Suicide risk

1. Suicide – risk assessmemt
and management

2. introduction
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. Terms and definitions
• 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. epidemiology
• 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. Etiology
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. Risk Factors
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. 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.

17. At risk individuals
• 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

18. • Amongst vulnerable groups-
Refugees and migrants
Bisexual or homosexual gender identity
prisoners

19. • 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

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

21. Warning Signs
• 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)

22. 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

23.  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

24. Presentation
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

25. Components of suicide
assessment
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

26. 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

27. 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

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

29. 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

30. Evaluation of attempt
• 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

31. scales
• 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

32. Treatment
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

33. Primary Prevention
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.

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

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

36. 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.

37. Treatment Interventions
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

38. 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.

39. 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)

40. 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

41. 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.

42. 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.

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

44. 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.

45. Secondary Prevention
• 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.

46. • 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

47. • Regularly scheduled office visits may improve the patient’s
medication continuation

48. 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.

49. 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

50. 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.

51. 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.

52. 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).

53. • 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.