 
of control 
Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
 Re-enactment of past experience of trauma or 
abuse 
 Feelings of being evil and bad common 
 Self-punishment for being bad 
Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
 For people who have past experiences of trauma and abuse and 
there was no recognition of it or they were actively denied by 
people around them 
 Way of testifying to the experience – remembering it 
 Linehan (1993) – Chronic invalidation: feelings are bad or wrong 
 Miller (1994) – “Men act out while women act out by acting in” 
Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
 A way of communicating distress not heeded by words 
 To care for the person who has harmed 
 To keep others at a distance 
 To make the person cared about feel guilty 
Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
 Simeon et al. (1992) found that people who self-injure tend to be extremely 
angry, impulsive, anxious, and aggressive, and presented evidence that some of 
these traits may be linked to deficits in the brain's serotonin system 
 Favazza (1993) refers to this study and to work by Coccaro on irritability to 
posit that perhaps irritable people with relatively normal serotonin function 
express their irritation outwardly, by screaming or throwing things; people with 
low serotonin function turn the irritability inward by self-damaging or suicidal 
acts 
 Zweig-Frank et al. (1994) also suggest that degree of self-injury is related to 
serotonin dysfunction 
 Steiger et al. (2000), in a study of bulimics, found that serotonin function in 
bulimic women was significantly lower in bulimics who also engaged in self-harm
 Rare genetic syndrome – Lesch-Nyhan (HG-PRT deficiency) 
 Large turnover of purines 
 Characterized by self harm 
 Link largely still unclear
Suicidal behavior disorder 
 With in last 24 months the individual has made suicide 
attempt 
 The act does not meet criteria for non suicidal self injury 
 Not applied to suicidal ideation or to preparatory acts 
 The act was not initiated during a state of delirium or 
confusion 
 The act was not undertaken solely for a political or religious 
objective 
Specifiers -current:not more than 12 months since last 
attempt 
in early remission:12-2 months since last attempt 
Degree of lethality-violent/non-violent
Non suicidal self-injury 
 In the last year, the individual has, on 5 or more days, 
engaged in intentional self-inflicted damage to the 
surface of his or her body, of a sort likely to induce 
bleeding or bruising or pain (e.g., cutting, burning, 
stabbing, hitting, and excessive rubbing), for purposes 
not socially sanctioned (e.g., body piercing, tattooing, 
etc.), but performed with the expectation that the injury 
will lead to only minor or moderate physical harm 
 The individual engages in the self injurious behavior 
with one or more of the following expectations 
 To obtain relief from a negative feeling or cognitive 
state 
 To resolve an interpersonal difficulty 
 To induce a positive feeling state
 The intentional injury is associated with at least 2 of the 
following:(1)psychological precipitant: interpersonal 
difficulties or negative feelings or thoughts, such as 
depression, anxiety, tension, anger, generalized 
distress, or self-criticism, occurring in the period 
immediately prior to the self-injurious act,(2)urge: 
prior to engaging in the act, a period of preoccupation 
with the intended behavior that is difficult to 
resist,(3)preoccupation: thinking about self-injury 
occurs frequently, even when it is not acted upon, 
(4)contingent response: the activity is engaged in with 
the expectation that it will relieve an interpersonal 
difficulty, negative feeling, or cognitive state, or that it 
will induce a positive feeling state, during the act or 
shortly afterwards 
 The behavior is socially not sanctioned and is not 
restricted to picking a scab or nail biting 
 Its consequences cause clinically significant distress or 
interference in interpersonal academic or other 
important areas of functioning
 Chapter XX External causes of morbidity and 
mortality 
 X60-X84(includes purposely self-inflicted 
poisoning or injury; suicide) 
 X60-69 –intentional poisoning… 
 X70-X82- intentional self harm by…methods 
 X83-intentional self harm by other specified 
means 
 X84-intentional self harm by unspecified means
 The behavior does not occur exclusively during 
states of psychosis, delirium, or intoxication. In 
individuals with a developmental disorder, the 
behavior is not part of a pattern of repetitive 
stereotypies. The behavior cannot be accounted 
for by another mental or medical disorder (i.e., 
psychotic disorder, pervasive developmental 
disorder, mental retardation, Lesch–Nyhan 
syndrome, stereotyped movement disorder 
with self-injury, or trichotillomania)
 Rating scales 
 Psychological autopsy-A procedure for 
investigating a person's death by 
reconstructing what the person thought, felt, 
and did before death, based on information 
gathered from personal documents, police 
reports, medical and coroner's records, and 
face-to-face interviews with families, friends, 
and others who had contact with the person 
before the death
 SSI/MSSI-The Scale for Suicide Ideation (SSI) 
was developed in 1979 by Aaron Beck 
 Suicide Intent Scale (SIS)- assess the severity of 
suicide attempts 15 questions which are scaled 
from 0-2 
 Suicide Behaviors Questionnaire- Linehan in 
1981 
 1988 it was transformed from a long 
questionnaire to a short four questions that can 
be completed in about 5 minutes
 Life Orientation Inventory- The Life Orientation 
Inventory (LOI) is a self-report measure that comes 
in both a 30 question and 110 question form 
 Reasons For Living Inventory- It was developed 
in 1983 by Linehan et al. and contains 48 items 
answered on a Likert scale from 1 to 6. The 
measure is divided into six subscales: survival and 
coping beliefs, responsibility to family, child 
concerns, fear of suicide, fear of social disproval, 
and moral objections
1.Alcohol 
2.Anti social behavior 
3.Previous IP care 
4.OP care 
5.Previous attempts resulting in hospital 
admission 
6.Not living with relatives 
 Score 0:only 5%risk of repeating within a year 
 Score 5 :50% risk of repeating within a year
48 
Level of concern 
about potential 
suicidal behavior: 
Sum of items 
coded as 
present 
Suicide 
risk factor groups: 
Lowest concern 0 1. Any history of a suicide attempt 
Some concern 1-2 2. Long-standing tendency to lose temper or become 
aggressive with little provocation 
Increased concern 3-4 3. Living alone, chronic severe pain, or recent (within 
3 months) significant loss 
High Concern 5-7 4. Recent psychiatric admission/discharge or first 
diagnosis of MDD, bipolar disorder or schizophrenia 
5. Recent increase in alcohol abuse or worsening of 
depressive symptoms 
6. Current (within last week) preoccupation with, or 
plans for, suicide 
7. Current psychomotor agitation, marked anxiety or 
prominent feelings of hopelessness
Predisposing factors 
 Disturbed family background 
 Drug and alcohol abuse 
 Conduct disorder/anti social behavior 
 Physical illness 
 Losing the parent before age 13 
Precipitating factors 
 Break in relationship 
 Exposure to someone who died violently 
 High frequency of moves
 Hopelessness 
 Intoxication 
 Clinical syndromes 
 Sex, age, race 
 Religion 
 Living alone 
 Lack of sense of belonging
 Bereavement 
 Unemployment 
 Health status 
 Impulsivity 
 Rigid thinking 
 Stressful events 
 Release from hospital
 Common in females 
 Young people(<35yrs) 
 Low social class, deprived back ground, ower 
crowding 
 Impulsivity 
 Premenstrual syndrome in females
 Based on a stress-diathesis model of suicidal 
behavior 
 Acts to modify reactions to stressors both 
acutely and chronically in the context of 
vulnerability (i.e. positive diathesis). 
 The treatment includes a 12-week acute phase 
and a continuation phase, over 6 months of 
contact. 
 CBT-SP is primarily individual therapy but 
also includes family interventions as needed to 
reduce the suicide risk.
Mainly works on deficits the 
abilities or motivations to 
cope with suicidal crises.
 These risk factors are identified by conducting 
a detailed chain analysis of the sequence of 
events, and their reactions to these events, that 
led to the suicidal crisis. 
 A core feature of the treatment is the 
development of an individualized case 
conceptualization that identifies problem areas 
to be targeted and the specific interventions to 
be employed during periods of acute emotional 
distress.
Addressing Family/milieu risk factors 
Focus on problematic romantic relationships, 
physical, verbal or sexual abuse, dysfunctional 
family beliefs, high expectations and low 
reinforcement, or poor work performance and 
incorporates specific family /milieu therapy 
techniques to address these contextual 
concerns
CBT-SP phases 
 1)Acute phase 12-16 weekly sessions 
 Mostly individual sessions 
 6 family sessions 
 (+ Family “check-ins” (5–15 minutes) may also be conducted ) 
 initial phase, a middle phase, and an end of acute treatment phase 
 2)Continuation phase 
 12 weeks up to 6 sessions that are tapered in frequency. 
 Additionally, there may be up to three family sessions during the 
continuation phase 
 Total duration 6 months.
 occurs during the first three sessions 
 consist of five main components: Chain 
Analysis, Safety Planning, Psycho education, 
Developing Reasons for Living and Hope, Case 
Conceptualization.
Chain analysis 
Safety planning& Psycho 
education 
Developing reasons for 
living &Case 
conceptualization
Chain analysis 
 The basic strategy that sets the framework for the 
CBT-SP is a detailed chain analysis of events 
associated with the index suicide attempt or 
suicidal crisis. 
 The chain analysis includes identification of 
vulnerability factors and activating events 
associated with the crisis as well as the’ thoughts, 
feelings and behaviors in reaction to these events. 
 To conduct a chain analysis of a suicide attempt, 
the therapist asks the person to describe the events 
that led to and followed the suicide attempt as well 
as the details of the actual attempt.
Outcomes of chain analysis 
 Developing rapport actively 
 Engages patient in treatment 
 facilitates the development of a 
conceptualization of patients’ suicidality and 
assessment of future risk 
 it gives patients the opportunity to feel 
understood and counteract a frequent feeling 
that the suicidal behavior “just happened
Safety Planning 
 Safety planning is a technique to help patients remain 
safe and not to engage in further suicidal behavior, at 
least until the next therapy session. 
 The intent of safety planning is to help individuals 
lower their imminent risk for suicidal behavior by 
consulting this pre-determined set of potential coping 
strategies and list of individuals or agencies whom 
they may contact. 
 Given that the highest risk period for a re-attempt is 
shortly after the indexed attempt, as well as during 
during the time immediately following discharge 
from inpatient treatment, it is essential to develop a 
safety plan early in treatment for high suicide risk 
patients who are being treated as outpatients.
 The safety plan includes a stepwise increase in 
the level of intervention from internal (“within-self”) 
strategies to external (“outside-self”) 
strategies. 
 Internal strategies- a list of activities that the 
patient could do to cope with suicidal urges 
without the assistance of other people. 
 External strategies- a range of behaviors from 
receiving help from friends or family members 
to emergency psychiatric evaluation and 
possible hospitalization.
 The safety plan is always written and kept 
where it can be retrieved during times of crises. 
 Family members, especially spouse & parents, 
may be involved in the safety planning. The 
therapist and patient collaborate on how the 
family can be helpful in supporting the patient 
to use the safety plan. 
 It is important to discuss with the patient and 
family members the elimination of any 
potential lethal means in the patient’s 
environment.
 For the initial session, there may not be 
sufficient time to develop a full elaboration of 
the safety plan based on a chain analysis. 
However, it is essential to develop a 
rudimentary safety plan and chain analysis, 
both of which are elaborated in later sessions. 
 Thus, the first session always includes a 
written safety plan and is further modified in 
subsequent sessions as more information was 
gathered through a more detailed chain 
analysis.
Psycho education 
 explain to the patient and family members the 
nature of suicidal behavior, the role of 
depression and the need for securing potential 
lethal means 
 Inputs from family members for chain analysis 
and making safety plan
Addressing Reasons for Living and Building Hope 
 Given that hopelessness is often associated with 
suicide risk, it is important to include treatment 
strategies that instill a sense of hope. 
 Discuss the patient’s personal reasons for living. 
 Delineating reasons to live is an important activity 
because learning to cope with suicidal urges is rather 
empty if there are no reasons to want to cope. 
 The therapist should explain how recalling reasons to 
stay alive may be impaired during a crisis. The ability 
to recall reasons for living can be used as a specific 
coping strategy in distressing times.
 The patient is also encouraged to construct a 
“Hope Kit,” a concrete implementation of the 
patients’ reasons to stay alive. 
 The kit serves as a memory aid to be used in 
times of crisis, can help to increase hopefulness 
about the future and provide reminders about 
patients’ sense of purpose. 
 Hope kits can contain pictures of loved ones, 
reminders of aspirations and places that give 
them pleasure (e.g. seashells, picture of 
mountains).
Case Conceptualization 
 Following the first two sessions, the therapist develops a case 
conceptualization based on the chain analysis. As mentioned 
earlier, the therapist identifies the specific cognitive, behavioral, 
affective, and contextual problems that were identified during the 
chain analysis and then selects corresponding strategies to address 
these problems. 
 The therapist and patient discuss the specific goals for reducing 
suicidal risk and then discuss the suggested approach in a 
collaborative manner. Adjustments to the treatment plan are made 
for each patient. The prioritization of specific skills training should 
include those skills that are most likely to prevent a subsequent 
suicide attempt and that build on the adolescent’s existing 
strengths. Once the interventions are collaboratively selected by 
the therapist and patient, the treatment plan is presented to the 
family for feedback.
 During the middle phase of acute treatment 
(approximately sessions 4–9), after the 
immediate suicidal crisis has resolved, the 
primary area of intervention is behavioral 
and/or cognitive skills training using 
individual or family sessions. Skills training is 
included as a series of optional individual and 
family modules. These modules are presented 
below.
Individual Skill Modules 
 Individual skill modules include: (1) 
Behavioral activation and increasing 
pleasurable activities; (2) Mood monitoring, (3) 
Emotion regulation and distress tolerance 
techniques; (4) Cognitive restructuring; (5) 
Problem solving; (6) Goal setting; (7) 
Mobilizing social support; and (8) 
Assertiveness skills.
Family Skill Modules 
 The goal of CBT-SP’s family intervention is 
focused on reducing suicide risk by 
encouraging family support; improving the 
family’s problem solving skills; and modifying 
the family’s communication patterns. 
 The family modules may be implemented as 
part of or as adjunctive to the corresponding 
individual module, or they may be 
implemented during a distinct, separate 
session.
 The majority of CBT-SP sessions are devoted to introducing and teaching 
new skills and uses multiple modalities to assist the patient to learn the 
relevant skill. 
 These include presenting the rationale, explaining and teaching the skill, 
using role-play during the session to rehearse the skill, and working 
collaboratively to develop a homework assignment so that the new skill 
can be used in the patient’s life. 
 Each session ends with a summary and a collaborative agreement about 
a homework assignment. 
 The therapist helps the patient to summarize the key points that have 
been raised or the key elements of new learning that appear to be relevant 
to prevent recurrence of suicidal behavior. 
 In the first few sessions, the therapist may be very active in summarizing 
the content of the session but it is important for the patient to do it by 
him- or herself as the therapy proceeds. In addition, it is very important 
for the therapist to elicit feedback throughout the session and at the end 
of the session. Feedback helps the therapist to understand those aspects of 
the session that were perceived to be most helpful and to address any 
issues that may have been upsetting for the patient.
 The final component of the acute intervention 
phase includes a relapse prevention task. Once 
patients have successfully completed the 
relapse prevention task, the continuation phase 
is conducted.
 Relapse Prevention Task 
 This module, conducted at approximately sessions 
10 to 12, usually marks the end of the acute phase 
of treatment. The relapse prevention task is an “in-vivo” 
guided-imagery technique to test the efficacy 
of the acquisition of skills and coping capabilities 
in preventing suicidal behavior in the future. If the 
patient has difficulty completing the relapse 
prevention task, the therapist and patient identify 
obstacles to its completion and may review 
previously taught skills or add new skills.
 The relapse prevention task includes five steps: 
(1) Preparation, (2) Review of the Indexed 
Attempt or Suicidal Crisis, (3) Review of the 
Attempt or Suicidal Crisis using Skills, (4) 
Review of a Future High Risk Scenario, and (5) 
Debriefing and Follow-up.
 They are told that by imagining the suicide attempt and 
reliving the pain that was experienced, patients will have 
the opportunity to assess whether the coping skills learned 
in therapy can be recalled. 
 During the review of the indexed attempt or suicidal crisis, 
the patient is asked to imagine the sequence of events that 
led to the index suicide attempt and the associated thoughts 
and feeling leading up to and following the suicide attempt. 
 Next, the clinician again leads patients through the same 
sequence of events, but this time the therapist encourages 
the patient to imagine using the skills learned in therapy to 
cope with the events, feelings and thoughts. 
 As they imagine the chain, patients are asked to describe the 
sequence of events and coping skills out loud and using the 
present tense. Patients are encouraged to rehearse applying 
the skills learned in therapy to the situation described in the 
chain analysis to result in a better outcome.
 During the next step, patients are encouraged to imagine, 
and describe in detail, a future scenario that could lead to a 
suicidal crisis. 
 A crucial part of the task is for patients to anticipate when 
and how they can apply the skills learned in therapy in 
future situations. 
 Finally, debriefing is conducted after the relapse prevention 
task has been completed and follow-up plans are 
formulated. Patients are provided with support and 
encouragement for conducting this task. In addition, 
feedback should be obtained from patients. At the end of the 
intervention and in the following sessions the therapist and 
patient review the changes the patient has made over the 
course of treatment and the skills he/she have learned. It is 
crucial that they also review the safety plan before patients 
leave the relapse prevention session.
Continuation Phase 
 During the continuation phase, the therapist may 
introduce new skills or continue to help the patient 
or family to learn and implement the skills 
introduced in the acute phase. The termination 
sessions include explicit discussion of reactions to 
the conclusion of treatment, review of successful 
strategies that were learned in the therapy and the 
goals that were accomplished as well as a 
discussion of whether treatment is needed for 
other problems the patient may be experiencing.
 In this final phase, the therapist also encourages the patient 
to identify specific anticipated difficult or stressful situations 
and review the use of the new skills as they would apply to 
these future situations. It is important to prepare the patient 
for mood fluctuations and setbacks and discuss specific 
signs of personal risk that have been identified through the 
chain analysis and the course of treatment with the patient. 
The importance of continuation or maintenance treatment 
for both partially and fully recovered patients should be 
emphasized. Issues surrounding ending treatment also 
should be discussed with the family and include: (1) Review 
of warning signs of depressive symptoms and suicidal 
crises, (2) Goals achieved in therapy, (3) Impact of treatment 
on the rest of the family, (4) Strategies for handling possible 
future episodes, and (5) The current need for further 
treatment.
developed by Marsha M. Linehan, a psychology 
researcher at the University of Washington, to 
treat people with borderline personality 
disorder(BPD) and chronically suicidal 
individuals
Emotional 
mind 
Logical 
mind 
Wise 
mind
 Core mindfulness-experiencing the event as it 
is with a relaxed mind(taught by deep 
breathing skills) 
 Interpersonal skills 
 Emotional regulation skills-not controlling: 
learning how to express ones negative 
emotions and how to process them 
 Distress tolerance-how to cope up crisis
 Doctors have the highest rate of suicide 
among all the professions. In the US every year, 
between 300 and 400 physicians take their own 
lives. And, in sharp contrast to the general 
population, where male suicides outnumber 
female suicides four to one, the suicide rate 
among male and female doctors is the same
 The rate of suicidal deaths among doctors is 2-4 
per cent as against only about 1-2 per cent 
among general population. 
 Male physicians have a 70 per cent higher 
suicide rate than males in other professions; 
and female physicians have a 400 per cent 
higher rate than females in other professions
 Doctors face severe mental stress and strain. 
This is usually more than what an average 
person experiences. this results in mental and 
physical strains. If these stress and strains are 
not managed properly and there are various 
precipitating factors, they can manifest as 
depression, and under this depressed state the 
doctors try or commit suicide
 Stress in the life of a doctor begins right from this childhood: 
in fact from his school leaving days, when he faces the tough 
competitive medical entrance examination followed by high 
expectations of parents and relatives with high social 
stigma. There is tough tiring schedule of at least five and a 
half years of education period. He not only has to pass out, 
but to secure good marks to get admission in desired post 
graduate subject. In the present era of specialization and 
super specialization, the training period ordinarily extends 
to another 3 to 6 years resulting in: 
1. Delay in the settlement of life. 
2. Delay in the marriage and in the further planning. 
3. Extended financial dependence on parents and the 
relatives. 
4. Stress to get good job opportunities and work satisfaction
 Medical students and residents also more 
vulnerable 
 Burnout, Depression and Suicide among 
Medical Students 
 In episodes of depression, the trainees, having 
both the knowledge and access to dangerous 
drugs, may get driven to use them and commit 
suicide in their week moments
 A study by Abhinav Goyal et al (Journal of 
Mental Health and Human Behaviour, 2012) on 
265 undergraduate students of a medical 
college in Delhi reported an association as high 
as 53.6 per cent with suicidal ideation. 
 Suicidal ideation was highest in first 
professional year (64.4%) and lowest in third 
professional year (40.4%). About 4.9 per cent 
students seriously contemplated suicide and 
2.6 per cent attempted suicide at least once in 
their life
 A suicide survivor or survivor of suicide is 
one of the family and friends of someone who 
has died by suicide 
 Estimates are that for every suicide, "there are 
seven to ten people intimately affected"
 Suicide is a criminal offence under Section 309 of 
the IPC with a punishment of up to one year in jail 
and a fine. 
 The offence is bailable, non-compoundable and 
triable by any Magistrate 
 Suicide is never to be presumed. Intention is the 
essential legal ingredient. 
 If a person before age for criminal responsibility 
commits suicide he cannot be held liable 
 "Mental Health Care Bill 2012“- 'need to care and 
not punish people with mental illness'
 Medically assisted suicide(euthanasia, or the 
right to die) is currently a controversial ethical 
issue involving people who are terminally ill, 
in extreme pain, and/or have minimal quality 
of life through injury or illness
 In P. Rathinam v. Union of India, had taken the 
view that S. 309 of the IPC was unconstitutional, 
since it was violative of the provisions of Art. 21 of 
the Constitution. It was held that the right to die 
was part of the right to life under Art. 21 of the 
Constitution and hence if S. 309 of the I.P.C. was 
held to be unconstitutional any person abetting a 
commission of suicide by another was merely 
assisting in the enforcement of the fundamental 
right under Art. 21, and, therefore, S.306 I.P.C. 
penalising assisted suicide was equally violative of 
Art. 21 of the Constitution.
Suicide tourism-is mass-media term for a form 
of 'tourism' associated with the pro-euthanasia 
movement, which organizes trips for potential 
suicide candidates in the few places where 
euthanasia is permitted. 
 This is in the hopes of encouraging the 
decriminalization of the practice in other parts 
of the world
 World Suicide Prevention Day – September 
10th – each year since 2003. 
 In 2014, the theme of World Suicide Prevention 
Day is 'Suicide Prevention: One World 
Connected.‘ 
 International Survivors of Suicide Loss Day - 
November 22, 2014
 Nanjing Yangtze River Bridge, 
Nanjing, China – over 2,000 
suicides from 1968 to 2006 
 Golden Gate Bridge, San 
Francisco, California, U.S. – 
over 1,500 suicides 
 Prince Edward Viaduct, 
Toronto, Ontario, Canada- 492 
suicides committed before the 
Luminous Veil, a barrier of 
9,000 steel rods, was 
constructed. Nicknamed "a 
magnet of suicide". 
 Aokigahara forest, Mount Fuji, 
Japan – up to 108 suicides a 
year; one source cites as the 
second most popular spot.
 Suicide point (Green valley), Kodaikanal. 
India.
 Accidental deaths and suicides in India 2012;National Crime 
Records Bureau Ministry of Home Affairs 
 Shorter Oxford textbook of psychiatry 6th edition 
 Textbook of Postgraduate Psychiatry,2nd edition JN Vyas, Niraj 
Ahuja 
 www.dsm5.org 
 www.psychotherapy.net 
 www.cssrs.columbia.edu 
 www.suicide.org/international suicide statistics
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Suicide and deliberate selfharm ppt vimhans

  • 1. Presenter:Dr.Santhosh Goud DNB Resident Chairperson:Dr.P.Krishna mohan MD DPM
  • 2.
  • 3.  Suicide(Latin suicidium, from sui caedere, "to kill oneself")  Suicide attempted/DSH/para suicide Unsuccessful but potentially lethal action  Suicide cluster/Copycat suicide Individuals or groups committing suicide after publicity about suicide of acquaintances or public figures  Suicide pact agreement or pledge between two or more persons to take their own lives simultaneously
  • 4.  Suicidal ideation is any self-reported thoughts of engaging in suicide-related behavior  To have suicidal intent is to have suicide or deliberate self-killing as one's purpose.  This is contrasted with suicidal motivation, or the driving force behind ideation or intent, which need not be conscious.
  • 5.  Suicide-suicide is conscious act of self induced annihilation, best understood as a multi-dimensional malaise in a needful individual, who defines an issue for which suicide is perceived as the best solution(Shneidman)  Suicide is the intentional act of self destruction committed by someone knowing what he is doing and knowing the probable consequences of his action. The verdict of suicide should be supported with evidence. It can never be presumed(Legal)
  • 6.  Suicidal act is the injury with varying degrees of lethal intent, and suicide is defined as a suicidal act with fatal outcome(WHO,1968)  Suicide -Death caused by self-directed injurious behavior with any intent to die as a result of the behavior(CDC).  The Government of India classifies a death as suicide if it meets the following three criteria:  It is an unnatural death,  the intent to die originated within the person,  there is a reason for the person to end his or her life. The reason may have been specified in a suicide note or unspecified
  • 7.  Males>Females  Men 10 years earlier than females(45-55)  Whites>Black(India north<south)  Protestants>Catholics (orthodoxy is a protecting factor)  Divorced>never married>married(children are protecting factor)  Higher social status  Sexual orientation-elevated suicide risk among gay and lesbian people  Physical Illness-Psychosomatic illness  Occupation- Physicians >other professions  Retirement and unemployment  Season- greatest during the late spring and early summer months, despite the common belief that suicide rates peak during the cold and dark months of the winter season
  • 8.  According to the World Health Organization, approximately one million people die by suicide worldwide every year,  The global suicide rate is 16 per 100,000 population  The suicide rate varies from 0.5/100,000 in Jamaica to 75.6/100,000 in Lithuania for men and from 0.2/100,000 in Jamaica to 16.8/100,000 in Sri Lanka for women
  • 9.  The number of suicides in the country during the decade (2002–2012) has recorded an increase of 22.7% (1,35,445 in 2012 -1,10,417 in 2002).  India in 2012 had nearly 2.6 lakh suicides, dwarfing China's 1.2 lakh.  The rate of suicides has shown a declining trend since 2002 to 2003 and thereafter an increasing trend is observed during 2005 to 2010. However, it was declined in 2011(from 11.4 in 2010 to 11.2 in 2011) and remained static in 2012.  South Indians accounting for a rate above 15 and North Indians below 3
  • 10.  Puducherry reported the highest suicide rate at 36.8 per 100,000 people, followed by Sikkim, Tamil Nadu and Kerala  The lowest suicide rates were reported in Bihar (0.8 per 100,000), followed by Nagaland, then Manipur.  In India, about 46,000 suicides occurred each in 15-29 and 30-44 age groups in 2012 - or about 34% each of all suicides  Poisoning (33%), hanging (31%) and self-immolation (9%) were the primary methods used to commit suicide in 2012  80% of the suicide victims were literate, higher than the national average literacy rate of 74%
  • 11.  In the year 2012, Chennai reported the highest total number of suicides at 2,183, followed by Bengaluru (1,989), Delhi (1,397) and Mumbai (1,296).  Jabalpur (Madhya Pradesh) followed by Kollam (Kerala) reported the highest rate of suicides 45.1 and 40.5 per 100,000 people respectively, about 4 times higher than national average rate.  West Bengal reported 6,277 female suicides, the highest amongst all states of India, and a ratio of male to female suicides at 4:3
  • 12.  In 2012, family problems and illness were the two major reasons for suicides, together accounting for 46% of all suicides. Drug abuse addiction (3.3%), love affairs (3.2%), bankruptcy or sudden change in economic status (2.0%), poverty (1.9%) and dowry dispute (1.6%) were the other causes of suicides
  • 13.  Sociological approach  Psychological approach  Biological aspects  Psychiatric approach
  • 14. • Emile Durkheim (1867) Le Suicide. Etude de Sociologie • Each society has a specific tendency toward suicide • Refuted contribution of individual factors • Social integration / Social regulation
  • 15.
  • 16.  Aaron T. Beck – Cognitive Theory  Cognitions = Mental processes that are involved in information gathering, thinking, remembering etc and exists in three forms: - Dysfunctional automatic thoughts skew perceptions of self, others and future - Schemas: framework or concept that helps organize the information gathered
  • 17.
  • 18.
  • 19.  Post-mortem studies have shown changes in central neurotransmission of serotonin, nor-adrenaline and post-synaptic signal transduction  Dysfunction of Hypothalamic-pituitary-adrenal axis (stress response) predicts suicide in depressed patients  Increased suicide risk associated with low cholesterol levels  Reduced 5-HIAA levels in CSF of depressed patients who suicide
  • 20.  Family history of suicide increases the risk two-fold especially in women and children independent of family psychiatric history  Concordance rates of suicide higher among monozygotic twins  Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.  Genetic factors account for 45% of suicidal thoughts and behaviors: 7 types of genes have been focused on serotonin transporter(SERT), tryptophan hydroxylase (TPH) 1 and 2, three serotonin receptors (5- HTR1A, 5-HTR2A, and 5-HTR1B), and the monoamine oxidase promoter(MAOA)
  • 21. Combines psychological and biological factors Holmes & Rahe 1967
  • 22. Holmes & Rahe 1967 STRESS DIATHESIS  A force that disrupts the equilibrium or normal functioning of an individual’s mental or physical state. Different types of stressors may precipitate suicidal behavior. Negative Life events Acute substance intoxication Acute psychiatric condition  Innate vulnerability or predisposition (in the form of traits) for developing the suicidal state Familial / genetic influences Chronic multiple psychiatric problems Hopelessness Being male / loneliness
  • 23.
  • 24.  Study by S.Gupta and C.L. Pradhan more family conflicts and broken love affairs in suicide attempters vs financial issues and death of close family member in people having only suicidal ideations (Indian journal of preventive and social medicine vol.38 no.3&4, 2007)
  • 25.  The primary and necessary mental state called 'idiozimia' by Federico Sanchez (from idios=self and zimia=loss) followed by suicidal thoughts, hopelessness, loss of will power, hippocampal damage due to stress hormones, and finally either the activation of a suicidal belief system, or in the case of panic or anxiety attacks the switching over to an anger attack, are the converging reasons for a suicide to occur
  • 26.  90% of suicides can be traced to depression, linked either to manic-depression (bipolar), major depression (unipolar), schizophrenia or personality disorders, particularly borderline personality disorder  Anorexia nervosa has a particularly strong association with suicide: the rate of suicide is forty times greater than the general population
  • 27.
  • 28.  Mental state  affective state of hopelessness,  severe anger and hostility, or with agitation, anxiety, fearfulness, or apprehension  Specific psychotic symptoms, such as grandiose delusions, delusions of thought insertion and mind reading  Command hallucinations??
  • 29. Predictors of risk  Direct statement  Plan  Past attempts  Indirect behaviors and gestures  Depression
  • 30.
  • 31.  Helps in short-term management of problematic emotions  Stress-relieving function  Consequences – disapproval by others and a sense of inability to solve problems  Regulation of unpleasant self-states (eg. depersonalization) common to people experiencing trauma  Sense of mastery and control for people who feel powerless or out of control Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
  • 32.  Re-enactment of past experience of trauma or abuse  Feelings of being evil and bad common  Self-punishment for being bad Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
  • 33.  For people who have past experiences of trauma and abuse and there was no recognition of it or they were actively denied by people around them  Way of testifying to the experience – remembering it  Linehan (1993) – Chronic invalidation: feelings are bad or wrong  Miller (1994) – “Men act out while women act out by acting in” Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
  • 34.  A way of communicating distress not heeded by words  To care for the person who has harmed  To keep others at a distance  To make the person cared about feel guilty Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001
  • 35.
  • 36.  Simeon et al. (1992) found that people who self-injure tend to be extremely angry, impulsive, anxious, and aggressive, and presented evidence that some of these traits may be linked to deficits in the brain's serotonin system  Favazza (1993) refers to this study and to work by Coccaro on irritability to posit that perhaps irritable people with relatively normal serotonin function express their irritation outwardly, by screaming or throwing things; people with low serotonin function turn the irritability inward by self-damaging or suicidal acts  Zweig-Frank et al. (1994) also suggest that degree of self-injury is related to serotonin dysfunction  Steiger et al. (2000), in a study of bulimics, found that serotonin function in bulimic women was significantly lower in bulimics who also engaged in self-harm
  • 37.  Rare genetic syndrome – Lesch-Nyhan (HG-PRT deficiency)  Large turnover of purines  Characterized by self harm  Link largely still unclear
  • 38. Suicidal behavior disorder  With in last 24 months the individual has made suicide attempt  The act does not meet criteria for non suicidal self injury  Not applied to suicidal ideation or to preparatory acts  The act was not initiated during a state of delirium or confusion  The act was not undertaken solely for a political or religious objective Specifiers -current:not more than 12 months since last attempt in early remission:12-2 months since last attempt Degree of lethality-violent/non-violent
  • 39. Non suicidal self-injury  In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, and excessive rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm  The individual engages in the self injurious behavior with one or more of the following expectations  To obtain relief from a negative feeling or cognitive state  To resolve an interpersonal difficulty  To induce a positive feeling state
  • 40.  The intentional injury is associated with at least 2 of the following:(1)psychological precipitant: interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act,(2)urge: prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist,(3)preoccupation: thinking about self-injury occurs frequently, even when it is not acted upon, (4)contingent response: the activity is engaged in with the expectation that it will relieve an interpersonal difficulty, negative feeling, or cognitive state, or that it will induce a positive feeling state, during the act or shortly afterwards  The behavior is socially not sanctioned and is not restricted to picking a scab or nail biting  Its consequences cause clinically significant distress or interference in interpersonal academic or other important areas of functioning
  • 41.  Chapter XX External causes of morbidity and mortality  X60-X84(includes purposely self-inflicted poisoning or injury; suicide)  X60-69 –intentional poisoning…  X70-X82- intentional self harm by…methods  X83-intentional self harm by other specified means  X84-intentional self harm by unspecified means
  • 42.  The behavior does not occur exclusively during states of psychosis, delirium, or intoxication. In individuals with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior cannot be accounted for by another mental or medical disorder (i.e., psychotic disorder, pervasive developmental disorder, mental retardation, Lesch–Nyhan syndrome, stereotyped movement disorder with self-injury, or trichotillomania)
  • 43.  Rating scales  Psychological autopsy-A procedure for investigating a person's death by reconstructing what the person thought, felt, and did before death, based on information gathered from personal documents, police reports, medical and coroner's records, and face-to-face interviews with families, friends, and others who had contact with the person before the death
  • 44.  SSI/MSSI-The Scale for Suicide Ideation (SSI) was developed in 1979 by Aaron Beck  Suicide Intent Scale (SIS)- assess the severity of suicide attempts 15 questions which are scaled from 0-2  Suicide Behaviors Questionnaire- Linehan in 1981  1988 it was transformed from a long questionnaire to a short four questions that can be completed in about 5 minutes
  • 45.  Life Orientation Inventory- The Life Orientation Inventory (LOI) is a self-report measure that comes in both a 30 question and 110 question form  Reasons For Living Inventory- It was developed in 1983 by Linehan et al. and contains 48 items answered on a Likert scale from 1 to 6. The measure is divided into six subscales: survival and coping beliefs, responsibility to family, child concerns, fear of suicide, fear of social disproval, and moral objections
  • 46.
  • 47. 1.Alcohol 2.Anti social behavior 3.Previous IP care 4.OP care 5.Previous attempts resulting in hospital admission 6.Not living with relatives  Score 0:only 5%risk of repeating within a year  Score 5 :50% risk of repeating within a year
  • 48. 48 Level of concern about potential suicidal behavior: Sum of items coded as present Suicide risk factor groups: Lowest concern 0 1. Any history of a suicide attempt Some concern 1-2 2. Long-standing tendency to lose temper or become aggressive with little provocation Increased concern 3-4 3. Living alone, chronic severe pain, or recent (within 3 months) significant loss High Concern 5-7 4. Recent psychiatric admission/discharge or first diagnosis of MDD, bipolar disorder or schizophrenia 5. Recent increase in alcohol abuse or worsening of depressive symptoms 6. Current (within last week) preoccupation with, or plans for, suicide 7. Current psychomotor agitation, marked anxiety or prominent feelings of hopelessness
  • 49. Predisposing factors  Disturbed family background  Drug and alcohol abuse  Conduct disorder/anti social behavior  Physical illness  Losing the parent before age 13 Precipitating factors  Break in relationship  Exposure to someone who died violently  High frequency of moves
  • 50.  Hopelessness  Intoxication  Clinical syndromes  Sex, age, race  Religion  Living alone  Lack of sense of belonging
  • 51.  Bereavement  Unemployment  Health status  Impulsivity  Rigid thinking  Stressful events  Release from hospital
  • 52.  Common in females  Young people(<35yrs)  Low social class, deprived back ground, ower crowding  Impulsivity  Premenstrual syndrome in females
  • 53.  Based on a stress-diathesis model of suicidal behavior  Acts to modify reactions to stressors both acutely and chronically in the context of vulnerability (i.e. positive diathesis).  The treatment includes a 12-week acute phase and a continuation phase, over 6 months of contact.  CBT-SP is primarily individual therapy but also includes family interventions as needed to reduce the suicide risk.
  • 54. Mainly works on deficits the abilities or motivations to cope with suicidal crises.
  • 55.  These risk factors are identified by conducting a detailed chain analysis of the sequence of events, and their reactions to these events, that led to the suicidal crisis.  A core feature of the treatment is the development of an individualized case conceptualization that identifies problem areas to be targeted and the specific interventions to be employed during periods of acute emotional distress.
  • 56. Addressing Family/milieu risk factors Focus on problematic romantic relationships, physical, verbal or sexual abuse, dysfunctional family beliefs, high expectations and low reinforcement, or poor work performance and incorporates specific family /milieu therapy techniques to address these contextual concerns
  • 57. CBT-SP phases  1)Acute phase 12-16 weekly sessions  Mostly individual sessions  6 family sessions  (+ Family “check-ins” (5–15 minutes) may also be conducted )  initial phase, a middle phase, and an end of acute treatment phase  2)Continuation phase  12 weeks up to 6 sessions that are tapered in frequency.  Additionally, there may be up to three family sessions during the continuation phase  Total duration 6 months.
  • 58.  occurs during the first three sessions  consist of five main components: Chain Analysis, Safety Planning, Psycho education, Developing Reasons for Living and Hope, Case Conceptualization.
  • 59. Chain analysis Safety planning& Psycho education Developing reasons for living &Case conceptualization
  • 60. Chain analysis  The basic strategy that sets the framework for the CBT-SP is a detailed chain analysis of events associated with the index suicide attempt or suicidal crisis.  The chain analysis includes identification of vulnerability factors and activating events associated with the crisis as well as the’ thoughts, feelings and behaviors in reaction to these events.  To conduct a chain analysis of a suicide attempt, the therapist asks the person to describe the events that led to and followed the suicide attempt as well as the details of the actual attempt.
  • 61. Outcomes of chain analysis  Developing rapport actively  Engages patient in treatment  facilitates the development of a conceptualization of patients’ suicidality and assessment of future risk  it gives patients the opportunity to feel understood and counteract a frequent feeling that the suicidal behavior “just happened
  • 62. Safety Planning  Safety planning is a technique to help patients remain safe and not to engage in further suicidal behavior, at least until the next therapy session.  The intent of safety planning is to help individuals lower their imminent risk for suicidal behavior by consulting this pre-determined set of potential coping strategies and list of individuals or agencies whom they may contact.  Given that the highest risk period for a re-attempt is shortly after the indexed attempt, as well as during during the time immediately following discharge from inpatient treatment, it is essential to develop a safety plan early in treatment for high suicide risk patients who are being treated as outpatients.
  • 63.  The safety plan includes a stepwise increase in the level of intervention from internal (“within-self”) strategies to external (“outside-self”) strategies.  Internal strategies- a list of activities that the patient could do to cope with suicidal urges without the assistance of other people.  External strategies- a range of behaviors from receiving help from friends or family members to emergency psychiatric evaluation and possible hospitalization.
  • 64.  The safety plan is always written and kept where it can be retrieved during times of crises.  Family members, especially spouse & parents, may be involved in the safety planning. The therapist and patient collaborate on how the family can be helpful in supporting the patient to use the safety plan.  It is important to discuss with the patient and family members the elimination of any potential lethal means in the patient’s environment.
  • 65.  For the initial session, there may not be sufficient time to develop a full elaboration of the safety plan based on a chain analysis. However, it is essential to develop a rudimentary safety plan and chain analysis, both of which are elaborated in later sessions.  Thus, the first session always includes a written safety plan and is further modified in subsequent sessions as more information was gathered through a more detailed chain analysis.
  • 66. Psycho education  explain to the patient and family members the nature of suicidal behavior, the role of depression and the need for securing potential lethal means  Inputs from family members for chain analysis and making safety plan
  • 67. Addressing Reasons for Living and Building Hope  Given that hopelessness is often associated with suicide risk, it is important to include treatment strategies that instill a sense of hope.  Discuss the patient’s personal reasons for living.  Delineating reasons to live is an important activity because learning to cope with suicidal urges is rather empty if there are no reasons to want to cope.  The therapist should explain how recalling reasons to stay alive may be impaired during a crisis. The ability to recall reasons for living can be used as a specific coping strategy in distressing times.
  • 68.  The patient is also encouraged to construct a “Hope Kit,” a concrete implementation of the patients’ reasons to stay alive.  The kit serves as a memory aid to be used in times of crisis, can help to increase hopefulness about the future and provide reminders about patients’ sense of purpose.  Hope kits can contain pictures of loved ones, reminders of aspirations and places that give them pleasure (e.g. seashells, picture of mountains).
  • 69.
  • 70. Case Conceptualization  Following the first two sessions, the therapist develops a case conceptualization based on the chain analysis. As mentioned earlier, the therapist identifies the specific cognitive, behavioral, affective, and contextual problems that were identified during the chain analysis and then selects corresponding strategies to address these problems.  The therapist and patient discuss the specific goals for reducing suicidal risk and then discuss the suggested approach in a collaborative manner. Adjustments to the treatment plan are made for each patient. The prioritization of specific skills training should include those skills that are most likely to prevent a subsequent suicide attempt and that build on the adolescent’s existing strengths. Once the interventions are collaboratively selected by the therapist and patient, the treatment plan is presented to the family for feedback.
  • 71.  During the middle phase of acute treatment (approximately sessions 4–9), after the immediate suicidal crisis has resolved, the primary area of intervention is behavioral and/or cognitive skills training using individual or family sessions. Skills training is included as a series of optional individual and family modules. These modules are presented below.
  • 72. Individual Skill Modules  Individual skill modules include: (1) Behavioral activation and increasing pleasurable activities; (2) Mood monitoring, (3) Emotion regulation and distress tolerance techniques; (4) Cognitive restructuring; (5) Problem solving; (6) Goal setting; (7) Mobilizing social support; and (8) Assertiveness skills.
  • 73. Family Skill Modules  The goal of CBT-SP’s family intervention is focused on reducing suicide risk by encouraging family support; improving the family’s problem solving skills; and modifying the family’s communication patterns.  The family modules may be implemented as part of or as adjunctive to the corresponding individual module, or they may be implemented during a distinct, separate session.
  • 74.  The majority of CBT-SP sessions are devoted to introducing and teaching new skills and uses multiple modalities to assist the patient to learn the relevant skill.  These include presenting the rationale, explaining and teaching the skill, using role-play during the session to rehearse the skill, and working collaboratively to develop a homework assignment so that the new skill can be used in the patient’s life.  Each session ends with a summary and a collaborative agreement about a homework assignment.  The therapist helps the patient to summarize the key points that have been raised or the key elements of new learning that appear to be relevant to prevent recurrence of suicidal behavior.  In the first few sessions, the therapist may be very active in summarizing the content of the session but it is important for the patient to do it by him- or herself as the therapy proceeds. In addition, it is very important for the therapist to elicit feedback throughout the session and at the end of the session. Feedback helps the therapist to understand those aspects of the session that were perceived to be most helpful and to address any issues that may have been upsetting for the patient.
  • 75.  The final component of the acute intervention phase includes a relapse prevention task. Once patients have successfully completed the relapse prevention task, the continuation phase is conducted.
  • 76.  Relapse Prevention Task  This module, conducted at approximately sessions 10 to 12, usually marks the end of the acute phase of treatment. The relapse prevention task is an “in-vivo” guided-imagery technique to test the efficacy of the acquisition of skills and coping capabilities in preventing suicidal behavior in the future. If the patient has difficulty completing the relapse prevention task, the therapist and patient identify obstacles to its completion and may review previously taught skills or add new skills.
  • 77.  The relapse prevention task includes five steps: (1) Preparation, (2) Review of the Indexed Attempt or Suicidal Crisis, (3) Review of the Attempt or Suicidal Crisis using Skills, (4) Review of a Future High Risk Scenario, and (5) Debriefing and Follow-up.
  • 78.  They are told that by imagining the suicide attempt and reliving the pain that was experienced, patients will have the opportunity to assess whether the coping skills learned in therapy can be recalled.  During the review of the indexed attempt or suicidal crisis, the patient is asked to imagine the sequence of events that led to the index suicide attempt and the associated thoughts and feeling leading up to and following the suicide attempt.  Next, the clinician again leads patients through the same sequence of events, but this time the therapist encourages the patient to imagine using the skills learned in therapy to cope with the events, feelings and thoughts.  As they imagine the chain, patients are asked to describe the sequence of events and coping skills out loud and using the present tense. Patients are encouraged to rehearse applying the skills learned in therapy to the situation described in the chain analysis to result in a better outcome.
  • 79.  During the next step, patients are encouraged to imagine, and describe in detail, a future scenario that could lead to a suicidal crisis.  A crucial part of the task is for patients to anticipate when and how they can apply the skills learned in therapy in future situations.  Finally, debriefing is conducted after the relapse prevention task has been completed and follow-up plans are formulated. Patients are provided with support and encouragement for conducting this task. In addition, feedback should be obtained from patients. At the end of the intervention and in the following sessions the therapist and patient review the changes the patient has made over the course of treatment and the skills he/she have learned. It is crucial that they also review the safety plan before patients leave the relapse prevention session.
  • 80. Continuation Phase  During the continuation phase, the therapist may introduce new skills or continue to help the patient or family to learn and implement the skills introduced in the acute phase. The termination sessions include explicit discussion of reactions to the conclusion of treatment, review of successful strategies that were learned in the therapy and the goals that were accomplished as well as a discussion of whether treatment is needed for other problems the patient may be experiencing.
  • 81.  In this final phase, the therapist also encourages the patient to identify specific anticipated difficult or stressful situations and review the use of the new skills as they would apply to these future situations. It is important to prepare the patient for mood fluctuations and setbacks and discuss specific signs of personal risk that have been identified through the chain analysis and the course of treatment with the patient. The importance of continuation or maintenance treatment for both partially and fully recovered patients should be emphasized. Issues surrounding ending treatment also should be discussed with the family and include: (1) Review of warning signs of depressive symptoms and suicidal crises, (2) Goals achieved in therapy, (3) Impact of treatment on the rest of the family, (4) Strategies for handling possible future episodes, and (5) The current need for further treatment.
  • 82. developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder(BPD) and chronically suicidal individuals
  • 83. Emotional mind Logical mind Wise mind
  • 84.  Core mindfulness-experiencing the event as it is with a relaxed mind(taught by deep breathing skills)  Interpersonal skills  Emotional regulation skills-not controlling: learning how to express ones negative emotions and how to process them  Distress tolerance-how to cope up crisis
  • 85.
  • 86.
  • 87.  Doctors have the highest rate of suicide among all the professions. In the US every year, between 300 and 400 physicians take their own lives. And, in sharp contrast to the general population, where male suicides outnumber female suicides four to one, the suicide rate among male and female doctors is the same
  • 88.  The rate of suicidal deaths among doctors is 2-4 per cent as against only about 1-2 per cent among general population.  Male physicians have a 70 per cent higher suicide rate than males in other professions; and female physicians have a 400 per cent higher rate than females in other professions
  • 89.
  • 90.  Doctors face severe mental stress and strain. This is usually more than what an average person experiences. this results in mental and physical strains. If these stress and strains are not managed properly and there are various precipitating factors, they can manifest as depression, and under this depressed state the doctors try or commit suicide
  • 91.  Stress in the life of a doctor begins right from this childhood: in fact from his school leaving days, when he faces the tough competitive medical entrance examination followed by high expectations of parents and relatives with high social stigma. There is tough tiring schedule of at least five and a half years of education period. He not only has to pass out, but to secure good marks to get admission in desired post graduate subject. In the present era of specialization and super specialization, the training period ordinarily extends to another 3 to 6 years resulting in: 1. Delay in the settlement of life. 2. Delay in the marriage and in the further planning. 3. Extended financial dependence on parents and the relatives. 4. Stress to get good job opportunities and work satisfaction
  • 92.  Medical students and residents also more vulnerable  Burnout, Depression and Suicide among Medical Students  In episodes of depression, the trainees, having both the knowledge and access to dangerous drugs, may get driven to use them and commit suicide in their week moments
  • 93.  A study by Abhinav Goyal et al (Journal of Mental Health and Human Behaviour, 2012) on 265 undergraduate students of a medical college in Delhi reported an association as high as 53.6 per cent with suicidal ideation.  Suicidal ideation was highest in first professional year (64.4%) and lowest in third professional year (40.4%). About 4.9 per cent students seriously contemplated suicide and 2.6 per cent attempted suicide at least once in their life
  • 94.  A suicide survivor or survivor of suicide is one of the family and friends of someone who has died by suicide  Estimates are that for every suicide, "there are seven to ten people intimately affected"
  • 95.  Suicide is a criminal offence under Section 309 of the IPC with a punishment of up to one year in jail and a fine.  The offence is bailable, non-compoundable and triable by any Magistrate  Suicide is never to be presumed. Intention is the essential legal ingredient.  If a person before age for criminal responsibility commits suicide he cannot be held liable  "Mental Health Care Bill 2012“- 'need to care and not punish people with mental illness'
  • 96.  Medically assisted suicide(euthanasia, or the right to die) is currently a controversial ethical issue involving people who are terminally ill, in extreme pain, and/or have minimal quality of life through injury or illness
  • 97.  In P. Rathinam v. Union of India, had taken the view that S. 309 of the IPC was unconstitutional, since it was violative of the provisions of Art. 21 of the Constitution. It was held that the right to die was part of the right to life under Art. 21 of the Constitution and hence if S. 309 of the I.P.C. was held to be unconstitutional any person abetting a commission of suicide by another was merely assisting in the enforcement of the fundamental right under Art. 21, and, therefore, S.306 I.P.C. penalising assisted suicide was equally violative of Art. 21 of the Constitution.
  • 98. Suicide tourism-is mass-media term for a form of 'tourism' associated with the pro-euthanasia movement, which organizes trips for potential suicide candidates in the few places where euthanasia is permitted.  This is in the hopes of encouraging the decriminalization of the practice in other parts of the world
  • 99.  World Suicide Prevention Day – September 10th – each year since 2003.  In 2014, the theme of World Suicide Prevention Day is 'Suicide Prevention: One World Connected.‘  International Survivors of Suicide Loss Day - November 22, 2014
  • 100.  Nanjing Yangtze River Bridge, Nanjing, China – over 2,000 suicides from 1968 to 2006  Golden Gate Bridge, San Francisco, California, U.S. – over 1,500 suicides  Prince Edward Viaduct, Toronto, Ontario, Canada- 492 suicides committed before the Luminous Veil, a barrier of 9,000 steel rods, was constructed. Nicknamed "a magnet of suicide".  Aokigahara forest, Mount Fuji, Japan – up to 108 suicides a year; one source cites as the second most popular spot.
  • 101.  Suicide point (Green valley), Kodaikanal. India.
  • 102.  Accidental deaths and suicides in India 2012;National Crime Records Bureau Ministry of Home Affairs  Shorter Oxford textbook of psychiatry 6th edition  Textbook of Postgraduate Psychiatry,2nd edition JN Vyas, Niraj Ahuja  www.dsm5.org  www.psychotherapy.net  www.cssrs.columbia.edu  www.suicide.org/international suicide statistics