The document discusses suicide and suicidal behaviors from various perspectives including definitions, classifications, epidemiology, risk factors, theories and approaches. Some key points: - Suicide is defined as death caused by self-directed injurious behavior with intent to die. Attempted suicide refers to non-fatal self-harm. - Worldwide, about 1 million people die by suicide each year, with rates varying greatly between countries and demographics. In India, suicide is the second leading cause of death among 15-29 year olds. - Risk factors include male gender, family history of suicide, mental illnesses like depression and schizophrenia, substance abuse, physical illness, unemployment, and relationship or financial problems. -

1. Presenter:Dr.Santhosh Goud
DNB Resident
Chairperson:Dr.P.Krishna mohan
MD DPM

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

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

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

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

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

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

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

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).

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

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

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