This document defines various terms related to suicide and discusses suicide from epidemiological, etiological, and clinical perspectives. It notes that over 90% of suicides are associated with psychiatric disorders like depression and substance abuse. Key risk factors include male gender, older age, social isolation, impulsivity, and a family history of suicide. A comprehensive suicide assessment evaluates psychiatric illnesses, risk and protective factors, and determines the level of risk to guide treatment and safety planning.

1. SUICIDE
DR. YASHASREE POUDWAL
DEPT. OF PSYCHIATRY
K.J. SOMAIYA HOSPITAL

4. TERMS AND DEFINITIONS
 SUICIDE: Death caused by self-directed injurious
behavior with any intent to die as a result of the
behavior.
 LEGAL DEFINITION: INTENTIONAL act of self destruction
committed by someone knowing what he is doing and
the probable consequences of his action.
 SUICIDE ATTEMPT: A non-fatal self-directed potentially
injurious behavior with any intent to die as result of the
behavior. A suicide attempt may or may not result in
injury.

5.  INDIRECT SUICIDE:
 The act of setting out on an obviously fatal course without
directly committing the act upon oneself. Indirect suicide is
differentiated from legally defined suicide by the fact that
the actor does not pull the figurative (or literal) trigger.
Examples of indirect suicide include a soldier enlisting in the
army with the express intention and expectation of being
killed in combat.
Another example would be "suicide by cop” in which a police
officer is provoked into using lethal force against them.
High risk-taking behaviors and unhealthy lifestyles may
reflect an intent to die. Studies have suggested that many
more auto accidents are some form of indirect suicide than
believed

6.  PARA SUICIDE:
 Suicide attempts or gestures and self-harm
where there is no result in death. It is a non-fatal
act in which a person deliberately causes
injury to him/herself or ingests any prescribed
or generally recognized therapeutic dose in
excess. Studies have found that about half of
those who commit suicide have a history of
Para suicide.
 SELF-HARM (SH) OR DELIBERATE SELF-HARM
(DSH):
The intentional, direct injuring of body tissue
most often done without suicidal intentions.
The person's primary intention is to relieve
unbearable emotions, sensations of unreality,
or feelings of numbness by injuring their body.

7.  SUICIDAL GESTURES
Include cutting, whereby the cut is not deep enough to cause
significant blood loss, or taking a non-lethal overdose of
medication.
Suicidal gestures are typically done to alert others of the
seriousness of the individual's clinical depression and suicidal
ideation, and are usually treated as actual suicide attempts by
hospital staff. Some suicidal gestures do lead to death, despite
the individual not having the intention of dying.
 SUICIDE THREAT:
 Any interpersonal action, verbal or nonverbal, stopping short
of a directly self-harmful act, that a reasonable person would
interpret as communicating or suggesting that a suicidal act
or other suicide-related behavior might occur in the near
future.

8.  SUICIDAL IDEATION:
 Thoughts of suicide. These thoughts can range in
severity from a vague wish to be dead to active
suicidal ideation with a specific plan and intent.
Although most people who undergo suicidal
ideation do not commit suicide, some go on to
make suicide attempts.

9.  SUICIDE SURVIVOR:
 A friend or family
member who has
experienced the suicide
death of someone they
cared about

10. Shneidman’s Ten Commonalities
of Suicide (1985)
1. The common stimulus is unendurable psychological pain (i.e.,
psychache).
2. The common stressor in suicide is frustrated psychological needs.
3. The common purpose of suicide is to seek a solution.
4. The common goal of suicide is cessation of consciousness.
5. The common emotion in suicide is hopelessness-helplessness.
6. The common internal attitude toward suicide is ambivalence.
7. The common cognitive state in suicide is constriction.
8. The common interpersonal act in suicide is communication of intention.
9. The common action in suicide is egression (i.e., escape).
10. The common consistency in suicide is with life-long coping patterns.

11. SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness
Neurobiology
Severe Medical
Illness
Impulsiveness
Access To Weapons
Hopelessness
Life Stressors
Family History
Suicidal
Behavior
Personality
Disorder/Traits
Co-morbidity
Psychodynamics/
Psychological Vulnerability
Substance
Use/Abuse
Suicide

12. EPIDEMIOLOGY
 GLOBAL SCENARIO
 Over 1 million per yr
 GLOBAL SUICIDE RATE – 16/100000
 1.8% Deaths- due to suicide
 2nd leading cause of death in youth after road traffic accidents
 AGE
Comparatively rare before puberty
Males- more in 20-30yrs, after 65 yrs of age
Females- highest in middle age
Elderly & Late adolescence are at additional risk

13.  Suicidal attempt - 20 times common than completed
suicide and is more common in females (completed suicide
is more common in males).
 Suicidal thought - attempt – act= 100 : 10 : 1
 Psychiatric illness (90%) –Depression ,Schizophrenia,
Alcoholism , Drug addiction, Organic disorders (epilepsy,
brain disease, mild dementia),Personality disorders

15. GENDER DIFFERENCES
MALES
 Completed rates higher
 More lethal and more
violent methods used
 More premeditation,
depression
 Substance use more
common
 Less likely to seek
professional help with
issues
FEMALES
 Attempts higher
 Less lethal and violent
methods preferred
 More impulsive, labile
 Substance use less common
 More likely to seek
professional help with
issues

16. China, India and
Japan may
account for 40%
of all suicides
(WHO estimates)

17. INDIAN SCENARIO
 > 10% OF SUICIDES IN THE WORLD
 Suicide rate 21.1 per 100000 (2012) (67% increase over 1980 values)
 1 SUICIDE EVERY 5 MIN, 1 ATTEMPT PER MIN.
 242 males and 129 females commit suicide daily on an average
 275 below the age of 45
 Southern states - Kerala, Karnataka, Andhra Pradesh, Tamil Nadu
have a suicide rate of > 15
 Northern States of Punjab, Uttar Pradesh, Bihar and Jammu-Kashmir,
the suicide rate is < 3.
 71 %- <44 yrs of age
 male: female ratio of 1: 0.66

18.  Poisoning (36.6%), hanging (32.1%) and self-immolation
(7.9%) most common methods
 Males – more of socioeconomic causes
Females-more of emotional and personal causes
 Presence of suicidal thought – 5 -10% in the Indian
population.
 India accounted for the highest estimated number of
suicides in the world in 2012, according to a recent
WHO report which found that one person commits
suicide every 40 seconds globally.

20.  According to the official data, reason for suicide is
not known for about 43% of suicides, while illness
and family problems contribute to about 44%

21.  M:F = 64 :36
 Boy : girl =48 : 52
 More than 60% in
age group 15-
44yr.
 37% in 15 - 29 yr.
 34% in 30 to 44yr.

23. CLASSIFICATION
 DURKHEIMS CLASSIFICATION
1. EGOISTIC
High isolation, excessive individuation, not strongly integrated into
society
2. ALTRUISTIC
Excessive integration into group or society, insufficient individuation
3. ANOMIC
Experiences trauma, society changes. if bond between people
loosened, with no regulation and norms of living in society.
4. FATALISTIC
Excessive regulation, no personal freedom and hope e.g. farmer
suicide in India

24.  COMMON METHODS
 A asphyxiation
 B blunt force trauma
 C cuts, stabs
 D drowning, drugs, chemicals, poisons
 E electricity, explosives
 F fire
 G guns
 H hanging, hypothermia
 I intentional overdose
 Pact/ cult suicides, suicide missions etc

26.  Mass/Family suicide –
237 cases in 2006. Max. in Chhattisgarh, then Kerala
and Rajasthan.
 Govt. servant- 1.8% of total. Students 5.2%
 More than 20% – by housewives.
 47% married male, 25.3% married females
 72.2% married, 20.7% unmarried
 One-fifth of senior citizen suicide victims – belong to
Kerala.
 Max. child suicide – Andhra Pradesh 14.8% (364 out of
2464)

27. ETIOLOGY

28. PSYCHOLOGICAL
 FREUD – anger turned inwards against introjected,
ambivalently cathected love object
 ZILBOORG – fantasies
 MENINGER- wish to die, wish to kill, wish to be
killed
 KLEIN – defense mechanisms involved
 GOMEZ- D/t illness
 ROTJENBERG- Alternative to intense psychological
pain
 JAMISON, STYRON- utter hopelessness

29. BIOLOGICAL
 GENETICS
 Polymorphism- in genes for tryptophan hydroxylase, MAO-A
 5-HT2A receptor, 5-HTT involved
 FAMILY STUDIES- Relatives of suicidal subjects have a four-fold
increased risk compared to relatives of non-suicidal
subjects
 TWIN STUDIES- Twin studies indicate a higher concordance of
suicidal behavior between identical rather than fraternal
twins.
 ADOPTION STUDIES- a greater risk of suicide among biologic
rather than adoptive relatives.

30. NEUROCHEMICAL/
NEUROANATOMICAL
 Low CSF 5HIAA
 DECREASED 5HT transporter binding in PFC
 INCREASED binding post synaptic 5HT1A,2A in PFC
 INCREASED CRF conc. In CSF
 DECREASED CRF binding sites in frontal cortex
 Decreased NE transmission in locus cereleus, decreased
neurons

31.  Elevated 24-hour urinary cortisol
production
 significantly smaller 24-hour urinary output
of the dopamine metabolite homovanillic
acid (HVA) , increased plasma cortisol
levels
 Dexamethasone non suppression, HPA axis
hyperactivity
 Increased plasma AVP conc. Decreased
cholesterol levels
 Blunted TSH, Prolactin responses

32. BIOPSYCHOSOCIAL MODEL
(STRESS-DIATHESIS MODEL)
 These hold that individuals who are
born with genetically modulated
tendencies toward impulsivity (the
diathesis), when stressed by
external events later in life—
particularly if they become
depressed—are more likely to harm
themselves than those not so
predisposed.

34. RISK FACTORS
Demographic male; widowed, divorced, single; increases with age; white
Psychosocial lack of social support; unemployment; drop in socio-economic
status; firearm access
Psychiatric psychiatric diagnosis (es); comorbidity
Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease;
hemodialysis; systemic lupus erthematosis; pain syndromes;
functional impairment; diseases of nervous system
Psychological
Dimensions
hopelessness; psychic pain/anxiety; agitation; psychological
turmoil; decreased self-esteem; fragile narcissism &
perfectionism
Behavioral
Dimensions
impulsivity; aggression; severe anxiety; panic attacks;
agitation; intoxication; prior suicide attempt
Cognitive
Dimensions
thought constriction; polarized thinking; rigidity
Trauma sexual/physical abuse; neglect; parental loss; traumatic
events
Genetic & Familial family history of suicide, mental illness, or abuse

35. PROTECTIVE FACTORS
 Children in the home, except among those with postpartum
psychosis
 Pregnancy
 Deterrent religious beliefs
 Life satisfaction
 Reality testing ability
 Positive coping skills
 Positive social support
 Positive therapeutic relationship

36. PROTECTIVE FACTORS
Research has found that the following protective factors can
counterbalance suicidal vulnerabilities:
 having social supports
 being cognitively flexible
 obtaining treatment (especially psychotropic medications)
 being a younger female
 being physically healthy
 being hopeful
They conclude that suicidal outcome is not only a joint product of
risk, vulnerability, and psychiatric disorder, but also
counterbalanced by protection, competency, and resilience.

37. DETERMINATION OF RISK
Psychiatric Examination
Risk
Factors Protective
Factors
Specific Suicide
Inquiry
Modifiable Risk
Factors
Risk Level:
Low, Med., High

38. SUICIDE AND PSYCHIATRIC DISORDERS
 Mental disorders (mainly depression and substance abuse) contribute to
more than 90% causes of suicide
 MOOD DISORDERS – Risk 6-15%
 Bipolar pts. – nearly 10-20% risk of suicide. Rest 10%
 patients with depressive disorders commit suicide early in the illness than
later
 more depressed men than women commit suicide;
 single, separated, divorced, widowed, or recently bereaved.
 middle-aged or older, Social isolation.
 Suicide among depressed patients- likely at the onset or the end of a
depressive episode esp. in months after
 Inadequate treatment
 Comorbid SUBSTANCE USE disorder, psychotic depression, +ve family history

39. SCHIZOPHRENIA AND SUICIDE
 10% risk. Esp. early on in the illness
 Risk factors : young age, male gender, single
marital status, a previous suicide attempt, a
vulnerability to depressive symptoms, and a recent
discharge from a hospital, Personal and family
history, Living alone or not living with the family,
Higher education ,Recent loss events
 Agitation, Sense of worthlessness, hopelessness,
Sleep disturbance, Fear of mental disintegration,
Poor adherence to treatment, Comorbid
Depression (recent or past), Substance
dependence, Impulsivity

40. SUBSTANCE USE AND SUICIDE
 7-15% RISK
 MAINLY male, middle-aged, unmarried, friendless,
socially isolated, and currently drinking, previous
suicide attempt, within a year of the patient's last
hospitalization; post discharge period, IP loss,
comorbid depression, mood disorder, ASPD
 ADOLESCENTS with iv drug use

41.  Other axis 1 disorders – anxiety disorders,
panic disorder, dysthymia, adjustment
disorder, conduct disorder, dementia,
delirium
 AXIS II DISORDERS
 BORDERLINE PD (8.5%)
 ASPD (5%)
 NARCISSISTIC PD
IMPULSIVITY

42.  SUICIDE IN CHILDHOOD AND ADOLESCENCE
 Rare in < 5 yrs. of age, increasing in pre-pubescence,
adolescence
 Ideation more common than attempts
 Impulsivity, psychiatric disorders, substance use, aggression,
poor problem solving
 Copy cat suicides, internet suicides, “ werther syndrome”
 Suicide more common in boys, attempts more common in
girls
 risk factors in suicide include a family history of suicidal
behavior, exposure to family violence, impulsivity, substance
abuse, and availability of lethal methods

43.  SUICIDE IN ELDERLY
 More in males, single, widowed, divorced, living
alone, chronic illness, mood disorder
 High lethality, few warning signs, greater planning
TERMINALLY ILL
MIGRANT POPULATION

44. COMPONENTS OF SUICIDE ASSESSMENT
• Appreciate the complexity of suicide / multiple
contributing factors
• Conduct a thorough psychiatric examination,
identifying risk factors and protective factors and
distinguishing risk factors which can be modified from
those which cannot
• Ask directly about suicide; The Specific Suicide
Inquiry
• Determine level of suicide risk: low, moderate, high
• Determine treatment setting and plan
• Document assessments

45. Areas to Evaluate in Suicide Assessment
Psychiatric
Illnesses
Comorbidity; Affective Disorders; Alcohol /
Substance Abuse; Schizophrenia; Cluster B
Personality disorders.
History Prior suicide attempts, aborted attempts or self
harm; Medical diagnoses; Family history of suicide /
attempts / mental illness
Individual
strengths /
vulnerabilitie
s
Coping skills; personality traits; past responses to
stress; capacity for reality testing; tolerance of
psychological pain
Psychosocial
situation
Acute and chronic stressors; changes in status;
quality of support; religious beliefs
Suicidality
and
Symptoms
Past and present suicidal ideation; plans, behaviors;
intent; methods; hopelessness; anhedonia; anxiety
symptoms; reasons for living; associated substance
use; homicidal ideation

46. Suicide Risk Categories
I. Baseline – Absence of an acute (i.e., crisis) overlay, no
significant stressors not prominent symptomatology. Only
appropriate for ideators and single attempters.
II. Acute – Presence of acute (i.e., crisis) overlay, significant
stressor(s) and or prominent symptomatology. Only
appropriate for ideators and single attempters.
III. Chronic high risk – Baseline risk for multiple attempters.
Absence of an acute (i.e., crisis) overlay, no significant
stressors not prominent symptomatology.
IV. Chronic high risk with acute exacerbation – Acute risk
category for multiple attempters. Presence of acute (i.e.,
crisis) overlay, significant stressor(s) and/or prominent
symptomatology.

47. RATING SCALES
 PIERCE SUICIDE RISK SCORE
 BECKS SUICIDAL INTENTION SCALE
 BECKS HOPELESSNESS SCALE
 MODIFIED SAD PERSONS SCALE
 SUICIDE PROBABILITY SCALE
 CALIFORNIA SUICIDE RISK ESTIMATION SCALE
 WEISSMAN AND JORDAN RISK- RESCUE RATING
SCALE

48. SUICIDAL THOUGHTS, PLANS,
BEHAVIOR
 Elicit the presence of suicidal ideation
 Elicit the presence of suicide plan
 degree of suicidality including intent and lethality
 Consider assessing the patient's potential to harm
others in addition to him- or herself

49. GENERAL GUIDELINES FOR PRACTICE
AND TREATMENT
1. Establish a clear treatment plan with the client as to how
suicidal thoughts, feelings, and behaviors will be managed
on an outpatient basis.
2. Closely monitor and document ongoing suicidality until it
resolves.
3. Consider and use all appropriate modalities (e.g., various
therapies: CBT, DBT, EMDR, Behavioral Activation Therapy,
journaling, exercise, couples counseling, bibliotherapy),
vocational counseling, medication, etc.
4. Routinely seek professional consultation and document
such.
5. Document the resolution of suicidality; monitor for any
future reoccurrence.

50. SOMATIC TREATMENTS
ECT Evidence for short-term reduction of suicide
Benzodiazepines May reduce risk by treating anxiety
Antidepressants A mainstay treatment of suicidal patients with
depressive illness / symptoms.
Lithium and
Anti-convulsants
Lithium has a demonstrated anti-suicide effect;
anticonvulsants not so much
Antipsychotics Evidence for Clozapine reducing suicidality in
schizophrenia and schizo-affective disorders

51. PSYCHOTHERAPY
 CBT, PROBLEM SOLVING
 DIALECTICAL
 GROUP THERAPY
 SHORT TERM
 INTERPERSONAL
 PSYCHOANALYTICAL

52. FOLLOW UP ESSENTIAL,
DOCUMENTATION ESSENTIAL
 LEGAL ASPECTS –
 firearm control legislation, restrictions on pesticides, restrictions on the
prescription and sale of barbiturates and other medications
 SUICIDAL ATTEMPT ILLEGAL ( SEC 309 IPC)
 ABETTMENT OF SUICIDE PUNISHABLE (SEC 306 IPC)
 SUICIDE HELPLINES- AASRA, SAMARITAN, SNEHA
 SUPPORT GROUPS, NO SELF HARM CONTRACTS
 DECREASED MEDIA SENSATIONALISATION

53. WHEN A SUICIDE OCCURS
Despite best efforts at suicide assessment and
treatment, suicides can and do occur in clinical
practice
Approximately, 12,000-14,000 suicides per year occur
while in treatment.
To facilitate the aftercare process:
 Ensure that the patient’s records are complete
 Be available to assist grieving family members
 Remember the medical record is still official and
confidentiality still exists
 Seek support from colleagues / supervisors

54. COLLABORATIVE ASSESSMENT &
MANAGEMENT OF SUICIDALITY (CAMS)
METHOD
 Developed by Dr. David Jobes (2006).
 A specific clinical approach and a philosophy of working with suicidal clients.
 The CAMS approach conceptualizes the assessment and treatment of suicidal
patients in a fundamentally different way than current conventional approaches.
 CAMS is inherently designed to help shift clinicians’ attitudes and approaches by
changing our conceptualization of suicide as a clinical problem and thereby
changing how we assess and treat this problem.
 CAMS approach does not focus on alleviating problems like depression, but rather
concerns itself with suicidality. By maximizing alliance and motivation CAMS assists
the client to develop coping and problem-solving skills to make suicide an
unnecessary option.
The core multipurpose tool used in all phases of the CAMS is the Suicide Status Form
(SSF).Use of the SSF within CAMS enables both parties to examine and work with
the client’s suicidality in a relatively objective manner.

55. NOTE ON CONTRACTING FOR
SAFETY!!!
The concept of contracting for safety (also known as no-suicide
contracts or agreements, no-harm contracts, and suicide prevention
contracts), although a popularly accepted method for managing
suicidal patients for more than 30 years, has no scientific evidence to
support its effectiveness.
At times, contracting is often the primary factor in clinical decision-making,
justifying a lower level of intervention or concern.
The ultimate focus of suicide contracting is not on the safety
agreement itself but on the process it engenders to engage staff and
patient in a dynamic, meaningful relationship for identifying patient
needs, encouraging disclosure of distress, and assuring consistent
support and appropriate interventions.

56. PREVENTION OF SUICIDE

58. AREAS OF FOCUS
• Education and awareness programs for the general
public and professionals
• Screening methods for high-risk persons
• Treatment of psychiatric disorders
• Restricting access to lethal means
• Media reporting of suicide.

60. •WHO DECLARED THE FIGHT
AGAINST SUICIDE AS A
PRIORITY FOR THE FIRST
TIME IN THE YEAR 2000.

61. Suicide Prevention
(SUPRE) Project - WHO
 By WHO Dept. of Mental Health and
Substance Abuse (1999).
 Objectives-
1. To reduce mortality/morbidity due to
suicidal behavior.
2. To break taboo surrounding suicide.
3. To bring together national authorities and
public.

62. WORLD SUICIDE PREVENTION
DAY
• Efforts to prevent suicide have been celebrated on 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.'
• The theme reflects the fact that connections are important at
several levels if we are to combat suicide.
• World Suicide Prevention Day in 2014 is significant because it
marks the release by the WHO of the World Suicide Report (WSR).
The report follows the adoption of the Comprehensive Mental
Health Action Plan 2013-2020 by the World Health Assembly,
which commits all 194 member states to reducing their suicide
rates by 10% by 2020.

63. THANK YOU