Dr.

Sagun Ballav Pant

Assistant Professor
Department of Psychiatry and Mental health
 Introduction
Suicide is derived from the Latin word
for “ self-murder.”

Suicide: a fatal act of self-injury(self-

harm) undertaken with more or less
conscious self-destructive intent,
however vague and ambiguous.
Nonfatal suicidal thoughts and behaviors:
• suicide ideation: thoughts of engaging in behavior intended to
end one's life
• suicide plan: the formulation of a specific method through
which one intends to die
• suicide attempt: engagement in potentially self-injurious
behavior in which there is at least some intent to die.
• Nonsuicidal self-injury : self-injury in which a person has no
intent to die

Suicide cluster: Individuals or groups committing suicide shortly

after suicide(s) or acquaintances or public figures, or after
publicity about suicide clusters
 Deliberate self-harm (parasuicide) refers to behavior through
which people deliberately inflict acute harm upon themselves,
poison themselves, or try do so with non-fatal outcome.

Attempted suicide: is an event in which there is a failure of

conscious effort to end life.
Different than parasuicide
Epidemiology of suicide
 Epidemiology of suicide

• Approximately 0.5% to 1.4% of people end their life by suicide.

• Close to 800 000 people die due to suicide every year, which is
one person every 40 seconds.
• Suicide is the second leading cause of death among 15-29 year
olds globally.
• Suicide accounted for 1.4% of all deaths worldwide, making it
the 17th leading cause of death in 2015.
• There are indications that for each adult who died of suicide
there may have been more than 20 others attempting suicide.
• It is the fifth highest cause of years of life lost in the developed
world.
 Modes of suicide
• Hanging is universally available and it is the most common suicide globally.

• Nowadays, the increasing suicide rate in many Asian societies has been
largely linked with pesticides and other poisons.

• Firearms, carbon monoxoide and hanging are active suicide methods with
the highest potential to cause death.

• jumping from a height or leaping in the front of a moving vehicle are more
passive ways, but are also higher damaging in nature.

• Poisoning, drowning, or wrist cutting are typically methods which leave

more time for help seeking and intervention.
In Nepal
• A study from 2001, looking at the methods of completed suicides in
Nepal, noted that 70% of completed suicide were from hanging, 18% by
poisoning, and 12% from drowning, burning or stabbing 12

• Another study reported that 96% of suicides were by organophosphorus

poisoning.

• The different in rates and methods of suicide reported may reflect

inaccurate reporting because of legal and social consequences of suicide
or deliberate self harm
 Risk factors for suicide sociodemographic variables
Gender Male
Age Elderly
Social status Low
Educational status Low
Marital status Unmarried, separated, divorced, widowed
Residential status Living alone
Employment status Unemployment, retired, insecure employment
Economic status Weak(males)
Profession Farmer, female doctor, student, sailor
Special subpopulation Students, prisoners, immigrants, refugees, religious sects

Special institutions Hospitals, prisons, army

Region Uneven distribution locally by urban-rural residential or sub-cultural
area
Season and time Spring and autumn, weekend, evening, anniversary
Life events Adverse life events such as loses & separations, criminal charges

Social support Low

Social integration lacking
 Clinical determinants of suicide

family history Suicidal behaviors, mental disorders

Mental disorders Any disorder, depression, personality disorder,

substance use, schizophrenia

Contact with psychiatric Any contacts, recent contacts, post-discharge period,

services psychotropic drugs

Psychiatric symptoms Hopeless, helpless, depressed, psychotic, delirious,

anxious, aggressive, introversive

Suicidal behavior Previous suicide attempts, suicidal ideations, death

wishes, indirect gestures

Physical health Severe physical illness such as cancer, AIDS, stoke,

epilepsy, permanent sickness

Availability of suicidal Easy access to lethal methods

methods
The precipitating circumstances for suicide from 16 American
states in 2008.
• Virtually all mental disorders carry an increased risk of suicide

• The risk in functional mental disorders is double that in substance

abuse disorders, which in turn carry double the risk of suicide
compared to organic disorders

• In anorexia nervosa and major depression: risk 20 fold

• Other mood disorders and psychoses: risk 10- 15 fold
• In anxiety, personality, and substance abuse disorders suicide risk
is at lower levels but about 5- 10 times higher than the expected
value
• In substance disorders the risk is dependent in the type of
disorder, being clearly lowest in alcohol, cannabis and nicotine
abusers
Etiology of suicide

• Cultural factors
• Sociological factors
• Psychological factors
• Neurobiological factors
A Hindu widow burning herself with the corpse
of her husband, 1820s.
• In Hinduism, suicide is generally frowned upon and is considered
equally sinful as murdering another in contemporary Hindu
society

• Hindu Scriptures state that one who commits suicide will become
part of the spirit world, wandering earth until the time one would
have otherwise died, had one not committed suicide.

• In most forms of Christianity, suicide is considered a sin

• Suicide is not allowed in Islam. It asks man and woman to wait

for his or her destiny rather than snatching it from the hands of
god.
• Culture defines basic attitudes towards life and death, and also
towards suicide in society.

• We still have stigma against suicide

• Western culture has had a tendency to emphasize the

individual’s free will and the shouldering responsibility for one’s
life, while egoist and anomic trends in society have intensified
and altruism had almost disappeared.

• Such changes may have increased the incidence of suicide in

society.
Sociological theories
• The suicide victim’s moral predisposition to commit suicide, not
his or her individual experiences, is felt to be the crucial factor.

• Suicides are seen as a disturbance or symptom of a relationship

between society and individuals.
Life events and social support

The life situations preceeding suicide is typically characterized by an excess

of adverse life events and recent stressors
Usually the sum effect of events is overwhelming and more important than a
single life event

The most common life events preceeding suicide:

Job problems
family discord,
somatic illness,
financial trouble,
unemployment,
separation and death and illness in family

 In most cases, life events are not accidental, but are usually also dependent in
the individual’s own behavior.
Psychological Theories

• PSYCHODYNAMIC THEORY- extreme expression

of anger at the love object who has abandoned the
person
• IMPULSIVITY- behavioral characteristic that seems
best to predict impulsive suicides. Scored high on
impulsivity & sensation seeking.
• COGNITIVE THEORY- Hopelessness &
dichotomous thinking.
• Poor coping
 Neurobiology of suicide
Serotonergic system
A meta-analysis of prospective studies of 5-HIAA found that in
mood disorders lower CSF 5-HIAA increased the chance of death
by over fourfold overfollow-up periods of 1-14 years.
Multiple postmortem studies, report lower brainstem levels of 5-
HIAA and serotonin.
Suicide attempters with low serotonin -10 times likely to repeat.
Noradrenergic system and HPA axis
The noradrenergic system and the HPA axis are two key stress
response systems.

Postmortem studies of suicides have documented fewer

noradrenergic neurons in the Locus Ceruleus.
 Genetics
• Family, twin, and adoption studies support a genetic
contribution to suicidal behaviour independent of psychiatric
disorder.
• Suicide is familial: relatives have 3 X risk of suicidal acts
• Adoption studies: Increased risk for biological relatives
• Identical twins are more concordant for suicidal behaviors
• Proportion of risk due to genetic factors > 50%
SUICIDE- High Risk: Identification
Socio-demographic & clinical factors: SAD PERSON
• Single, Divorced or widowed status
• Living Alone, isolated, Bereavement in childhood
• Disabled or Unemployed or retired
• Psychiatric illness (depression, schizophrenia, ..)
• Physical illness (terminal, painful, chronic, debilitating,
AIDS)
• Past History of suicidal attempt/ Personality traits
• Ethanol/ alcohol and other substance ab/use
• Family history- Relatives’ suicide
• Recent life Stressors
• Other problems/ stressors/ illness/ fear
• No Hope
SUICIDE: Management
Myths:
• Patients who talk about suicide rarely commit suicide

• Asking about suicide in patients may provoke suicidal

acts.

Management strategies- ‘ACT’

• A = Acknowledge problem when ‘Warning Signs of
suicide’
• C = Care of the person
• T = Treatment of the cause
SUICIDE: Assessment-
WHAT TO EXPLORE?
• Suicide detail and intent- Frequency and severity of
the ideas, plans and means to commit suicide
• Caution- misleading and false improvement and
denial
 SUICIDE: Assessment-
HOW TO ASK/ EXPLORE ?

• It is not easy to ask patients about their suicidal ideas. It

is helpful to lead into the topic gradually. A sequence
of useful questions is:
1. Do you feel unhappy and helpless?
2. Do you feel desperate?
3. Do you feel unable to face each day?
4. Do you feel life is a burden?
5. Do you feel life is not worth living?
6. Do you feel like committing suicide?
SUICIDE: Assessment-
WHEN TO ASK ?

• After a rapport has been established;

• When the patient feels comfortable about expressing
his or her feelings;
• When the patient is in the process of expressing
negative feelings.
SUICIDE: Assessment- FURTHER QUESTIONS
• The process does not end with confirmation of the presence of suicidal
ideas.
• It continues with further questions aimed at assessing the frequency and
severity of the idea and the possibility of suicide. It is important to know
whether the patient has made any plans and has the means to commit
suicide.
• It is crucial for questions not to be demanding or coercive, but to be
asked in a warm way showing the physician’s empathy with the patient.
Such questions might include:
Have you made any plans for ending your life?
How are you planning to do it?
Do you have in your possession [pills / guns / other means]?
Have you considered when to do it?
SUICIDE:
Referral to a Specialist Care-
WHEN TO REFER A PATIENT ?

Patients should be referred to a psychiatrist when they

have:
• A psychiatric disorder;
• A history of a previous suicide attempt;
• A family history of suicide, alcoholism and
psychiatric disorder;
• Physical ill-health;
• No social support.
SUICIDE: Management-
HOW TO REFER?
After deciding to refer a patient, the physician
should:
• Take the time to explain to the patient the reason for
the referral;
• Allay anxiety about stigma and about psychotropic
medication;
• Make clear that pharmacological and psychological
therapies are effective;
• Emphasize that referral does not mean ‘abandonment’
• Arrange an appointment with the psychiatrist;
• Allocate a time for the patient after his or her
appointment with the psychiatrist;
• Ensure that the relationship with the patient continues.
SUICIDE: Management-
WHEN TO HOSPITALIZE A PATIENT ?

Some indications for immediate hospitalization:

• Recurrent thoughts of suicide; frequent expressions
• High level of intent to die in the immediate future (the next few
hours or days);
• Agitation or panic;
• Existence of a plan to use a violent and immediate method
• No social support

Do not leave the patient alone;

Look/ active search for means of self harm
Seek for help of relatives and specialists
SUICIDE: Prevention-
SUMMARY OF STEPS IN SUICIDE PREVENTION
Main steps for the assessment and management of patients when
the physician suspects or identifies a suicide risk-
• Suicide risk: identification, assessment and plan of action
• Suicide risk Symptom Assessment/ Action
1. Emotionally disturbed- Enquire about
• suicidal thoughts
• Listen with empathy
2. Vague ideas of death- Enquire about
• suicidal thoughts
• Listen with empathy
3. Vague suicidal thoughts- Assess the intent (plan and
method)
• Explore possibilities
• Identify support
General principles of prevention

Broadly there are two approaches to suicide

prevention
1)Population approaches
2)High-risk group strategies
Population strategies
a) Reducing availability of means of suicide:
- coal gas
- carbon monoxide
-fire arms
-antidepressants
-analgesics
-improving safety measures
b) Education of primary care physicians
c) Influencing media portrayal of suicidal behaviour
d) Education of the public about mental illness and its treatment
e) Educational approaches in schools
f) Befriending agencies and telephone helplines
Suicide prevention helpline Nepal
9840021600
suicide help line (new)- toll free- 1660122223
Strategies for high risk groups
a) Patients with psychiatric disorders
1) Risk identification
2) Prevention strategies

b) Elderly people

c) Suicide attempters

d) High-risk occupational groups

e) Prisoners
thankyou