SUICIDE

BY
DR NASEEM AHMAD KHAN
PSYCHIATRIST&PSYCHOTHERAPIST
DISTRICT HEADQUATER HOSPITAL CHITRAL
SUICIDE IS AN ACT WITH A FATAL OUTCOME, DELIBERATELY
INITIATED AND PERFORMED IN THE KNOWLEDGE OR
EXPECTATION OF ITS FATAL OUTCOME
EPIDEMIOLOGY

• CURRENT SUICIDE RATE IN THE UK (10.1 PER 100,000 IN MEN AND 2.8
PER 100,000 IN WOMEN)
• REPORTED SUICIDE ARE VERY LOW IN ISLAMIC COUNTRIES
• THE GENDER DIFFERENCES ARE LESS IN ASIAN THAN IN WESTERN
COUNTRIES
• SUICIDE RATES HAVE BEEN HIGHEST IN SPRING AND SUMMER FOR EVERY
DECADE SINCE 1921-1930
DEMOGRAPHIC CHARACTERISTICS
• 3 TIMES AS COMMON IN MEN AS IN WOMEN
• HIGHEST RATES IN THE ELDERLY
• RATES LOWER AMONG THOSE WHO HAVE NEVER BEEN MARRIED, AND
INCREASING PROGRESSIVELY THROUGH WIDOWERS, WIDOWS AND
DIVORCED
• RATES HIGHER IN UNEMPLOYED
• RATES PARTICULARLY HIGH IN CERTAIN PROFESSIONS, PARTICULARLY
THOSE WITH ACCESS TO LETHAL MATERIAL
• RATE 4 TIMES THE EXPECTED RATE IN VETERINARY SURGEONS
• RATE DOUBLE IN PHARMACISTS AND FARMERS
• ALSO HIGHER IN DOCTORS, PARTICULARLY FEMALES
RISK FACTORS
• DISTAL
• GENETIC LOADING
• PERSONALITY CHARACTERISTICS (E.G. IMPULSIVITY, AGGRESSION)
• RESTRICTED FETAL GROWTH AND PERINATAL CIRCUMSTANCES
• EARLY TRAUMATIC LIFE EVENTS
• NEUROBIOLOGICAL DISTURBANCES (E.G. 5 HT DYSFUNCTION AND HYPOTHALAMIC PITUITARY
AXIS HYPERACTIVITY)
• PROXIMAL
• PSYCHIATRIC DISORDER
• PHYSICAL DISORDER
• PSYCHOSOCIAL CRISIS
• AVAILABILITY OF MEANS
• EXPOSURE TO MODELS
RISK FACTORS
• PSYCHIATRIC AND MEDICAL FACTORS
• 90% WHO DIE FROM SUICIDE HAVE SOME FORM OF MENTAL DISORDER
• MOST FREQUENT CONDITIONS INCLUDE
• 4% OF DEPRESSED PATIENTS DIE BY SUICIDE
• IN BIPOLAR DISORDER LIFETIME RISK IS ELEVATED TO 10-15% MORE
• PERSONALITY DISORDER DIAGNOSED IN 40-50% OF PEOPLE WHO COMMIT SUICIDE
• LIFETIME RISK IS 7% IN ALCOHOLICS
• DRUG MISUSE RELATIVELY COMMON IN THOSE WHO DIE BY SUICIDE
• LIFETIME RISK IS 5% IN SCHIZOPHRENIA PATIENTS
• OTHER RISK FACTORS ARE PAST HISTORY OF DELIBERATE SELF HARM AND POOR
PHYSICAL HEALTH
RISK FACTORS

• SOCIAL FACTORS
• UNEMPLOYMENT
• POVERTY
• DIVORCE
• SOCIAL FRAGMENTATION
• MEDIA COVERAGE OF SUICIDE
• RATES LOWER AT THE TIME OF WAR AND REVOLUTION
• RATES HIGHER AT THE TIME OF BOTH MARKED ECONOMIC PROSPERITY AND
DEPRESSION
RISK FACTORS

• BIOLOGICAL FACTORS
• GENETIC FACTORS
• DECREASED ACTIVITY OF BRAIN 5-HT PATHWAYS
• LOWER MARKERS OF 5 HT FUNCTION SUCH AS CSF 5-HIAA AND THE DENSITY
OF 5-HT TRANSPORTERS
RISK FACTORS

• PSYCHOLOGICAL FACTORS
• HOPELESSNESS
• HELPLESSNESS
• IMPULSIVITY
• DICHOTOMOUS THINKING
• COGNITIVE CONSTRICTION
• PROBLEM SOLVING DEFICITS
• OVERGENERALIZED AUTOBIOGRAPHICAL MEMORY
TYPES AND MODELS OF SUICIDE
• DURKHEIM SOCIOLOGICAL MODEL OF SUICIDE
DURKHEIM DESCRIBED 4 TYPES OF SUICIDE;
• EGOISTIC
DECREASED INTEGRATION IN THE SOCIETY AND SOCIAL ALIENATION
THE PERSON SEE THEMSELVES AS BEING ALONE OR OUTSIDER
• ALTRUISTIC
OVER INTEGRATION INTO THE SOCIETY
SUICIDE COMMITTED FOR THE BETTERMENT OF OTHERS
• ANOMIC
LACK OF SOCIAL REGULATION AND BREAKDOWN OF SOCIAL EQUILIBRIUM E.G. ECONOMIC
INSTABILITY, FRIGHTENING UNCERTAINTY, BANKRUPTCY, LOSS OF JOB, LOSS OF FAMILY ETC.
SUICIDE SEEN AS A MEAN OF ESCAPE
• FATALISTIC
STRICT RULES, TOO MUCH REGULATION AND HIGH EXPECTATIONS
TYPES AND MODELS OF SUICIDE
• INTERPERSONAL THEORY OF
SUICIDAL BEHAVIOR
PROPOSED BY THOMAS JOINER
THREE COMPONENTS THAT TOGETHER
LEAD TO SUICIDE ATTEMPTS
• THWARTED BELONGINGNESS: PAIN
CAUSED WHEN FUNDAMENTAL NEED
FOR CONNECTEDNESS IS NOT
FULFILLED
• PERCEIVED BURDENSOMENESS: THE
BELIEF THAT ONE IS A BURDEN ON
OTHERS OR SOCIETY
• ACQUIRED CAPABILITY
TYPES AND MODELS OF SUICIDE

• ESCAPE THEORY OF SUICIDE

• PROPOSED BY BAUMEISTER,1990
• SUICIDE AS AN ESCAPE FROM NEGATIVE SELF-AWARENESS AS A RESULT OF
FAILURES, DISAPPOINTMENT AND SETBACKS
• STRESS DIATHESIS MODEL OF SUICIDE
• PROPOSED BY MANN ET AL, 1999
• DIATHESIS OR PREDISPOSITION TO SUICIDE AS A RESULT OF GENETIC
FACTORS, EPIGENETIC MECHANISMS (PARTICULARLY INVOLVING SEROTONIN)
AND CHILD ABUSE
ASSESSMENT
ASSESSMENT OF RISK

• MOST OBVIOUS SIGN: DIRECT STATEMENT OF INTENT

• THEY MAY GIVE HINTS INSTEAD OF OPEN STATEMENTS
• THERE MAY BE A SUBTLE CHANGE IN THEIR WAY OF TALKING ABOUT
DEATH
ASSESSMENT OF RISK
• FACTORS THAT POINT TO GREATER RISK
• MARKED HOPELESSNESS
• PREVIOUS ATTEMPTS
• SOCIAL ISOLATION
• OLDER AGE
• UNEMPLOYMENT/POVERTY
• ALCOHOL DEPENDENCE
• DEPRESSIVE DISORDER
• SCHIZOPHRENIA
• ABNORMAL PERSONALITY
• CHRONIC PAINFUL ILLNESS
• EPILEPSY
COMPLETING HISTORY

• DETAILED PSYCHIATRIC HISTORY

• CURRENT PROBLEMS AND PATIENT’S REACTIONS TO THEM
• LOSSES, BOTH PERSONAL (E.G. BEREAVEMENT OR DIVORCE) AND
FINANCIAL, AS WELL AS LOSS OF STATUS
• PHYSICAL ILLNESS
• PREVIOUS PERSONALITY
MENTAL STATE EXAMINATION
• ASSESSMENT OF MOOD SHOULD BE PARTICULARLY THOROUGH
• ASSESSMENT OF SUICIDAL INTENT
• START BY ASKING IF LIFE IS TOO MUCH
• IF LIFE IS NOT WORTH LIVING
• IF THEY HAVE DEATH WISHES
• IF THEY HAVE SUICIDAL IDEATIONS
• IF THEY HAVE SUICIDAL INTENT
• IF THEY HAVE SUICIDAL PLANS
• IF THEY HAVE ANY PREPARATIONS
MENTAL STATE EXAMINATION

• ASSESS FOR PSYCHOTIC SYMPTOMS

• COGNITIVE FUNCTIONS SHOULD NOT BE OVERLOOKED
• RULE OUT ANY HOMICIDAL IDEAS (MAY BE PRESENT IN SUICIDAL
PATIENTS WHO BELIEVE IT MAY BE AN ACT OF MERCY TO KILL OTHER
PEOPLE, TO SPARE THEM OF INTOLERABLE SUFFERING)
ASSESSMENT OF SERIOUSNESS OF SUICIDAL ATTEMPT
• FACTORS THAT SUGGEST HIGH SUICIDAL INTENT
• EXCESSIVE PREMEDITATION
• COMMUNICATING INTENT TO OTHERS
• PREPARATIONS MADE IN ANTICIPATION FOR DEATH (E.G. MAKING A WILL, ORGANIZING
INSURANCE)
• PREPARATIONS MADE FOR THE ACT (E.G. PURCHASING MEANS OF SUICIDE, SAVING UP
TABLETS ETC.)
• ACT CARRIED OUT IN ISOLATION
• PRECAUTIONS TAKEN TO AVOID DISCOVERY
• LEAVING A NOTE
• ACT TIMED SO THAT INTERVENTION IS UNLIKELY
• NOT ALERTING POTENTIAL HELPERS AFTER THE ACT
• ADMISSION OF SUICIDAL INTENT
MANAGEMENT
GENERAL ISSUES

• THE FIRST STEP IS TO DECIDE WHETHER THE PATIENT SHOULD BE

ADMITTED TO THE HOSPITAL OR TREATED AS AN OUTPATIENT
• ADMISSION CRITERIA
• HIGH SUICIDE INTENT
• SERIOUS SUICIDAL ATTEMPT
• SEVERE ASSOCIATED PSYCHIATRIC ILLNESS
• NON AVAILABILITY OF SOCIAL SUPPORT OUTSIDE HOSPITAL
• IF HOSPITAL TREATMENT IS ESSENTIAL AND THE PATIENT REFUSES IT,
ADMISSION UNDER COMPULSORY ORDER WILL BE NECESSARY
MANAGEMENT IN COMMUNITY

• ORGANIZING APPROPRIATE SOCIAL SUPPORT

• CONTINUING ASSESSMENT OF SUICIDAL RISK
• APPROPRIATE TREATMENT
• DRUGS LEAST DANGEROUS IN OVERDOSE SHOULD BE CHOSEN
• SMALL QUANTITIES SHOULD BE PRESCRIBED
• MEDICATION SHOULD BE KEPT SAFELY BY THE CARER
MANAGEMENT IN COMMUNITY

• ENSURE SAFE ENVIRONMENT

• KEEPING EYE ON PATIENT’S ACTIVITIES BY CARERS
• REMOVING POTENTIAL MEANS OF SUICIDE (E.G. GUNS, KNIVES, ROPES,
MEDICINES ETC.)
• BOTH PATIENT AND CARERS SHOULD KNOW HOW TO OBTAIN IMMEDIATE
HELP IN AN EMERGENCY
• LIAISE CLOSELY WITH OTHER MEMBERS OF COMMUNITY TO ENSURE
PROMPT AND APPROPRIATE RESPONSE IN EMERGENCY
MANAGEMENT IN HOSPITAL
• GENERAL REQUIREMENTS
• SAFE WARD ENVIRONMENT
• PREVENTING ACCESS TO OPEN WINDOWS AND OTHER PLACES WHERE
JUMPING COULD LEAD TO SERIOUS INJURY
• REMOVE LIGATURE POINTS FROM WHICH HANGING COULD TAKE PLACE
• PREVENTING ACCESS TO WARD AREAS WHERE SELF-INJURY WOULD BE EASY
TO ENACT
• REMOVING POTENTIALLY DANGEROUS ITEMS
• ADEQUATE NUMBER OF WELL TRAINED STAFF
• AGREED POLICIES FOR OBSERVATION, ASSESSMENT AND REVIEW OF
PATIENT
MANAGEMENT IN HOSPITAL

• ON ADMISSION
• ASSESS RISK
• AGREE THE LEVEL OF OBSERVATION
• REMOVE ANY PERSONAL POSSESSIONS THAT MIGHT BE USED FOR
SUICIDE
• DISCUSS AND AGREE PLANS WITH THE PATIENT
• AGREE A POLICY FOR VISITORS
MANAGEMENT IN HOSPITAL

• DURING ADMISSION
• AGREED PLANS FOR THE LEVEL OF SUPERVISION
• REGULAR REVIEW OF RISK AND PLANS
• CLEAR COMMUNICATION OF PLANS BETWEEN STAFF, ESPECIALLY WHEN
SHIFT CHANGES
• APPROPRIATE TREATMENT FOR ANY CO-MORBID PSYCHIATRIC ILLNESS
• AGREE ACTION TO BE TAKEN IF THE PATIENT LEAVES THE WARD
WITHOUT NOTICE OR PERMISSION
MANAGEMENT IN HOSPITAL

• AT DISCHARGE
• ENSURE SOCIAL SUPPORT
• PRESCRIBE ADEQUATE BUT NON DANGEROUS AMOUNTS OF MEDICATION
• ARRANGE EARLY FOLLOW UP
• AGREE ACTION TO BE TAKEN IF PATIENT DOES NOT ATTEND
SUICIDE PREVENTION
SERVICE CHANGES
• EDUCATING PRIMARY CARE PHYSICIANS ABOUT DIAGNOSIS AND
TREATMENT OF AFFECTIVE DISORDER
• IMPROVING PSYCHIATRIC SERVICES
• TARGETING HIGH RISK GROUPS
• PATIENTS WHO HAVE RECENTLY RECEIVED INPATIENT PSYCHIATRIC
TREATMENT
• PATIENTS WHO HAVE RECENTLY DELIBERATELY HARMED THEMSELVES
• LONG TERM MEDICATION OF PSYCHIATRIC ILLNESS
• PRESCRIBING LESS TOXIC MEDICATION
• COUNSELLING SERVICES
• CRISIS CENTERS AND TELEPHONE HOTLINES
POPULATION STRATEGIES

• DETOXIFICATION OF GAS
• DETOXIFICATION OF CAR EXHAUST FUMES
• RESTRICTING AMOUNTS OF ANALGESICS
• REMOVING AND PREVENTING ACCESS TO HAZARDS
• PHYSICAL BARRIERS ON BRIDGES, TRAIN PLATFORMS AND OTHER
POTENTIALLY DANGEROUS PLACES
• IMPROVING ACCESS TO MENTAL HEALTH CARE
• INTRODUCTION OF 24 HOUR CRISIS SERVICES
POPULATION STRATEGIES

• MORE RESPONSIBLE MEDIA REPORTING OF SUICIDE

• AVOID EXCESSIVE DETAIL ABOUT METHOD USED
• SOCIAL POLICIES
• TO DEAL WITH UNEMPLOYMENT
• TO DEAL WITH POVERTY
• TO DEAL WITH SOCIAL ISOLATION
• PUBLIC EDUCATION ABOUT MENTAL ILLNESS AND ITS TREATMENT
THANKS FOR YOUR
COOPERATION