SUICIDE IDEATION,
BEHAVIOR AND
MANAGEMENT
By
SOLOMON MPHULUPULU PHIRI
Bsc in MHPN, Dip in RN
LEARNING OUTCOMES
At the end of the session learners should;
Have knowledge of the burden of suicide
Be able to identify risk factors for suicide
Be exposed to methods of evaluating the patient who is at
risk for suicide
Know about some available assessment tools and know how
to use them
THE BURDEN OF SUICIDE
Suicide is a complex phenomenon. It is a serious public
health issue, demanding our attention
Suicide’s psychological and social impact on the family and
society is immeasurable
It’s management needs a multisectoral approach; involving
health care providers, governments and various societal
sectors
IMPORTANCE
Suicidal ideation and behavior are among the most serious
and common psychiatric emergencies.
Reported rates of suicide may underestimate the true burden
because of misclassification of death due to legal or social
stigma
Suicide is understood as a multidimensional disorder
It is complex with psychological, social, biological, cultural
and environmental factors involved
EPIDEMIOLOGY
Over 800,000 people die due to suicide every year and there
are many more who attempt suicide
This is a ‘global’ mortality rate of 11.4 per 100,000
In 2012 suicide accounted for 1.4% of all deaths worldwide,
making it the 15th leading cause of death
It is estimated that there are 10 to 40 nonfatal suicide
attempts for every completed suicide
World Health Organization data
EPIDEMIOLOGY
19% of suicide victims had a history of prior attempts
16.5% had alcohol-related problems
In many developing countries, pesticide ingestion is
responsible for the majority of suicide deaths and may
account for 30% of suicides globally
MALAWI
Records from various police stations that is in 2019 showed
that 116 people killed themselves while in 2020, a total of
182 people killed themselves, meaning that there is a 57%
increase thus according to then Deputy national
spokesperson for Malawi police service.
Statistics from Malawi police service show that 208 people
have committed suicide from January to August, 2022, a
high figure than the 160 recorded during same period of
2021
It further shows that of the 208, 168 are men while 40 are
women
Of last year’s total 160, 147 were men while13 were women
thus according to deputy National police spokesperson Harry
Namwaza
#ZBSNews
The country has registered 256 suicide cases from January to
July this 2023
Malawi Police Service spokesperson Peter Kalaya has told
Zodiak that most of the people committed suicide due to
relationship challenges
Among the 256, 226 are men whereas 30 are women
(By Zuleika Nanguwo-Lilongwe, 31/07/23)
Men are killing themselves more than women according to
these figures
Main reasons are economic hardships, culture and lack of
coping skills
DEFINITIONS
Suicide – the intentional act of killing oneself
Suicidal ideation – having thoughts of killing oneself
Parasuicide – the act of intentionally inflicting a nonlethal
injury to oneself with the intent to die or commit bodily harm
Self-injurious behavior is the purposeful intent to inflict
harm on one’s body without an obvious intent to actually kill
oneself
CHARACTERISTICS OF
SUICIDE
1. Alternative to problem perceived as unsolvable by any
other means
2. Crisis thinking colors problem solving
3. Person is often ambivalent
4. Suicidal solution has an irrational component
5. Suicide is a form of communication
RISK FACTORS
PSYCHIATRIC DISORDERS
More than 90% of individuals who attempt suicide, and 95%
of those who successfully commit suicide, have a psychiatric
diagnosis
Severity of psychiatric illness is associated with risk of
suicide
Psychological pain
Hurt, anguish, misery
PSYCHIATRIC DIAGNOSIS
Psychiatric disorders most commonly associated with
suicide:
Depression
Bipolar disorder
Alcoholism or other substance abuse
Schizophrenia
Personality disorders
Anxiety disorder
PTSD
Delirium
HOPELESSNESS & IMPULSIVITY
Hopelessness is strongly associated with suicide
Hopelessness can persist even when other symptoms of
depression have remitted
Impulsivity is associated with acting on suicidal thoughts
Particularly among adolescents and young adults
Stress
Feelings of being pressured or overwhelmed
Agitation
Emotional urgency, need to take action, anger
HISTORY OF PREVIOUS SUICIDE
ATTEMPTS OR THREATS
Strongest single factor predictive of suicide
Patients with a prior history are 5 to 6 times more likely to
make another attempt
Consider outcome, lethality, opportunity for rescue of any
prior attempts
History of suicidal ideation
Content, frequency, intensity, duration
AGE, SEX & RACE
Risk of suicide increases with increasing age, however
young adults attempt suicide more often than older adults
Females attempt suicide nearly twice as often as males, but
males complete suicide three times more often
In the U.S. suicide rates have been higher among whites than
blacks. Native Americans have the highest rates
MARITAL STATUS
Highest risk among those never married
Followed in descending order of risk:
Widowed, separated or divorced
Married without children
Married with children
Living alone increases the risk of suicide
OCCUPATION
Risk is greater in patients in unskilled occupations than
skilled occupations
Physicians in the U.S. may be at increased risk of suicide
Unemployment and economic strain may lead to a higher
risk of suicide
In the U.S., the rate of suicide in military veterans exceeds
that of the general population
HEALTH
Suicide risk increases with physical illness
Consider chronicity of illness
Chronic pain
Varied data on the relationship between suicide risk and
HIV/AIDS infection
HIV infection alone does not appear to increase risk
Although, some studies show risk is increased in those with a
recent diagnosis, more intensive and frequent hospital care, or
comorbid psychiatric illness
FAMILY HISTORY &
GENETICS
Risk of suicide increases in patients with a family history of
suicide
Twin studies suggest that the increased risk of suicide has
both environmental and genetic components
History of family violence increases risk; as does history of
physical/emotional/sexual abuse in an individual
OTHER
Risk of suicide increases with
Accessibility to weapons, especially firearms
Recent significant loss (death, relationship)
Homelessness
Economic downturns
Living in a rural area
Recent suicide in geographical area/age group (suicide
contagion)
Protective Factors
Good coping mechanisms
Active treatment
Strong alliance with current treatment providers
Strong connection to faith and meaning (religion)
Good social support network
Future orientation
Help-seeking behavior
Expressed desire to live
Reasons for living
ASSESSMENT OF SUICIDAL
BEHAVIOR
WARNING SIGNS OF
SUICIDE
The first step in evaluating suicide risk is to determine the
presence of suicidal thoughts, including their content and
duration
Current explicit intent
Plan
Access
Lethality
Preparation
WARNING SIGNS TO WATCH
FOR
Giving away favourite things
Making out wills
Arranging care of children or pets
Extravagant spending
Statements of plan…action
Hyperactivity/restlessness
Talking About Dying – any mention of dying, disappearing,
jumping, or other types of self harm
Recent Loss – death, divorce, separation, broken
relationship, loss of job, money, status, self esteem, self
confidence, loss of religious faith, loss of interest in sex,
activities, hobbies, activities previously enjoyed.
Change In Personality – sad, withdrawn, irritable, anxious,
tired, indecisive, apathetic
Change in Behaviour – can’t concentrate, work, study,
routine tasks
Change in Sleep Pattern – insomnia, early waking,
oversleeping, nightmares
Change in Eating Habits – loss of appetite, weight, over
eating.
Brief Suicide Assessment
Is the patient currently thinking about suicide?
What is the nature of those thoughts (i.e. active or passive)?
Does the patient have a plan?
How specific is the plan?
Are the means easily accessible?
Is the method likely to be lethal?
Has the patient taken any preparatory steps?
ASSESSMENT TOOLS
There are a number of standardized scales to evaluate suicide
risk, but none is associated with a high predictive value
Colombia-Suicide Severity Rating Scale
Screening Tool for Assessing Risk of Suicide (STARS)
Suicide Assessment Five-Step Evaluation and Triage (SAFE-
T)
Beck Hopelessness Scale
COLUMBIA-SUICIDE
SEVERITY RATING SCALE
1. Have you wished you were dead or wished you could go to
sleep and not wake up?
2. Have you actually had any thoughts of killing yourself?
3. Have you been thinking about how you might kill yourself?
4. Have you had these thoughts and had some intention of
acting on them?
5. Have you started to work out or worked out the details of
how to kill yourself? Do you intend to carry out this plan?
6. Have you ever done anything, started to do anything, or
prepared to do anything to end your life?
Nursing management
Levels of intervention
Primary:
Activities that provide support, information and education to
prevent suicide
Secondary:
Treatment of the actual suicide crisis
Tertiary:
Interventions with family and friends of a victim who died of
suicide to reduce possible trauma
Nursing management
Create a safe environment. Remove all potentially harmful
objects from client’s access (glass, metal silverware,
electrical cords, vases, belts, shoe laces, metal nail files,
matches, razors…)
Suicide precautions include milieu therapy within the facility
Maintain close observation of client
Make rounds at frequent, irregular intervals
Assign staff to observe the client closely or consider one-to-
one supervision if necessary
Nursing management
Maintain special care in administration of medications
Encourage verbalization of honest feelings
This includes expression of angry feelings within appropriate
limits. Work towards adaptive coping skills
Identify community resources that client may use as support
system
Orient client to reality, as required
Most important, spend time with client
Nursing management
‘Offering hope’ is an important therapeutic variable in all
forms of therapy and especially critical with suicidal clients
Approach clients with a positive, optimistic attitude
Offer hope, but never make promises
Never promise the client the distressful circumstances will
definitely improve
You cannot offer guarantees
You can offer support and encouragement that change is
possible
Nursing management
Help the client locate the triggering event – the last event before
the suicidal crisis
‘Have there been any sudden changes in your life these past few
days?’
‘What was going on in you life when you started to get these suicidal
thoughts?’
Help the client to begin coping with the triggers and recent life
stressors
‘Where do you think we ought to start working?’
‘Would it help if we made a list of things you could do today?’
‘In the past, how did you cope with a similar event, emotion,
problem?’
Medical management
Aggressively treat psychiatric disorders
Avoid tricyclic antidepressants and monoamine oxidase
inhibitors if possible, as they may be lethal if taken in high
doses
SSRIs appear to be safer when taken in overdose and should
be the drug of choice in potentially suicidal depressed
patients
Patients with suicidal ideation who are at risk of overdosing
on any medication should be hospitalized
Consider ECT if condition is severe for quick recovery
PATIENT EVALUATION
Asking about suicide will not initiate suicidal thoughts or
actions
By contrast, many patients appreciate the opportunity to discuss
suicidal thoughts, and may not verbalize these issues without
being prompted
Sometimes the only clue to a suicidal patient is the initiation of
a visit
Unfortunately, our ability to predict who will attempt suicide
is limited; patients who are successful are similar to those
who are not
CLINICAL EVALUATION
Observe whether the patient is disconnected or disengaged
during the clinical interview
Lack of rapport is also a clinical sign associated with an
increased risk of suicide
It is generally agreed upon that suicide risk is the
combination of warning signs, risk factors and protective
factors
The suicidal state of a patient is dynamic and fluctuating,
requiring ongoing evaluation
