SUICIDE

MEANING OF SUICIDE: -
Suicide (Latin suicidium, from sui means 'kill' and caedere means 'oneself'), hence it is
an act of killing oneself. It is a self-destructive behavior that shows a high possibility
of happening in the immediate hours.

DEFINITION: -
Suicide – defined as an act with a fatal outcome that is deliberately initiated and
performed by the person in the knowledge or expectation of its fatal outcome

Terminologies: -
Suicide: Suicide is the intentional taking of one's own life.
Attempted suicide: It is self-injury with at least some desire to end one's life that does
not result in death.
Assisted suicide: It is suicide undertaken with the aid of another person.
Physician-assisted suicide (PAS): Suicide that is assisted by a physician or other
healthcare provider.
Euthanasia: It is also called mercy killing, act or practice of Painlessly putting to
death persons suffering from painful and incurable disease.

EPIDEMIOLOGY: -
 More than 8,00,000 people die by suicide every year around one person every
40 seconds, according to WHO's first global report on suicide prevention.
 75% of suicides occur in low- and middle-income countries.
 Worldwide suicide rates have increased by 60% in the past 45 years.
 Males die much more often by means of suicide than do females, although
females attempt suicide more often.
 Patient with alcoholism is 5-20 times more likely to commit suicide.
 Among adolescents' alcohol or drug misuse plays a role in up to 70% of
suicides.
 Suicide is one of the top three causes of death among the young in the age group
of 15-35 years.
 The psychological, social and financial impact of suicide on the family and the
society is immeasurable.
 A history of suicide attempt is the single most important risk factor for suicide
in the general population.
  Suicide is 10th leading cause of death worldwide.
 Suicide is 2nd leading cause of death among 15-29-year-olds.
 Ingestion of pesticide, hanging and firearms are among the most common
methods of suicide globally.

Suicides in India (Indian Journal of Medical Research, 2019)

 About 1 lakh people die by suicide in India every year
 Each suicide leaves at least 6 people devastated.
 Six lakhs’ people become survivors every year in India.
 Current prevalence rate in India is 10.8 per 10,00,000.

Important Consideration
Asking direct questions about suicidal attempt does not cause the patient to commit
suicide or instill the idea of committing suicide. In fact, patients feel relieved on being
asked about suicidal ideation and being explained that their ideas are part of an illness.

TYPES OF SUICIDE: -
According to Durkheim theory there are five major types of suicidal attempt or
suicide.
Type Description Example
1. Egoistic Person commits suicide because of Refugees, divorce.
suicide the feeling of lack of integration into
society, person feel separated,
helpless, useless and inadequate.
2. Altruistic Person feels that something larger Religious sacrifices or
suicide than himself is causing him to take suicide bombers.
his own life.
3. Anomic Person unable to cope with the Suicide rate increase
suicide sudden during COVID-19
unexpected major changes in the pandemic.
society or lack of regulation of the
individual by society.
4. Fatalistic This type of suicide is due to over Servant or slave
suicide regulation in society. commits suicide.
Childless woman
commits suicide.
5. Copycat Person commits suicide by imitating Many people committed
 suicide the suicide of another person. suicide by imitating the
suicide a famous
Bollywood actor in year
2020

THEORIES OF SUICIDE: -
Theories of suicide help one to understand its etiology and associated concepts.
1. Psychological Theories: -
Anger Turned Inward. Freud (1957) believed that suicide was a response to the
intense self-hatred that an individual possessed. The anger had originated toward a
love object but was ultimately turned inward against the self. Freud believed that
suicide occurred as a result of an earlier repressed desire to kill someone else. He
interpreted suicide to be an aggressive act toward the self that often was really directed
toward others.
Hopelessness. Hopelessness as a central underlying factor in the predisposition to
suicide.
Desperation and Guilt. With desperation, an individual feels helpless to change, but
he or she also feels that life is impossible without such change. Guilt and self-
recrimination are other aspects of desperation
History of Aggression and Violence. Violent behavior often goes hand-in-hand with
suicidal behavior. The suicidal behavior in violent individuals to conscious rage,
therefore citing rage as an important psychological factor underlying the suicidal
behavior.
Shame and Humiliation. Some individuals have viewed suicide as a ―face-saving‖
mechanism—a way to prevent public humiliation following a social defeat such as a
sudden loss of status or income. Often these individuals are too embarrassed to seek
treatment or other support systems.
Developmental Stressors. The stressors of conflict, separation, and rejection are
associated with suicidal behavior in adolescence and early adulthood. The principal
stressor associated with suicidal behavior in the 40- to 60-year-old group is economic
problems.

2. Sociological theory: -
Durkheim's Theory of Suicide
Durkheim emphasize social causes of suicide and stated that suicide is the result of
social disorganization or lack of social integration. He believed that the more cohesive
the society, and the more that the individual felt an integrated part of the society, the
less likely he or she was to commit suicide.

3. Biological Theories: -
Genetics. Twin studies have shown a much higher concordance rate for monozygotic
twins than for dizygotic twins.
Neurochemical Factors: -
deficiency of serotonin (measured as a decrease in the levels of 5-hydroxyindole
acetic acid [5-HIAA] of the cerebrospinal fluid) in depressed clients who attempted
suicide. Some changes in the noradrenergic system of suicide victims have also been
reported.

4. Interpersonal-Psychological Theory (Thomas Joiner)

Stated that when people feel self-burden and have a sense of low belongingness,
develop the desire for death.

5. Psychodynamic Theory
Sigmund Freud stated that suicide represents a psychological conflict, which cannot be
worked out due to the great force of depressed thinking.

[Link] Ericson Theory

Stated that hopelessness in an individual leads to a negative outlook on themselves and
future, ultimately leads to suicide.

LEVELS OF SUICIDAL BEHAVIOR: -

Ideation: Frequent and repeated thoughts of death.
Planning: A logical and well-prepared suicide plan with a good likelihood of success.
Gesture: Behavior or activity that is dangerous and/or harmful, but not potentially
lethal.
Attempt: Clear, self-destructive actions with a good probability or expectation of
lethality that do not result in death.
Successful suicide: Destructive and harmful action that results in one's own death.

RISK FACTORS: -
Marital Status
The suicide rate for single persons is twice that of married persons. Divorced,
separated, or widowed persons have rates four to five times greater than those of the
married
Gender
Women attempt suicide more, but men succeed more often. Successful suicides
number about 70 percent for men and 30 percent for women.
Age
Youth in the age group 15-29 years accounted for the largest proportion (34.5%) of
suicides followed by those in the age group 30-44 years (34.2%).
Religion
Depressed men and women who consider themselves affiliated with a religion are less
likely to attempt suicide than their nonreligious counterparts.
Socioeconomic Status
Individuals in the very highest and lowest social classes have higher suicide rates than
those in the middle classes. With regard to occupation, suicide rates are higher among
physicians, artists, dentists, law enforcement officers, lawyers, and insurance agents.

Ethnicity
With regard to ethnicity, statistics show that whites are at highest risk for suicide,
followed by Native Americans, African Americans, Hispanic Americans, and Asian
Americans.
Other Risk Factors
Individuals with mood disorders (major depression and bipolar disorder) are far more
likely to commit suicide than those in any other psychiatric or medical risk group.
Other psychiatric disorders that may account for suicidal behavior include
psychoactive substance abuse disorders, schizophrenia, personality disorders, and
anxiety disorders.
Psychosis, especially with command hallucinations, poses a higher-than-normal risk.
Affliction with a chronic painful or disabling illness also increases the risk of suicide
ETIOLOGY OF SUICIDE: -
Psychiatric/ physical factors:
 87-98% of the people commit suicide have underlying mental disorders such as
depression, substance abuse, schizophrenia, bipolar disorder.
  Prior suicide attempts (especially in the recent past).
 Chronic illness such as AIDS, cancer or other incurable terminal illness.

Biological factors:
 Higher incidence among people who have family history of suicide.
 Abnormalities in neurotransmitters especially low level of serotonin and
norepinephrine.
 Higher risk among people who restrict fat intake.
 Major depression.

Psychological factors:
 Loneliness, widowhood/widower hood.
 Painful chronic disease, impairing quality of life.
 Excessive chronic distress and psychological conflict.
 Cognitive distortion (feeling of helplessness, hope- lessness and worthlessness).
 Sense of low belongingness.
 Traumatic experiences.

Social factors:
 Social disorganization or lack of social integration.
 Interpersonal stress.
 Lack of social support.
 Financial difficulties, unemployment and poverty.
 Love failure, exam failure.
 Fail to fulfill social expectation or high social expectation. Problems in the
family, school, or job training.

Parameters to assess the risk of suicidal behavior is depicted below in Table

Table: Parameters to assess the risk of suicidal behavior
Parameter High risk Low risk
• Suicidal behavior • Alone • Close to someone
circumstances • Planned • Not planned
• Lethal methods • Low lethality methods
• Intention to die • High • Low
• Psychopathology • Present and severe • Absent or mild
• Coping mechanisms • Poor judgment • Good judgment
 • Weak impulse control • Good impulse control
• Strong hopelessness • Weak hopelessness
• Strong impotence • Weak impotence
• Communications • Poor or ambivalent • Good, clear
• Family support • Inconsistence • Consistent
• Environment stress • Severe • Low

Important Consideration
Media Coverage
• Werther effect: Media coverage of suicide may trigger the possibility of suicide
(copycat suicide).
• Papageno effect: In which coverage of effective coping mechanisms, coping in
adverse circumstances, as covered in the media about suicidal ideation, may have
protective effects and reduces the rate of suicide.

MYTHS ABOUT SUICIDE: -

Myth: Suicide cannot be prevented.
Fact: Suicide is preventable. The vast majority of people planning suicide don't really
want to die.

Myth: People who take their own life are cowards, weak or are just looking for
'attention'.
Fact: More than 90% of people who take their own life have at least one and often
more than one treatable mental illness such as depression, anxiety, etc.

Myth: Asking someone if they are thinking about suicide will put the idea in their
mind and cause them to act on it.
Fact: Asking direct questions about suicidal attempt does not cause the patient to
commit suicide. In fact, patients feel relieved on being asked about suicidal ideation
and being explained that their ideas are part of an illness.

Myth: Teenagers and college students are the most at risk for suicide.
Fact: Suicide risk increases with age.

Myth: Someone making suicidal threats won't really do it.

Fact: Those who talk about suicide are at risk for suicide (they are crying for help)
Myth: Talk therapy and/or medications don't work,
Fact: One of the best ways to prevent suicide is by getting treatment for mental
illnesses.

LEGISLATION FOR SUICIDE: -

Section 309: - Attempt to Commit Suicide: -
309. Attempt to commit suicide. —Whoever attempts to commit suicide and does any
act towards the commission of such offence, shall he punished with simple
imprisonment for a term which may extend to one year [or with fine, or with both]

THE MENTAL HEALTHCARE ACT, 2017

(1) Notwithstanding anything contained in section 309 of the Indian Penal Code any
person who attempts to commit suicide shall be presumed, unless proved otherwise, to
have severe stress and shall not be tried and punished under the said Code.
(2) The appropriate Government shall have a duty to provide care, treatment and
rehabilitation to a person, having severe stress and who attempted to commit suicide,
to reduce the risk of recurrence of attempt to commit suicide.

LEGAL ASPECTS
Section 305: - Abetment of suicide of child or insane person
If any person under eighteen years of age, any insane person, any delirious person, any
idiot, or any person in a state of intoxication commits suicide, whoever abets the
commission of such suicide, shall be punished with death or imprisonment for life, or
imprisonment for a term not exceeding ten years, and shall also be liable to fine.
Section 306: - Abetment of suicide
If any person commits suicide, whoever abets the commission of such suicide, shall be
punished with imprisonment of either description for a term which may extend to ten
years, and shall also be liable to fine.

PREVENTION OF SUOICIDE: -
1. Education
2. Screening
3. Means Restriction
4. Media
- Guidelines
 - Consideration
5. Treatment

1. EDUCATION: -
A. Individual and Public Awareness: -
 Primary risk factor for suicide is psychiatric illness as aware about it.
 Teach depression is treatable so no need to take stress or think deeply.
 Try to de-estimate the illness.
 Destigmatize treatment.
 Encourage health seeking behavior &continuation of treatment.

B. Professional Awareness: -
 Healthcare professional
 physician, paediatrician, nurse practiceners etc.
 Mental health professional
 Psychologist, social workers etc.
 Primary & secondary school staff
 Principle, teacher, counsellors, nurses
 College & university resource staff
 Counsellors, student health services, student residence services
 Gatekeepers
 Religious leader
 Police
 Fire departments
 Armed services

2. SCREENING: -
- Identify At Risk Individuals
- Identify the patient who have high prone mental disease R/T suicide
- Identify the ―WARNING SIGNS OF SUICIDE’’

Warning signs of suicide: -

 Suicidal threat
 Writing farewell letters
 Giving away treasured articles
 Making a will
 Closing bank account
  Appearing peaceful happy after a period of depression
 Refusing to eat /drink
 Refusing to maintain personal hygiene

3. MEANS RESTRICTIONS: -
 Fire alarm safety
 Construction of barriers of jumping sites
 Detoxification of domestic gas
 Restriction on pesticides
 Reduce lethality or toxicity of prescription
 Use lower toxicity antidepressants
 Restrict sales of lethal hypnotics e.g., Barbiturates

4. MEDIA: -
a) Media Guidelines
Encourage implementation of responsible media guidelines for reporting on suicide.
b) Media Considerations
 Consider how suicide is portrayed in the media
- TV
- Movies
- Advertisements
 The Internet danger
- Suicide chat rooms
- Instructions on methods
- Solicitations for suicide pacts.
KEY GATEKEEPERS
 Primary health care providers
 Mental health care providers
 Emergency health care providers
 Teachers and other school staff
 Community leaders
 Police officers and other first responders
 Military officers
 Social welfare workers
 Spiritual and religious leaders
 Traditional healers
In the WHO Mental Health Action Plan 2013-2020 - the global target of reducing the
suicide rate in countries by 10% by 2020.

WHO’s Mental Health Gap Action Programme, launched in 2008, includes suicide
prevention as a priority and provides evidence-based technical guidance to expand
service provision in countries

WORLD SUICIDE PREVENTION DAY: - Efforts to prevent suicide have been

celebrated on World Suicide Prevention Day – September 10th – each year since
2003.

MANAGEMENT OF ATTEMPTED SUICIDE: -

1. Assessment:
 Warning Signs of Suicide: People with suicidal tendencies exhibit warning
signs in their talk, behavior and mood.

Warning signs of suicide

Talk Behavior Mood
• If a person talks about: •Increased use of • Mood
• Killing themselves. alcohol or drugs. • Depression
• Having no reason to • Looking for a way to • Loss of interest
live. kill themselves. • Anger
• Being a burden to • Acting carelessly. • Irritability
others. • Withdrawing from • Humiliation
• Unbearable pain. activities. • Anxiety
• Isolating from family
and friends.
• Disturbed sleep.
• Making goodbye calls
to friends, relatives
• Giving away valued
properties.
• Aggression.
  Assessment of suicide plan: A suicide plan is one that is evidenced by specific
strategies to end one's life.

2. Treatment of attempt suicide:

• Medications:
 Antipsychotic medications (clozapine)
 Antidepressants (SSRIs)
 Anti-anxiety (benzodiazepines)
• Psychotherapy:
 Cognitive therapy
 Individual psychotherapy
 Psychological counseling
 Dialectical behavior therapy

NURSING MANAGEMENT OF ATTEMPTED SUICIDE

Assessment
Assessing the risk of suicide in a person expressing suicidal thoughts is crucial in
attempting to prevent deaths. There are a number of risk-predicting score systems for
determining suicidal intent.

Important Consideration
- Establish rapport, develop a trusting relationship.
- Use open questions.

• Assess risk factors

• Assess current intent and plans:
 Do you feel that life is worth living?
  Do you wish you were dead?
 Have you thought about ending your life?
 If yes, what is your plan?
 Do you have access to away to carry out your plan?

High Tip
Suicide Risk Assessment "IS PATH WARM"
I = Ideation: Talked about or threatened to hurt or kill themselves, or looked for ways
to do it.
S = Substance use: Increased their use of alcohol or other drugs.
P = Purposelessness: Mentioned having no reason to live or no purpose in life.
A = Anxiety: Showed increased anxiety and changes in sleep patterns.
T = Trapped: Talk about feeling trapped, like there's no way out.
H = Hopelessness: Expressed feeling hopeless about the future.
W = Withdrawal: Withdrawn from friends, family members or activities they enjoy.
A = Anger: Shown uncontrolled anger or say they want to seek revenge.
R = Recklessness: Engaged in risky activities, seemingly without thinking.
M = Mood change: Experienced dramatic changes in their mood.

NURSING DIAGNOSIS
1. Risk for suicide related to history of prior suicide attempt,
hopelessness/helplessness as evidence by statements of despair, suicide plan,
suicide behavior or suicide cues.
Expected Outcomes
• Patient will remain safe.
• Patient will state that he/she wants to live.
• Patient will use adaptive coping to deal with the situation.

Nursing Interventions
At community level
• Make sure that the patient stays with family or friends.
• Encourage patient to talk freely about feelings and help to plan the alternative ways
of handling anger and frustration.
• Remove harmful objects and keep away from the reach of the patient.
• Provide family crisis counseling and links family with self-help groups.
Rationale:
• Relieve isolation and provide safety and comfort.
• Help client to deal with strong emotions.
• To provide a safe environment.
• Reestablishes social ties and reduces sense of isolation.

In the Hospital
• Create a safe environment o (taking away sharp objects, items, and so on). Place the
patient in least restrictive environment.
• Have one-on-one monitoring of patient at one arm's length away or suicide
observation. Make 15-minute visual check of mood, behavior and verbatim
statements.
• Encourage the client to talk about their feelings. Avoid negative criticism of patient.
• Make a no-suicide contract with the patient.
Rationale:
• To provide a safe environment.
• Protection and preservation of the client's life is the priority.
• Talking about feelings can minimize suicidal acting out.
• The no-suicide contract helps the patient to know what to do when they begin to feel
overwhelmed.

2. Ineffective coping related to impulsivity and inadequate coping skills as

evidenced by destructive behavior toward self or others.
Expected Outcomes
• Patient will demonstrate adaptive behaviors of dealing with emotional pain.
• Patient will demonstrate a reduction of self-destructive behaviors.
Nursing Interventions
• Assess client's strengths and positive coping skills.
• Assess the client's maladaptive coping behaviors.
• Assess the need for assertiveness training.
• Identify situations that trigger suicidal thoughts.
• Assess the client's social supports.

Rationale:
• Help to build alternatives to self-defeating behaviors.
• Help to identify areas to teaching and planning strategies.
• Assertiveness skills can help the client to develop a sense of balance and control.
• Helps to identify required adaptive coping skills.
• To enhance social support.

3. Hopelessness related to perceived helplessness as evidenced by lack of

motivation, loss of interest in life and passivity.
Expected Outcomes
• Patient will express the will to live.
• Patient will have an expression of positive future orientation.
• Patient will have an expression of meaning in life.
Nursing Interventions
• Encourage clients to reframe negative thinking into positive thinking.
• Work with client to identify areas of strengths.
• Identify things that have given meaning and joy to life in the past. (e.g., religious,
group activities).
• Discuss with the client about his dreams and wishes for the future.
• Teach problem-solving steps to the patient.
Rationale:
• Helps patient to find alternative approaches of thinking.
• Motivate patient to focus on his strength.
• Recalls patient's strength and creativity
• Promote meaning into life.
• To teach adaptive ways of dealing with the problems.