The document contains summaries of three psychiatric cases. The first case involves a 13-year-old boy who ingested agricultural pesticides after an argument with his mother and had symptoms of depression after losing his father. The second case describes a 16-year-old medical student experiencing symptoms of depression including fatigue, irritability, and suicidal ideation due to high stress and standards. The third case involves a 16-year-old girl with a history of suicidal thoughts and self-harm who was admitted to psychiatry due to active suicidal plans and symptoms of depression in the context of family dysfunction.

1. Dr. Tauhid Iqbali
M.D. Pediatrics

2. CASE#1
13 year old boy, presented to our emergency department with
fast breathing and altered sensorium, mother gave history of
agricultural pesticide ingestion following an argument with
her.

3. CASE#1 cont..
• Mother revealed that, he lost his father 6 month back, who
died of some liver problem, since then he was in a state of
solitude, depression and persistently refuse to go to work,
who was working as labourer in agriculture fields previously
and due to this he was in a constant dispute with his mother.

4. CASE#2
Akira is a 16 year-old girl. She has a very demanding, high
stress schedule as a second year medical student. Akira has
always been a high achiever. She has very high standards for
herself and can be very self-critical when she fails to meet them.
Lately, she has struggled with significant feelings of
worthlessness and shame due to her inability to perform well.
For the past few weeks Akira has felt unusually fatigued and
found it increasingly difficult to concentrate on studies.

5. CASE#2 cont..
• Her friends have noticed that she is often irritable and
withdrawn. She has called in sick on several occasions,
which is completely unlike her. On those days she stays in bed
all day, watching TV or sleeping. At home, Akira’s mother
has noticed changes as well. She’s shown little interest in
household work and has had difficulties falling asleep at
night. Although she hasn’t ever considered suicide, Akira has
found herself increasingly dissatisfied with her life. She’s
been having frequent thoughts of wishing she was dead.

6. CASE#3
Rehana is a 16 year-old girl admitted to psychiatry department
of PMCH because of active suicidal ideations manifested by
holding a knife to her arm that morning. Rehana has a history
of suicidal ideation and has tried to cut herself in the past, but
reported that the knife would not penetrate her skin. She was
concerned that she would not be able to stop herself again.
Rehana reported depression for the past 2 years and an
obsession with death since 8th grade. She is an obese girl who
appeared sad, making poor eye contact and demonstrating
poor social skills. Her affect was flat and apathetic. Rehana
reported difficulty sleeping, decreased energy, irritable mood
and trouble with her appetite.

7. CASE#3 cont..
• She also reported significant feelings of worthlessness,
helplessness and hopelessness. In addition to the above
symptoms, Rehana spoke about her imaginary friends,
which she has had since 6 years of age. Rehana’s parents
are divorced. Her mother is a victim of domestic violence,
and her father is an alcoholic. Rehana was diagnosed at
AIIMS Delhi Major Depressive Disorder with psychotic
disorder - not otherwise specified, schizophrenia
probability disorder.

8. Attitudes to Suicide
How does the word
‘suicide’
make you feel?
Do any of these attitudes apply to you?

9. People serious
about suicide
can’t be helped
so what’s the
point?
People who
talk about
suicide are
just attention
-seekers
People who
die by suicide
don’t give
warning signs
It’s mostly
young men
who die by
suicide
Talking about
suicide might
give someone
the idea to do
it

10. Suicide
WHAT IS IT?
Death caused by self-directed injurious
behavior with any intent to die as a result of
the behavior.

11. Suicide attempt: A non-fatal self-directed
potentially injurious behavior (may or may not
result in injury) with any intent to die as result of
the behavior.
Suicidal ideation: Thoughts of suicide that can range
in severity from a vague wish to be dead to active
suicidal ideation with a specific plan and intent.

12. Suicide is a Serious Problem?
• Average global suicide rate is 14.5 deaths per 100,000 people
• 3rd leading cause of death for young people ages 10-24 and
accounts for 20% of all deaths annually
• According to the WHO, every year, almost one million people
die from suicide and 20 times more people attempt suicide; a
global mortality rate of 16 per 100,000, or one death every
40 seconds and one attempt every 3 seconds, on average.
• Suicide worldwide was estimated to represent 1.8% of the
total global burden of disease in 1998; in 2020, this figure is
projected to be 2.4%

13. Suicide is a Serious Problem? Cont..
• WHO statistics and studies covering global patterns
of youth suicides rank India amongst the Top 3, along
with the US and Australia.
• The rates of suicide have greatly increased among
youth, and youth are now the group at highest risk.
• Top methods used – poisoning, firearms, suffocation.

14. Age specific suicide rates in India

15. Region specific suicide rates in India
Figures are higher in the better-off
southern states and the lowest in
the Hindi heartland.
A study published in the British medical journal The Lancet indicates that the suicide
rate in the 15-19 group living around Vellore in Tamil Nadu, India, was 148 per 100,000
for women, and 58 per 100,000 for men.
Teens in Southern India
Have the World's Highest
Suicide Rates

17. Risk and Protective Factors
Risk factors – Increase likelihood that a young
person will engage in suicidal behavior
Intrapersonal
Social/situational
Cultural/environmental
Protective factors – Mitigate or eliminate risk
Intrapersonal
Social/situational
Cultural/environmental

18. Consider the balance between the two

19. Risk Factors: Intrapersonal
• Recent or serious loss
• Mental disorders (particularly mood disorders)
• Hopelessness, helplessness, guilt, worthlessness
• Previous suicide attempt
• Alcohol and other substance use disorders
• Disciplinary problems
• High risk behaviors
• Sexual orientation confusion

20. Mental illness- 90- 95% have a diagnosed
mental disorder
Psychiatric patients: Depressive disorder- 80%
Alcohol related disorders – 4-60%
Schizophrenic disorder- 3-10%
Personality disorder- 5-44%
Organic mental disorder- 2-7%

21. Risk Factors: Social/Situational
• Recent or serious loss (e.g., death, divorce,
separation, broken relationship; self-esteem; loss
of interest in friends, hobbies, or activities
previously enjoyed)
• Family history of suicide
• Witnessing family violence
• Child abuse or neglect
• Lack of social support
• Sense of isolation
• Victim of bullying or being a bully

22. Sociological Factors
 Durkheim’s Theory:
Emile Durkheim ( French Sociologist )
suicide

23. Egoistic - This type of suicide occurs when the degree of
social integration is low
Altruistic - degree of social integration too high
Anomic – Integration into society is disturbed

24. Cyber bullying
• Online bullying - 1/3 of children
• Every 30 mts a child attempts suicide due to
bullying

25. Risk Factors: Cultural/Environmental
• Access to lethal means (i.e. firearms, pills)
• Stigma associated with asking for help
• Barriers to accessing services
• Lack of bilingual service providers
• Unreliable transportation
• Financial costs of services
• Cultural and religious beliefs (e.g., belief that suicide
is noble resolution of a personal dilemma)

26. Protective Factors
• Skills in problem solving, conflict resolution and handling
problems in a non-violent way
• Strong connections to family, friends, and community support
• Restricted access to highly lethal means of suicide
• Cultural and religious beliefs that discourage suicide and
support self-preservation
• Easy access to a variety of clinical interventions
• Effective clinical care for mental, physical, and substance use
disorders
• Support through ongoing medical and mental health care
relationships

27. Warning Signs
A warning sign does not mean automatically
that a person is going to attempt suicide, but
it should be responded to in a serious &
thoughtful manner
Do not dismiss a threat as a cry for attention!
What kinds of warning
signs are cause
for concern?

28. Specific Warning Signs
• Talking About Dying - Any mention of dying, disappearing,
jumping, shooting oneself, or other types of self harm
• Change in Personality - Sad, withdrawn, irritable, anxious,
tired, indecisive, or apathetic
• Change in Behavior - Difficulty concentrating on school,
work, or routine tasks
• Change in Sleep Patterns - Insomnia, often with early
waking or oversleeping, nightmares
• Change in Eating Habits - Loss of appetite and weight,
overeating
• Fear of losing control - Acting erratically, harming self or
others

29. • “I can't go on anymore"
• "I wish I was never born"
• "I wish I were dead"
• "I won't need this anymore“
• "My parents won't have to worry about me anymore"
• “Everyone would be better off if I was dead”
• “Nobody cares if I live or die “
Verbal warning signs

30. • Pesticide poisoning(30%)
• Hanging
Common Methods of Suicide

31. • Firearms
• Drug overdose
• Fatal injuries

32. • Exsanguinations
• Suffocation
• Drowning

33. • Parasuicide : injures themselves by self mutilation
but do not wish to die
• Cyber-suicide : suicide pact made between
individuals who meet on the internet
• Copycat suicide : a suicide within a peer
group/publicized suicide can serve as a model for
next suicide in absence of sufficient protective
factors (Werther syndrome)
• Anniversary suicide: persons take their lives on the
day a member of their family did
Terminologies

34. STAGES OF SUICIDE
Ideation
Threatening
Attempting
34
Intervention

35. Treatment of suicide attempters
For every completed case of suicide there are
about 20 non fatal attempts
Repetition – 15-25% within a year
Poor problem solving skills
Treatment

36. Psychosocial treatment
a) Problem-solving
b) Psychotherapy
c) Distress-tolerance skills
d) Outreach
e) Provision of emergency cards
f) Family therapy
cont..

37. Pharmacological treatment
a) Antidepressants- fluoxetine, should be
always combined with other therapies
b) Neuroleptics- flupenthixol 20mg for 6 months
c) Lithium

38. 1) Assessment- ( SAD PERSON’S scale – high specificity
but low sensitivity so not used anymore)
2) Treatment:
a) Psychiatric disorders to be treated
b) Community therapy- problem solving and outreach
c) Adolescents – family therapy, group therapy
Management in clinical practice

39. • General principles
• Population strategies
• High-risk strategies
Prevention
39

40. “Are you thinking of suicide?”
“Have you been contemplating suicide?”
“Sometimes people who say things like that are thinking of suicide. Are you
thinking of suicide?”
Be calm and matter-of-fact
“Are you suicidal?”
“I’m worried about you and I need to ask; are you thinking of suicide?”
Ask About Suicide
General principles

41. Be Aware of your Tone and Expression

42. Be quiet and listen
Don’t advise, lecture,
interrogate or judge

43. Safe Plan
“How long can you keep yourself
safe?”
“Who can help?”

44. Time for Action - Some Suggestions
Don’t turn your back when people hint at mental
health concerns

45. Population strategies:
Intervention at community level:
1. Increasing public awareness
2. Campaign to reduce stigma
3. Guidelines for the mass media
4. Regulating formulations, packaging and sale of pesticides
5. Regulation of over-the-counter medication
6. Gender-related legislation and action
7. Introducing alcohol policies

46. Interventions at institutional and
organizational levels:
1. Establishing sentinel centres and developing an information
system
2. Training of personnel working in high risk settings
3. Establishing crisis intervention and counselling centres and
telephone hotlines
4. Increase in specific clinical training programmes for lay
counsellors
5. Redesigning the curriculum for medical and nursing
personnel
6. Intervention programmes for high schools

47. High-risk strategies
1. Patients with psychiatric disorder
a) Risk identification
b) Preventive strategies- active treatment of
individuals and psychological therapy

48. 2. Suicide attempters
3. High-risk occupational groups- all these groups
have easy access to methods of suicide (removing
the access)
4. Prisoners- young males held at remand
Ensuring that prison cells are safe in terms of
absence of structures favorable for suicide

49. SUICIDE PREVENTION DAY-10TH
SEPTEMBER

50. When someone is suicidal , he or she will always
remain suicidal
• Heightened suicide risk is often short-term and
situation-specific.
• While suicidal thoughts may return, they are not
permanent and individual with previously suicidal
thoughts and attempts can go on to live a long
life.
Myths

51. Talking about suicide is a bad idea and can be
interpreted as encouragement
Given the widespread stigma around suicide,
most people who are contemplating suicide do
not know who to speak to. Rather than
encouraging suicidal behaviour, talking openly
can give an individual other options or the time
to rethink his/her decision, thereby preventing
suicide.

52. Only people with mental disorders are
suicidal
Suicidal behaviour indicates deep
unhappiness but not necessarily mental
disorder.

53. Most suicides happen suddenly without
warning
The majority of suicides have been preceded
by warning signs, whether verbal or
behavioural.

54. Someone who is suicidal is determined to die
On the contrary, suicidal people are often
ambivalent about living or dying

55. People who talks about suicide do not mean
to do it
People who talk about suicide may be
reaching out for help or support

56. Key message