SUICIDAL THREAT

By DR. BIZIMUNGU MUCYO Nelly

PGY1 /PSYCHIATRY
216083192
 CONTENTS
• INTRODUCTION
• EPIDEMIOLOGY
• ETIOLOGY
• PATIENT EVALUATION
• MANAGEMENT
• REFERENCES
 INTRODUCTION
• Definition: Suicidal threat refers to verbal or non-verbal indications of
intent to harm oneself with the possibility of death.

• Major public health issue.

• Leading cause of preventable mortality globally.
• Associated with significant mental health morbidity.

• 50% of patient who commit suicide verbalize their project

• Ingestion of pesticide, hanging and firearms are among the most
common methods of suicide globally.
 EPIDEMIOLOGICAL
OVERVIEW
GLOBAL STATISTICS
• Global Suicide Rates:
• Over 700,000 suicides occur annually worldwide, according to the WHO.
• Suicide is the 4th leading cause of death among individuals aged 15–29
years.

• Gender Differences:
• Males have higher suicide completion rates due to the use of more lethal
methods.
• Females tend to attempt suicide more often but have lower completion
rates.
SUICIDE IN RWANDA
• Prevalence:
• Rwanda reports an estimated 3.8 suicides per 100,000 population (WHO, 2021).
• Risk Factors Specific to Rwanda:
• Post-Genocide Trauma: Many individuals still experience PTSD and depression linked to
the 1994 genocide.
• Youth Vulnerability: A significant proportion of suicides involve adolescents and young
adults, often triggered by academic stress, unemployment, or relationship issues.
• Substance Abuse: Alcohol and drug use contribute significantly to suicide risks, especially
among young men.
• Gender Dynamics:
• Suicide rates are higher in men, reflecting global trends.
• Women experience high levels of domestic violence, which can increase suicide attempts.
 ETIOLOGY
1. Neurobiological Underpinnings
Serotonergic Dysregulation
• Reduced serotonergic activity, particularly in the prefrontal cortex and limbic system, is a
well-documented hallmark of suicidality.

HPA Axis Dysfunction

• Dysregulation of the HPA axis, often characterized by hypercortisolemia, is a consistent
finding in suicidal patients.

Neuroanatomical Changes
• Structural MRI studies consistently demonstrate reduced gray matter volume in the
dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC), and amygdala—
regions integral to emotion regulation, decision-making, and impulse control.
 ETIOLOGY
2. Genetic and Epigenetic Contributions
Genetic Predisposition
• Twin and family studies estimate the heritability of suicidal behavior to be
30–50%.
 ETIOLOGY
3. Neurotransmitter Dysregulation
• Glutamate: Increased glutamatergic activity has been linked to
excitotoxicity and mood instability in suicidal patients.

• Dopamine: Dysregulation in mesolimbic dopaminergic pathways

contributes to anhedonia and impaired reward processing, common in
suicidality.

• Gamma-Aminobutyric Acid (GABA): Lower GABAergic activity in the

prefrontal cortex is associated with poor inhibitory control, increasing
susceptibility to impulsive actions.
 ETIOLOGY
4. Psychological and Behavioral Dimensions
• Impulsivity and Aggression:
• Impulsivity, often linked to serotonergic dysfunction, is a critical component
of suicidal behavior, particularly in younger individuals.
• Aggression, whether directed outwardly or turned inward as self-harm,
further elevates risk.
• Hopelessness and Cognitive Distortions:
• Suicidal individuals frequently exhibit pervasive hopelessness, rigid cognitive
biases, and a heightened focus on perceived failures or losses.
 ETIOLOGY
5. Role of Psychiatric Comorbidities
Major Depressive Disorder (MDD)
• Up to 60% of suicide victims meet criteria for MDD. Core symptoms include
hopelessness, guilt, and impaired executive function.
Bipolar Disorder
• Mixed mood states and rapid cycling phases heighten vulnerability due to
concurrent depressive symptoms and impulsivity.
Substance Use Disorders
• Acute intoxication or withdrawal disrupts judgment and exacerbates impulsive
behaviors, significantly increasing suicide risk.
Anxiety Disorders and PTSD
• Chronic hyperarousal, intrusive thoughts, and maladaptive coping strategies,
such as avoidance, contribute to elevated risk.
 ETIOLOGY
• 6. Environmental and Social Contributors
Early-Life Adversity:
• Exposure to childhood trauma, including abuse and neglect, has long-term
effects on HPA axis function and emotional regulation.
Acute Stressors:
• Interpersonal conflicts, financial strain, or exposure to suicide in close
contacts act as precipitating factors.
Social Isolation:
• Reduced social support networks magnify feelings of loneliness and
hopelessness.
 PATIENT EVALUATION
A. Establish Rapport and Assess Safety
• Build trust: create a supportive, non-judgmental, and empathetic
environment to facilitate open communication. Establishing rapport is
crucial for obtaining accurate information.

• Immediate safety: Ensure the patient is in a safe environment where

they cannot act on suicidal thoughts immediately. Assess whether there is
an acute risk that warrants emergency intervention, including involuntary
hospitalization if necessary.
 PATIENT EVALUATION
B. Explore Suicidal Thoughts and Intent
• Presence of suicidal ideation: Directly ask about suicidal thoughts
using open-ended questions such as, “Have you been having thoughts of
ending your life?”
• Plan: Determine whether the patient has a specific plan, the method
considered, access to means, and details of the plan. This is a critical
component in assessing the risk.
• Intent: Assess the level of intent to act on the suicidal thoughts,
including the patient’s perception of the lethality of the method and their
determination to follow through.
• Previous attempts: Inquire about any prior suicide attempts, including
the methods used, severity, and consequences. A history of previous
attempts is a significant risk factor for future suicides.
 PATIENT EVALUATION
C. Risk Factors Assessment
• Psychiatric diagnosis: Depression (especially major depressive disorder), bipolar
disorder, schizophrenia, and personality disorders (particularly borderline and
antisocial personality disorder) have strong associations with suicidal behavior.
• History of trauma and abuse: Childhood trauma, sexual abuse, and emotional
neglect are significant risk factors for suicidal ideation.
• Substance use: Alcohol and drug abuse often co-occur with suicidal behavior,
both as an impulsive trigger and as a means of escaping emotional pain.
• Social factors: Social isolation, relationship problems, financial stress,
unemployment, and a lack of social support increase suicide risk.
• Medical comorbidities: Chronic medical conditions that cause pain or functional
impairment (e.g., cancer, neurological disorders) may increase the likelihood of
suicidal thoughts.
• Cognitive distortions: Patients with suicidal ideation often experience black-and-
white thinking, feelings of hopelessness, and perceived burdensomeness.
 PATIENT EVALUATION
D. Protective Factors
• Social support: Strong family ties, friendships, or community
engagement can act as protective factors.
• Religious or spiritual beliefs: Some individuals derive meaning
from religious beliefs that discourage suicide.
• Future orientation: Hope for the future and reasons for living (such
as family, personal goals, or treatment plans) can mitigate the risk.
• Coping skills: A patient with adaptive coping mechanisms,
resilience, and problem-solving abilities is at a lower risk of
completing suicide.
 PATIENT EVALUATION
E. Screening for Other Disorders
• Depression: Evaluate for depressive symptoms (e.g., anhedonia,
fatigue, worthlessness, sleep disturbances, and appetite changes).
Major depression is a primary contributor to suicidal thoughts.
• Anxiety disorders: Generalized anxiety, panic disorder, and post-
traumatic stress disorder (PTSD) often coexist with suicidality.
• Psychosis: Delusions or hallucinations, especially those with
suicidal themes, require immediate attention.
• Personality disorders: Borderline and antisocial personality
disorders are associated with increased suicide risk.
 ASSESSMENT TOOLS
Columbia-Suicide Severity Rating Scale (C-SSRS)
• A tool for assessing suicidal ideation and behavior
• Used in clinical, emergency, and community settings
• Helps determine suicide risk level and need for intervention

Assessment Areas:
• Suicidal Ideation (Thoughts about suicide)
• Ranges from passive wish to be dead → active plan & intent
• Suicidal Behavior (Actions related to suicide)
• Attempts, interrupted/aborted attempts, preparatory behavior
 C-SSRS
Risk Assessment & Clinical Use
Risk Levels:
• Low: Passive thoughts, no plan or intent
• Moderate: Active thoughts with method, no intent/plan
• High: Active thoughts with intent, recent behavior

• https://cssrs.columbia.edu/wp-content/uploads/C-SSRS1-14-09-
Baseline.pdf
 MANAGEMENT
A. Safety First

• Hospitalization: If there is imminent danger of self-harm, the patient

may need to be hospitalized involuntarily in a psychiatric facility with
constant supervision. This decision should be based on the risk of the
patient acting on suicidal thoughts, especially if they have a detailed
plan, access to means, or a prior history of attempts.
 MANAGEMENT
B. Crisis Intervention and Psychosocial Support
• Psychotherapy: Engage the patient in brief, supportive psychotherapy.
The goal is to alleviate the immediate emotional distress, normalize the
experience, and empower the patient to reconsider the act of suicide.

• Family involvement: Engage supportive family members (with the

patient’s consent) to help create a supportive home environment,
monitor the patient’s safety, and provide emotional support.
 MANAGEMENT
C. Medication Management
• Antidepressants: In patients with major depression or anxiety disorders,
initiate appropriate pharmacotherapy. Selective serotonin reuptake
inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs)
are common choices, though careful monitoring is required, particularly in
the early stages of treatment due to the increased risk of suicide
associated with antidepressants in the first few weeks.
• Mood stabilizers or antipsychotics: For patients with bipolar disorder,
schizophrenia, or severe agitation, mood stabilizers (e.g., lithium,
valproate) or atypical antipsychotics (e.g., quetiapine, risperidone) may
be required.
• Benzodiazepines: These may be used sparingly for acute anxiety or
agitation, but long-term use is discouraged due to their potential to
increase impulsivity and risk.
 MEDICATION
Medication Typical Dosing Notes/Indications
Drug Class
Range
Often used for MDD,
OCD, and long-term
20–80 mg/day management of
Antidepressants Fluoxetine
depressive symptoms
associated with
suicidality
Sertraline 50–200 mg/day Indicated for MDD,
OCD, PTSD.
Escitalopram 10–20 mg/day Commonly used in
MDD and GAD;
beneficial for mood
stabilization in some
suicidal patients
Venlafaxine (SNRI) 75–225 mg/day Useful in MDD and
anxiety; may be
considered in
treatment-resistant
Mood Stabilizers Lithium 600–1800 mg/day Has robust anti-
(with serum levels of suicidal properties in
0.6–1.2 mEq/L) both bipolar and
unipolar depression
Valproate 500–2000 mg/day Used in bipolar
(commonly 750–1500 disorder; may serve
mg/day) as an adjunct in
reducing suicidality in
mood disorders
Antipsychotics Clozapine 300–900 mg/day FDA-approved for
reducing suicide risk
in schizophrenia;
reserved for
treatment-resistant
cases
Risperidone 1–6 mg/day Employed as adjunct
therapy in MDD with
psychotic features;
may help with
agitation in suicidal
patients
Olanzapine 5–20 mg/day Used as an adjunct in
treatment-resistant
depression,
sometimes in
combination with
SSRIs to address
suicidal ideation
Quetiapine 150–300 mg/day Often added for its
(adjunct dosing; may sedative and
vary with indication) anxiolytic effects in
 Lorazepam 1–4 mg/dose; up to 8 Provides rapid relief
mg/day as needed of acute anxiety and
agitation in suicidal
Anxiolytics patients; use short-
term with caution
regarding sedation
risks
Alprazolam 0.25–0.5 mg every 4– Short-term
6 hours as needed management of
anxiety; caution is
warranted due to risk
of dependency and
overdose
Diazepam 2–10 mg every 6–8 Used for acute
hours as needed anxiolysis and
calming agitation;
benefits must be
weighed against
potential for sedation
 FOLLOW-UP CARE AND LONG-
TERM MANAGEMENT
1. Detailed Psychotherapy
• Cognitive-behavioral therapy (CBT): Evidence supports CBT as one of
the most effective psychotherapeutic modalities for suicide prevention,
especially for addressing the cognitive distortions (e.g., hopelessness,
worthlessness) underlying suicidal ideation.

• Problem-solving therapy: Focus on addressing situational stressors,

enhancing coping strategies, and improving the patient’s ability to see
alternatives to suicide.
 2.Address Underlying Conditions
• Treatment of depression, anxiety, and other psychiatric
conditions: Continue to manage the underlying psychiatric disorders
contributing to suicidality. Ensure regular follow-up appointments to
monitor medication adherence and symptom progress.

• Substance abuse treatment: Address substance use through

rehabilitation programs, outpatient therapy, or medications (e.g.,
buprenorphine for opioid use disorder, disulfiram for alcohol use).
 3. Social Support and Safety Planning
• Building a safety plan: Collaborate with the patient to develop a
personalized safety plan, which includes recognizing warning signs of a
crisis, coping strategies, and emergency contacts.

• Social reintegration: Encourage re-engagement with community

resources, vocational training, or other social activities to improve the
patient’s sense of belonging and purpose.
 4. Family and Community Support
• Family psychoeducation: Educate family members about the patient’s
condition, the risk of suicide, and how they can support the patient’s
recovery.

• Collaboration with community services: Involve social workers, case

managers, or other community-based mental health services to provide
additional support, housing, and resources.
 LEGAL AND ETHICAL
CONSIDERATIONS
A. Confidentiality
• Be mindful of confidentiality, but always prioritize the patient's safety. In
cases where the patient is a danger to themselves, breaching
confidentiality may be necessary to prevent harm.

B. Involuntary Admission
• In situations where the patient is unable or unwilling to agree to
hospitalization, involuntary admission may be necessary. Ensure this
process follows the legal and ethical guidelines for the jurisdiction in
which you practice.
 REFERENCES
 World Health Organization. (2023). Preventing Suicide: A Global Imperative.

 American Psychiatric Association. (2022). DSM-5-TR®: Diagnostic and Statistical Manual of Mental
Disorders.

 Mann, J. J., et al. (2005). Neurobiology of suicidal behaviour. Nature Reviews Neuroscience, 6(10), 819-828.

 Joiner, T. E. (2005). Why People Die by Suicide. Harvard University Press.

 Linehan, M. M. (2015). DBT Skills Training Manual. Guilford Publications.