Psychiatry

1. By –Dr Rewa Sood

2.  The term suicide means a fatal self inflicted
destructive act with explicit or inferred
intent to die.
 In psychiatry ,suicide is the primary
emergency
 It is almost always the result of mental
illness, usually depression, and is amenable
to psychological and pharmacological
treatment.

3.  ABORTED SUICIDE ATTEMPT-potentially self
injurious behavior with explicit or implicit
evidence that the person intended to die but
stopped the attempt before physical damage
occurred
 DELIBERATE SELF HARM- willful self inflicting of
painful, destructive, or injurious acts without
intent to die
 LETHALITY OF SUICIDAL BEHAVIOR- objective
danger to life associated with a suicide method
or action

4.  SUICIDAL IDEATION-Thought of serving as the
agent of one’s own death
 SUICIDAL INTENT-Subjective expectation and
desire for a self destructive act to end in death
 SUICIDE ATTEMPT-Self injurious behavior with a
non fatal outcome accompanied by an explicit or
implicit evidence that the person intended to die
 SUICIDE-Self inflicted death with explicit or
implicit evidence that the person intended to
die

5.  PARASUICIDE- describes patients who injure
themselves by self mutilation but who
usually do not wish to die

6.  According to WHO(2014), global suicide rates
have increased 60% over the past 45 years, and
now more than 800,000 people die from suicide
every year—roughly one death every 40 seconds.
 India has the highest suicide rate in the South-
East Asian region, according to the World Health
Organization's latest report in 2019. India's
suicide rate stands at 16.5 suicides per 100,000
people.
 India also had the third-highest female suicide
rate (14.7) in the world

7.  Suicide is the 15th leading cause of death
globally, accounts for 1.4 % of all deaths
 The global suicide rate is 10.6 per 100000
population-15 /100000 for males and 8 /100000
for females.
 For every 1 suicide 25 people make a suicide
attempt
 135 people are affected by each suicide death
 This equates to 108 million people bereaved by
suicide worldwide every year

8. SOCIOLOGICAL FACTORS
Durkheim’s theory-
Divides suicide into 3 social categories-
egoistic,altruistic and anomic
PSYCHOLOGICAL FACTORS
FREUD’S THEORY -suicide represents aggression
turned inward against an introjected
,ambivalently cathected love object
MENNINGER’S THEORY –suicide is an inverted
homicide because of a patient’s anger towards
himself

9. BIOLOGICAL FACTORS
Decreased serotonin
GENETIC FACTORS
family history increases the risk

10. A)Gender Differences-
 Men commit suicide more than four times as
often as women
 women attempt suicide or have suicidal thoughts
three times as often as men
B) Age-
 Among men, suicides peak after age 45;
 among women, the greatest number of
completed suicides occurs after age 55.
 Rates of 29 per 100,000 population occur in men
age 65 or older

11. C) Race.
 Suicide rates among white men and women
are approximately two to three times as high
as for African American men and women
across the life cycle
D) Religion.
 Historically, Protestants and Jews in the
United States have had higher suicide rates
than Catholics. Muslims have much lower
rates

12. E)Marital Status.
 Marriage lessens the risk of suicide.
 Divorce increases suicide risk
 Widows and widowers also have high rates
F)Occupation.
 The higher the person’s social status, the
greater the risk of suicide, but a drop in
social status also increases the risk

13. G)Physical Health.
 The relation of physical health and illness to
suicide is significant. Previous medical care
appears to be a positively correlated risk
indicator of suicide: About one third of all
persons who commit suicide have had
medical attention within 6 months of death

14. H)Mental Illness
. Almost 95 percent of all persons who commit
or attempt suicide have a diagnosed mental
disorder.
 Depressive disorders - 80%
 schizophrenia -10 %
 dementia or delirium - 5 %

15. I) Psychiatric patients-
 3-12 times that of non patients
 Depression – 20%
 Schizophrenia -10%
 Bipolar disorder - 15-20%
 Alcohol dependence- 15%
 Antisocial personality disorder-5%

16. Disorder No of studies Pooled relative risk
MDD 4 19.9
Anxiety disorder 7 2.7
Schizophrenia 4 12.6
Bipolar disorder 4 5.7
Anorexia nervosa 9 7.6
Alcohol dependence 12 9.8
Opioid dependence 21 6.9
Psychostimulant
dependence
4 8.2
Amphetamine
dependence
1 4.5
Cocaine dependence 3 16.9

18. J) A past suicide attempt is perhaps the best
indicator that a patient is at increased risk of
suicide. Studies show that about 40 percent
of depressed patients who commit suicide
have made a previous attempt. The risk of a
second suicide attempt is highest within 3
months of the first attempt.

19.  The concept of imminent suicide imposes an
illusory time frame on an unpredictable act
(Pokorny 1983). Suicide is typically impulsive
in nature.
 As such, many patients remain uncertain to
the last moment, with little premeditation,
and are often ambivalent about dying

20.  Previous suicide attempt
 Family h/o suicide
 Cultural sanctions for suicide
 Stressful events such as
 Relationship break up
 Loss of loved one
 Argument with family and friends
 Financial ,legal or work related problems
 Isolation

21.  Amongst vulnerable groups-
 Refugees and migrants
 Bisexual or homosexual gender identity
 prisoners

22.  Relatives and close friends of people(suicide
survivors) who die by suicide are a high risk
group for suicide due to
 The psychological trauma of a suicide loss
 Potential shared familial and environmental risk
 Suicide contagion through the process of social
modelling
 The burden of stigma associated with this loss

23.  Factors that have been associated with a
decreased risk of suicide include the
following:
• Family cohesiveness
• Parenthood
• Pregnancy
• Religious affiliation
• Social support

24.  Suicide is associated with a tetrad of warning signs
1. The wish to die (as a way to end suffering or
facilitate a reunion with lost
loved ones)
2. The wish to kill (the aim to cause the destruction of
others, as well as oneself)
3. The wish to be killed (a form of reaction formation—
i.e. “I don’t hate you; you hate me”)
4. The wish to be rescued (a sign of ambivalence; a
desire to prove they are
loved and desired)

25. The following signs are often present in
suicidal patients.
 Talking about wanting to die or to kill oneself
 Looking for a way to kill oneself (e.g., searching
online suicide sites, buying a gun)
 Talking about feeling hopeless or having no
reason to live
 Talking about feeling trapped or in unbearable
pain (physical or emotional)
 Talking about being a burden to others

26.  Unwillingness to provide enough information
for clinician to assess suicide risk
 Increasing use of alcohol or drugs
 Acting anxious or agitated
 Behaving recklessly
 Sleeping too little or too much
 Withdrawing or isolating oneself
 Showing rage or talking about seeking
revenge
 Displaying extreme mood swings

27. Four types of suicide cases are commonly
encountered in the emergency department
1. Patients who report suicidal ideation
2. Patients who just survived a suicide attempt
3. Patients presenting with other, usually somatic
complaints but in whom suicidal thoughts are
discovered during a comprehensive evaluation
4. Patients who deny suicidal ideation but whose
behavior (or family’s report) suggests suicidal
potential or risk

28. 1. Conduct a thorough psychiatric evaluation
a. Identify specific psychiatric signs and
symptoms
b. Assess past suicidal behavior, including
intent of self-injurious acts
c. Review past treatment history
d. Identify familial history of suicide, mental
illness, and dysfunction
e. Identify current psychosocial situation and
nature of crisis
f. Identify patient’s psychological strengths
and vulnerabilities

29. 2. INQUIRE ABOUT SUICIDAL THOUGHTS,
PLANS, AND BEHAVIORS
a. Elicit the presence or absence of suicidal ideation
b. Elicit the presence or absence of a suicide plan
c. Assess the degree of suicidality, including suicidal intent
and lethality of plan
d. Understand the relevance and limitations of suicide
assessment scales

30. 3. Establish a diagnosis
4. Estimate the suicide risk
5. Develop and administer a treatment plan
6. Determine the most appropriate treatment
setting
7. Provide education to patient and family

31. 8. Monitor the patient’s psychiatric status and
response to treatment
9. Obtain consultation, if indicated
10. Reassess safety and suicide risk

32. 11. Ensure adequate documentation and risk
management
a. Detail general risk management plan and
document issues specific to suicide
b. Limit the use of suicide contracts
c. Communicate with pertinent parties, especially
patients’ clinicians and significant others
d. Implement mental health interventions for
surviving family and friends after suicide

33.  Suicidal communication before attempt
 Precaution taken to avoid discovery
 Intent to die
 Type of attempt(planned or impulsive)
 Was the method chosen dangerous
 Reaction to survival

34.  Columbia suicide severity rating scale is a
suicidal ideation and behavior rating scale
 Scale for assessment of lethality of suicide
attempt(SALSA scale)
 Beck's Suicide Intent Scale is a risk assessment
instrument using 15-items designed to examine
both subjective and objective aspects of
the suicide attempt, such as the circumstances
at the time of the attempt and the patient's
thoughts and feelings during the attempt

35.  Most suicides among psychiatric patients are
preventable, because evidence indicates that
inadequate assessment or treatment is often
associated with suicide.
 Some patients experience suffering so great
and intense, or so chronic and unresponsive
to treatment, that their eventual suicides
may be perceived as inevitable

36. PSYCHOEDUCATION AND TRAINING OF
HEALTH CARE WORKERS
 Over 75% of patients who committed suicide
had contact with primary care providers
within the year of their death, but only one-
third had contact with mental health services
 Therefore, caregivers should be trained in
the recognition of conditions associated with
high suicidal behavior, risk factors, warning
signs, and basic knowledge of intervention
modalities.

37. DIAGNOSING AND TREATING PEOPLE WITH
MENTAL DISORDERS
 A thorough history of current and past
psychiatric symptoms is necessary.

38. ADDRESSING SUBSTANCE USE DISORDERS
 Management of substance abuse and
alcoholism is pertinent to primary prevention
of suicide.

39. REDUCING ACCESS TO THE MEANS OF SUICIDE
 presence of firearms at home
 assorted medications or other lethal substances
 instead of hanging the fan by a hook to the
ceiling use of four springs hinged to the shaft of
the fan and ceiling, such that it will allow an
additional weight of 25kg. If a person tries to
attempt suicide, the weight increases and the
spring uncoils and the person will land safely.

40. RISK REDUCTION THROUGH HOSPITALIZATION
 Individuals at high risk of imminent suicide
should be hospitalized.
1. Key issues regarding imminent suicide risk
are
 intent and means,
 Severity of psychiatric illness,
 the presence of psychosis or hopelessness
 a lack of personal resources,
 older age among men

41. 2. Because interrupting a suicide has been
proved effective, psychiatric holds are
useful.
 The psychiatric hospitalization should allow
for a more extended period of observation by
trained personnel.

42. 3. Once hospitalized
 Monitor closely
 ensure the patient’s safety at all times,
especially during the first few days
 One-to-one sitter supervision (especially if
admitted to a medical floor for stabilization
after a suicide attempt)

43. 4. Voluntary admission should first be offered,
but if this is turned down, further assessment
is required to determine the potential need
for an involuntary hospitalization

44. Close Monitoring But No Hospitalization
 When patients have elevated but not
imminent suicide risk, they can be
discharged home with close observation by
family or friends.
1.not a viable option for
 patients who lack a support structure,
 those too unstable or psychotic
 who have already exhibited dangerous or
self-injurious behavior.

45. 2. If a patient is to be discharged home, all
potential lethal means must haven been
removed or secured. These include firearms,
medications, and other potential methods to
commit suicide.
3. Involvement of family, friends, or other
support systems is imperative.

46. 4. A patient’s reluctance regarding clinical
contact with care providers or support
system is cause for concern

47. 5. Despite the extensive use of safety
contracts in clinical practice, there is little
evidence that such contracts actually reduce
suicide
 a patient’s unwillingness to “contract for
safety” should be an indication that the
patient may not be safe in an outpatient
setting and that hospitalization may be
necessary.

49. Initiating Pharmacotherapy if Indicated
 Psychopharmacological treatment should be
initiated (or restarted in nonadherent patients)
 It is important to educate the patient regarding
 the lag between medication initiation and
symptom relief
 the possibility of adverse effect
 and the risk of sudden discontinuation of
pharmacological agents (e.g. serotonin,
benzodiazepines

50.  Identification of High-Risk Patients
 Close Follow-Up and Ongoing Prevention of
Suicide
 Adequate treatment of any underlying
psychiatric disorder through pharmacological
agents, psychotherapy, and family
interventions is essential.

51.  Patients should be discharged with a
treatment plan, which includes
 appropriate referral for follow-up
 close monitoring of mental status and
response to pharmacological treatment,
including potential adverse effect
 involvement of family members and/or
significant others, if appropriate and with
the patient’s Consent

52.  Regularly scheduled office visits may improve
the patient’s medication continuation

53. Development of a Suicide Prevention Action
Plan
 Review it with the patient or assist the
patient in starting to develop one.
 The goal of this plan is to help guide the
patient, or those within the patent’s support
structure, through difficult moments of
crisis.

54. Provision of Contact Information
 Important types of resources that can be
provided to patients with current or a past
history of suicidal ideation include outpatient
mental health referrals and crisis/suicide
hotline information

55. Psychoeducation
 An educational campaign should be directed
at patients, their families, and physicians,
with the objective of improving the
psychiatric (e.g., antidepressant,mood-
stabilizing, and/or antipsychotic) treatment
they are receiving.

56. Responsible Media Reporting
1. Inform the audience without
sensationalizing the suicide.
2. Use school, work, or family photographs,
rather than graphic images of incidents.
3. Keep details of the suicide to a minimum.

57. 4. Use the reporting opportunity to educate
the population about the warning signs of
impending suicide, provide tips as to what a
person should do if he or she suspects that
someone may be suicidal, and provide
information regarding assistance (e.g.,
suicide hotline number, crisis intervention
contact information).

58. CLUSTERS OF SUICIDES
 The media sometimes gives intense publicity to
“suicide clusters” - a series of suicides that occur
mainly among young people in a small area within a
short period of time. These have a contagious effect
especially when they have been glamorized,
provoking imitation or “copycat suicides”.
 A copycat suicide is defined as an emulation of
another suicide that the person attempting suicide
knows about either from local knowledge or due to
accounts or depictions of the original suicide on
television and in other media.
 A spike of emulation suicides after a widely
publicized suicide is known as the Werther effect.

60.  Widely reported studies modelling the effect of the
covid-19 pandemic on suicide rates predicted
increases ranging from 1% to 145%(ref .bmj 12 nov
2020), largely reflecting variation in underlying
assumptions
 There has been an increase in self-harm and suicide
ideation among people since the Covid-19 pandemic
hit, says a study ‘ COVID 19 BLUES’ conducted by
Bengaluru based Suicide Prevention India
Foundation(SPIF)

62.  A selective approach for subgroups at
increased risk for suicide, for example, for
individuals with a history of psychiatric
disorders, persons with symptoms of
significant emotional distress, COVID-19
survivors, frontline health care professionals
and elderly people.
 Active outreach is necessary, especially for
people with a history of psychiatric
disorders, COVID-19 survivors and older
adults.

63.  People with psychiatric disorders should be
advised to continue their treatment regimens
and to stay in touch with their mental health
professionals.
 Some psychiatric patients may need
adjustments in their treatment and increased
frequency of contact with their mental
health clinicians.

64.  TELEMEDICINE can improve accessibility of
mental health care.
 Also, vulnerable individuals should be
advised to limit watching, reading or
listening to traditional and social media news
stories.

65.  Up-to-date and valid information regarding
the COVID-19 outbreak can reduce these
fears.
 Similarly, symptoms suggestive of COVID-19
infection are associated with psychological
distress, and patients with such symptoms
should be evaluated for features of anxiety
and depression as well as for suicide risk

66.  These unprecedented times have put the
mental health of the elderly at higher risk of
relapse as they are already susceptible to
melancholy and disquietude
 Susceptible to both the infection and its
psychosocial implications

67.  Family interventions with social cohesion
may lead to improving the mental health of
the elderly, which can be referred to as a
phenomenon of resilience

68.  Suicide among doctors is a complex, multi-
factoral issue that has been plaguing the
country for decades now.
 Studies from across the world indicate that
suicide rates among doctors are higher than
in the general population.
 Among physicians, psychiatrists are
considered to be at greatest risk, followed by
ophthalmologists and anesthesiologists, but
all specialties are vulnerable.

69.  Public health policies must aim at improving
social work environment and contribute to
screening, assessment, referral, and
destigmatization of suicides in physicians
 Further, adequate quantity and quality
supplies of PPE, COVID-19 compliant work
practices and infection control measures are
required to harmonize and reduce the
burden of further stress and suicidal ideation

70. DECRIMINALIZATION OF SUICIDE
 According to the Section 115 of Mental
Healthcare Act (MHCA), 2017, suicide
attempters are presumed to have severe
stress, not to be punished and the
government should have duty to provide
care, treatment, and rehabilitation to reduce
the risk of recurrence. Decriminalization
might lead to openly seeking help,
improvement in epidemiological data, better
planning, and resource allocation

71.  On August 27, 2020, the Central government, in
a first, launched "KIRAN"— a mental health
rehabilitation helpline number (1800-599-0019)
— that intends to provide early screening, first-
aid, psychological support, distress management,
mental well-being and psychological crisis
management. The helpline will be managed by
the Department of Empowerment of Persons with
Disabilities (DEPwD).
 The line is operational and open to calls on a
trial basis

72.  AASRA is a Mumbai-based mental
health NGO which is noted for operating a 24
HOUR Helpline to cater to suicidal and
emotionally distressed individuals. The
service is an offshoot of Befrienders
Worldwide and Samaritans, whose India
chapter was established in 1960.

73.  Various webinars organised at IGMC - ‘Working
together to prevent suicide’ on World Suicide
Prevention Day, September 10
 Focussed on getting help that can be sought at
104, the medical helpline of the state
government.
 Facebook page named Stress /
depression/addiction management by
Department of psychiatry ,IGMC
 Helpline number provided by the Department of
Psychiatry