SUICIDE

1. MODERATOR: DR. VISHAL
SINHA
PRESENTATOR: DR.
RAMASHANKAR

2. DEFINITIONS
 SUICIDE: (Latin suicidium, from sui caedere, "to kill
oneself")
 A fatal act that represents the person's wish to die.
 ABORTED SUICIDE ATTEMPT: Potentially self-
injurious behaviour with explicit or implicit evidence
that the person intended to die but stopped the
attempt before physical damage occurred.
 DELIBERATE SELF-HARM: Wilful self-inflicting of
painful, destructive, or injurious acts without intent
to die.

3. DEFINITIONS
 LETHALITY OF SUICIDAL BEHAVIOR: Objective danger to life
associated with a suicide method or action.
 Lethality is distinct from and may not always coincide with an
individual's expectation of what is medically dangerous.
 SUICIDAL IDEATION: Thought of serving as the agent of one's
own death.
 Seriousness may vary depending on the specificity of suicidal plans
and the degree of suicidal intent.
 SUICIDAL INTENT: Subjective expectation and desire for a self-
destructive act to end in death.

4. DEFINITIONS
 SUICIDE ATTEMPT: Self-injurious behavior with a
nonfatal outcome accompanied by explicit or implicit
evidence that the person intended to die.
 SUICIDE: Self-inflicted death with explicit or
implicit evidence that the person intended to die.
 CHRONIC SUICIDE: (e.g., deaths through alcohol
and substance abuse and consciously poor adherence
to medical regimens for addiction, obesity, and
hypertension).

5. PARASUICIDE
 Patients who injure themselves by self-mutilation (e.g.,
cutting the skin), but who usually do not wish to die.
 Female: male ratio is almost 3: 1
 These patients are usually in their 20s and may be single or
married.
 Most cut delicately, not coarsely.
 Most claim to experience no pain.
 Reasons: anger at themselves or others, relief of tension.
 Personality disorder is common.
 They are significantly more intoverted, neurotic, and hostile.

6. EPIDEMIOLOGY
 The World Health Organization (WHO) estimates that of the
nearly 800,000 people who die from suicide globally every year (World
Health Organisation WHO; 2015 )
 Suicide accounted for 1.4% of all deaths worldwide. (WHO 2015)
 78% of global suicides occur in low and middle-income countries.
(WHO 2015)
 India and China alone account for 49% of global suicides.*
*Phillips MR, Cheng HG. The changing global face of suicide. Lancet. 2012;379:2318–2319.
 In 1967 the suicide rate in India was 7.8, but it has steadily
increased to 11.2 in 2011,12. (10.6 in 2014,15)
 India is labelled as “Suicide Capital of South-East Asia” as it has
recorded the highest number of suicides in South-East Asia in
2012, according to a WHO report. (Indian J Psychiatry. 2015 Oct-Dec; 57(4): 348–354.)

8. EPIDEMIOLOGY
 Suicide belt – (25 per 100,000) Scandinavia
 Prime suicide site of the world – Golden Gate
Bridge in San Francisco
 Maximum number of suicides (2015) were
reported in Maharashtra(12.7%) followed by
Tamil Nadu(11.8%) and West Bengal (10.9%)

9. EPIDEMIOLOGY

10. EPIDEMIOLOGY
 Puducherry reported the
highest suicide rate at 36.8
per 100,000 people, followed
by Sikkim, Telangana and
Chhattisgarh .
 The lowest suicide rates were
reported in Bihar (0.5)
followed by Nagaland, then
Manipur.
 (NCRB DATA 2015)

11. METHODS
 Women chose drowning and burning as modes of suicide,
while significantly more men chose hanging.
In India, Hanging was the most frequently reported
method (10 to 72%)
Second most frequently reported method was self-
poisoning (often ingestions of organophosphate
pesticides), (16 to 49%).
Drowning ranged from 3 to 39%
Burning or self-immolation ranged from 6 to 57%
Other reported methods of suicide include jumping off
heights (0.5 to 2%), being run over by a train (6 to
13%)and using a firearm (3%).

12. STRESSORS
 Interpersonal difficulties (Especially conflicts with
spouse or other family members)
 Psychosocial stress
 Financial problems
 Chronic illnesses
 Domestic violence
 Work-related problems
 Extramarital relationships
 Legal problems
 Academic difficulties
 Living alone, and other types of stressful life
events.

13. RISK FACTORS
 GENDER:
 M:F 4:1
 In India M:F 1.3:1 to 1.5:1.
 Women attempt suicide or have suicidal thoughts three times as
often as men.
 Men commit suicide using firearms, hanging, or jumping from high
places.
 Women more commonly take an overdose of psychoactive substances
or poison.
 Globally, the most common method of suicide is hanging.

14. RISK FACTORS
 AGE:
 Rare before puberty.
 Suicides in the 3rd decade of life (20 -29 years) account for
41 to 62%.
 Among older adults, the age-specific suicide rate increases
with age.
 Among children under 18 years of age also found that
suicide rates increase with age
 Among men, suicides peak after age 45 year and in
women peak after age 55.
 Older persons attempt suicide less often than younger
persons, but are more often successful

15. RISK FACTORS
 RACE: white >black
 RELIGION: Protestants and Jews in the United States have had
higher suicide rates than Catholics.
 MARITAL STATUS: unmarried > married - 2:1
 In India, most studies report that the majority of suicide
decedents were married at the time of death (57 to 73%)
 In one prospective study* of suicide autopsies, male suicide
decedents were more likely to be single (60.5%) while female
suicide decedents were more likely to be married (73.8%).
 Divorce increases suicide risk (M:F 3:1)
 Marriage is protective factor (except developing country)
 * Bastia BK, Kar N. A psychological autopsy study of suicidal hanging from Cuttack, India: focus on stressful life situations. Arch
Suicide Res. 2009;13:100–104.

16. RISK FACTORS
 Homosexual men and women appear to have higher rates of suicide
than heterosexuals
 ANNIVERSARY SUICIDES: Take their lives on the day a member of
their family did.
 OCCUPATION: Higher the person's social status, the greater the risk
of suicide, but a drop in social status also increases the risk.
 Suicide is higher among the unemployed than among employed
persons.
 Among occupational rankings, professionals, particularly physicians,
have traditionally been considered to be at greatest risk.

17. RISK FACTORS
 PHYSICIAN SUICIDES
 2-3 times more in physician.
 Most often depressive disorder, substance
dependence, or both.
 Among physicians, psychiatrists are considered to be
at greatest risk, followed by ophthalmologists and
anaesthesiologists.
 CLIMATE: No significant seasonal correlation with
suicide.

18. RISK FACTORS
 PHYSICAL HEALTH:
 Loss of mobility, disfigurement (particularly
among women) and chronic, intractable pain,
seizure disorder.
 Patients on hemodialysis are at high risk
drugs like reserpine, corticosteroids,
antihypertensive, and some anticancer
agents.
 Alcohol-related illnesses, such as cirrhosis,
are associated with higher suicide rates.

19. SUICIDE AND MENTAL ILLNESS
 Almost 90% of all persons who commit or attempt suicide
have a diagnosed mental disorder. (Centre for Suicide Prevention, 2007)
 Depressive disorders account for 80% of this figure,
schizophrenia accounts for 10%, and dementia or delirium
for 5%.
 25% are also alcohol dependent and have dual diagnoses.
 Persons with delusional depression are at highest risk.
 A history of impulsive behavior or violent acts increases
the risk of suicide.
 Risk of suicide- psychiatric patient : nonpatient 3-12:1
 Most of them of younger age group.
 1st three month after discharge are highest risk for suicide.

20. SUICIDE AND MENTAL ILLNESS
 MOOD DISORDERS:
 Approximately 60-70% of suicide victims suffered a
significant depression at the time of their deaths. (CTP)
 The lifetime risk of death by suicide among
individuals with bipolar disorder is approximately 15
to 20%.
 Commit suicide early in the illness rather than later.
 More depressed men than women commit suicide.
 Risk increase if single, separated, divorced, widowed,
recently bereaved or on inadequate treatment.

21. SUICIDE AND MENTAL ILLNESS
 SCHIZOPHRENIA:
 Up to 10 percent die by committing suicide.
 Maximum suicide during few year of illness.
 Only a small percentage committed suicide because of hallucinated
instructions or a need to escape persecutory delusions.
 Risk factors : Young age, male gender, single marital status,
previous suicide attempt, vulnerability to depressive symptoms,
recent discharge from a hospital, Personal and family history,
living alone or not living with the family, higher education, recent
loss events.
 In those with chronic schizophrenia greater risk is associated with:
 Hopelessness, Insight into illness, Higher cognitive function.

22. SUICIDE AND MENTAL ILLNESS
 SUBSTANCE USE
 Up to 15 percent of all alcohol-dependent persons
commit suicide.
 Mainly male, middle-aged, unmarried, friendless,
socially isolated, and currently drinking, previous
suicide attempt, within a year of the patient's last
hospitalization; post discharge period, IP loss,
comorbid depression, mood disorder, ASPD.
 Adolescents with iv drug use
 Number rather than type of substances is more
important for predicting suicide attempts (Borges et al., 2000)

23. SUICIDE AND MENTAL ILLNESS
 5% of patients with antisocial personality
disorder commit suicide
 BORDERLINE PD (10%)
 Uncompleted suicide attempts are made by
almost 20% of patients with a panic disorder
and social phobia
 PTSD has been associated with eight times
greater risk of suicide attempt than that in non-
PTSD populations.
 Hopelessness and impulsivity is considered a
risk factor for suicide ideation.

24. EVALUATION OF SUICIDE RISK
Variable High risk Low risk
DEMOGRAPHIC AND SOCIAL PROFILE
Age Over 45 years Below 45 years
Sex Male Female
Marital status Divorced/widowed Married
Employment Unemployed Employed
Interpersonal relationship Conflictual Stable
Family background Conflictual Stable
HEALTH
Physical Chronic illness Good health
Hypochondriasis Feels good

25. VARIABLES HIGH RISK LOW RISK
Mental Severe depression Mild depression
Psychosis Neurosis
Personality disorder Normal personality
Hopelessness Optimism
SUICIDAL ACTIVITY
Suicidal ideation Frequent, intense, prolonged Infrequent, low intensity,
transient
Suicide attempt Multiple attempts First attempt
Planned Impulsive
Rescue unlikely Rescue inevitable
Unambiguous wish to die Primary wish for change
Communication internalized
(self-blame)
Communication externalized
(anger)
Method lethal and available Method of low lethality or not
readily available

26. VARIABLES HIGH RISK LOW RISK
RESOURCES
Personal Poor achievement Good achievement
Poor insight Insightful
Affect unavailable or poorly
controlled
Affect available and
appropriately controlled
Social Poor rapport Good rapport
Socially isolated Socially integrated
Unresponsive family Concerned family

27. ETIOLOGY
 1) SOCIOLOGICAL FACTORS:
 DURKHEIM’S THEORY
 Emile Durkheim (French Sociologist )
 Each society has a specific tendency toward suicide
Suicide

28. DURKHEIM’S THEORY
EGOISTIC- bounds
which unite groups
weaken, and
individuality increases.
Too little integration
ALTRUISTIC- bonds
between groups too
strong. So individual
sacrifice themselves.
ANOMIC- Integration
into society is
disturbed
FATALISTIC- Luck &
Slavery Excessive
regulations

29. ETIOLOGY
 2) PSYCHOLOGICAL FACTORS:
 FREUD’S THEORY: “ Mourning and Melancholia”
 Aggression turned inward against an introjected,
ambivalenty, cathected love objects.
 MENNINGER'S THEORY:
 In “Man against Himself” conceived of suicide as
inverted homicide because of a patient's anger toward
another person.

30. ETIOLOGY
 3) BIOLOGICAL FACTORS:
 Serotonergic system: low concentration of 5-
HIAA (metabolite of serotonin).
 Dysfunction of Hypothalamic-pituitary-adrenal
axis (stress response) predicts suicide in
depressed patients.
 Increased suicide risk associated with low
cholesterol levels.

31. ETIOLOGY
 4) GENETIC FACTORS:
 Family history of suicide increases the risk two-fold especially in
women and children independent of family psychiatric history
 Concordance rates of suicide higher among monozygotic twins
 Adoption studies: A greater risk of suicide among biologic rather
than adoptive relatives.
 Genetic factors account for 45% of suicidal thoughts and
behaviors.
 Polymorphism of Tryptophan hydroxylase (TPH) 1 and 2, three
serotonin receptors (5-HTR1A, 5-HTR2A, and 5-HTR1B), and the
monoamine oxidase promoter(MAOA)

32. STRESS-DIATHESIS MODEL
STRESS
A force that disrupts the
equilibrium or normal
functioning of an individual’s
mental or physical state.
Different types of stressors may
precipitate suicidal behavior.
Negative Life events
Acute substance intoxication
Acute psychiatric condition
DIATHESIS
Innate vulnerability or
predisposition (in the form of
traits) for developing the
suicidal state
Familial / genetic influences
Chronic multiple psychiatric
problems
Hopelessness
Being male / loneliness

33. STRESS-DIATHESIS MODEL
Combines psychological and biological factors
Van Heeringen K. Stress–Diathesis Model of Suicidal Behavior. In: Dwivedi Y, editor. The Neurobiological Basis of Suicide. Boca Raton (FL): CRC Press/Taylor & Francis; 2012. Chapter 6.

34. PREDICTING SUICIDE
 Attempted suicide are at least 20 times more common than the
completed suicide
 Hopelessness Scale and pessimism items on the Beck Depressive
Inventory predicted suicides more accurately
 SAD PERSONS scale,
 Beck Suicidal Intent Scale
 Suicidal Intent Questionnaire (SIQ)
1. The Columbia-suicide severity rating scale (C-SSRS)
2. Suicide trigger scale (STS)
3. Suicide probability scale (SPS)


35. MANAGEMENTS
 Most suicides among psychiatric patients are
preventable
 The evaluation for suicide potential involves:
 complete psychiatric history
 thorough examination of the patient's mental
state
 inquiry about depressive symptoms
 suicidal thoughts, intents, plans, and
attempts. A lack of future plans.

36. GUIDELINES FOR ADMISSION
Admission generally indicated: high risk of suicide
After a suicide attempt or aborted suicide attempt if:
 Patient is psychotic
 Attempt was violent, near-lethal, or premeditated
 Persistent plan and/or intent is present
 Distress is increased or patient regrets surviving
 Patient is male, >45 years of age, especially with new onset of psychiatric illness or
suicidal thinking
 Current impulsive behavior, severe agitation,
 Patient has change in mental status with a metabolic, toxic, infectious, or other etiology
requiring further workup in a structured setting
 In the presence of suicidal ideation with:
Specific plan with high lethality, High suicidal intent

37. From the Practice Guidelines for Assessment and Treatment of the Suicidal Patient, 2nd ed. The
American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders
Compendium
Admission may be necessary: moderate risk of suicide
After a suicide attempt or aborted suicide attempt, except in circumstances for which
admission is generally indicated in the presence of suicidal ideation with:
 Psychosis
 Post attempts, particularly if medically serious
 Need for supervised setting for medication trial or electroconvulsive therapy
 Need for skilled observation, clinical tests, or diagnostic assessments that require a
structured setting
 In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence
from the psychiatric evaluation and/or history from others suggests a high level of
suicide risk and a recent acute increase in risk

38. Lesser risk
 Suicidality is a reaction to precipitating events (e.g., exam failure, relationship
difficulties), particularly if the patient's view of situation has changed since coming to
emergency department
 Plan/method and intent have low lethality
 Patient has stable and supportive living situation
 Patient is able to cooperate with recommendations for follow-up,
Outpatient treatment may be more beneficial than hospitalization: lesser risk of suicide
 Patient has chronic suicidal ideation and/or self-injury without prior medically serious
attempts,
 if a safe and supportive living situation is available and outpatient psychiatric care is
ongoing

39. TREATMENT MODALITY
 PHARMACOLOGICAL TREATMENT
 1) LITHIUM:
 Protecting against suicidal behavior in major
affective disorders (bipolar I and II disorder,
recurrent major depressive disorder)
 The rate of suicide decreased by 13–15-fold.
 Protective effect: recurrent major
depression>bipolar II disorder> bipolar I
disorder

40. TREATMENT MODALITY
 2) ANTIDEPRESSANTS
 Effective in management of depressive symptoms
 Paradoxical suicide: Patients recovering from a suicidal depression
are at particular risk. As the depression lifts, patients become
energized and, thus, are able to put their suicidal plans into action.
3) ANTIPSYCHOTICS
 The current first-line treatment for schizophrenia and schizoaffective
disorder is the second-generation antipsychotics.
 In late 2002 FDA’s approved use of clozapine for suicidal individuals
with schizophrenia

41. TREATMENT MODALITY
 PSYCHOSOCIAL TREATMENT
 Cognitive Behavioral Therapy
 Family Treatments
 Brief Interventions
ELECTROCONVULSIVE
THERAPY
 Validated treatment for major
depressive disorder
 Rapid onset of therapeutic action
and good response rates

42. LEGAL ASPECTS
 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].


43. THE MENTAL HEALTHCARE ACT, 2017
 115. (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.

44. 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.

45. WORLD SUICIDE PREVENTION DAY
• Efforts to prevent suicide have been celebrated on World Suicide
Prevention Day – September 10th – each year since 2003.
• In 2017, the theme of World Suicide Prevention Day is
“Take a Minute, Change a Life”.