.IXAININ<; R1ODUI.E FOR SOCIAL WORKERS1 MENTAL HEALTH PROFESSIONALS CONTENTS SEC:TION - 1. TIlE NATURE OF Sl!ICIDE Concept of Suicide Terminologies and Purpose Causes Risk E>aluation .. Classification of Suicide Characteristics of Suicide Early identification Observed behavioral patterns Assessment Treatment Management Strategies SECTION - XI. THE ROLE OF PROFESSIONALS IN PREVENTION Physician's role Psychiatrist's role Psychologist's role Educationalist's role Social worker's role SECTION - Ill .SOCIETIES ROLE TO \\.'ORE3 PREVENTION Cornmuni~'~ role National Policy Media's role SECTION - IV. MYTHS AND FACTS General iLl) ths Common facts Myths rols to contribute to suicide ( Role of myth in Suicide) SECTION - V REHAVIOIIIWL hlETHODS IN PREVENTION
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.IXAININ<; R1ODUI.E FOR SOCIAL WORKERS1
MENTAL HEALTH PROFESSIONALS
CONTENTS
SEC:TION - 1 . TIlE NATURE OF Sl!ICIDE Concept of Suicide Terminologies and Purpose Causes Risk E>aluation
. . Classification of Suicide Characteristics of Suicide Early identification Observed behavioral patterns Assessment Treatment Management Strategies
SECTION - XI. THE ROLE O F PROFESSIONALS IN PREVENTION Physician's role Psychiatrist's role Psychologist's role Educationalist's role Social worker's role
SECTION - I l l .SOCIETIES ROLE TO \\.'ORE3 PREVENTION Cornmuni~ '~ role National Policy Media's role
SECTION - IV. MYTHS AND FACTS General iLl) ths Common facts Myths rols to contribute to suicide ( Role of myth in Suicide)
SECTION - V REHAVIOIIIWL hlETHODS IN PREVENTION
This training module is developed with the aim of understanding concept,
risk, assessment, intervention and rehabilitation of suicide attempters. This training
module development is through adopting three strategies: The three strategic adapted
are ( I ) based on the literature(2) consultation with experts on these field and(3) based
on the present study findings.
Suicide is a global tragedy., taking away 50,00,000 lives every year. Every
seven minutes there is a suicide. As it is under reported because of social stigma
attached it, the actual figure is more than estimated. it occurs among all groups.
Suicide is a major Public health problem, 10,000 people killing themselves in world
every year, 10% of all deaths is due to suicide. It has been observed that among the
Indian states, the highest suicide rate is in Kerala during the last few decades. 55%
had given a hint about their suicide 113 had made obvious suncide threats, and 113 had
received adequate antidepressant in adequate dosage.
This manual is intended to guide the professional social workers in early
identification and management of suicidal behaviour.This manuel is useful to
ProFessionals working in the area of suicidologist, such as clinician, educators,
priests, epidemiologists. Its major focus is on the information on suicidal behaviour.
Concepts of Suicide.
On completion of this section, the social workers will be able to answer the
following questions.
1. What is suicnde"
2 . What are the nature and prevention of Suicide?
3 . What are the main causes of su~cide?
4. What are the main approaches to management?
The three broad categories of Suicide
Completed Su~cide (CS)
Attempted Su~cide (AS)
Suicidal Ideation (SI)
Completed Suic~de (CS) includes all deaths in which a willfull, self- inflicted, life
threatening act has resulted in death.
Para-suicide or suzczdal attempt 1s as "Every act of self injury consciouly aiming at
self- destructton
Suicidal ldeatlon 1s frequent intense, or proiclnged thought about suicide in one who
has not attempted suiclde ever, but only nourished the idea about suicide.
Suicide intent is the seriousness or intensity of the wish of a patients to terminate his
life.
Suicidal behaviour include completed suicide, non fatal deliberate self-harm (eg:
attempt. gestures, Para suicide, self injury, self poisoning, suicide
communication including su~cide threats, and suicidal Ideation.
Causative factors:
Suicide does occur Not a single factors, it due to Multifactors. So
Multidisciplinary approach is essential for prevention, treatment & rehabilitation.
Psycho-social factor may be directly or indirectly related to suicidal
behaviours in any of three ways
- Predisposing
- Prec~prtating
- Psycho-social factors
A person or mediating agent suicidal behaviour under certain conditions, early
loss and certain Personality characteristic such as neuroticism and impulsivity are
generally viewed as predisposing.
Psychological factors may act as precipitating or direct causal factors in suicidal
behaviour eg. Llfe events.
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Third, Psycho-social factors may be epiphenomena1 in other words they may be
related to phenomenon such as depression.
RISK EVALUATION
Risk factors can be helphl in identi@ing suicide risk. If intervention can be
started early we can prevent suicide to some extent. The major risk groups are:-
- Life events especially recent events and early loss such as that of a
parent during childhood due to death, divorce or legal separation.
- Bereavement, a prominent stress which precedes suicide.
- Depression ,6 - 15% (MDP approximately 30 times risk) most of them
during first 10 years. Several studies indicate that in many depressives
who committed suicide there had been inadequate assessment,
treatment or both.
It is responded that 2i3 of suicide victims had seen a physician or
Psychiatrist in the month before suicide.
55% had given a hint about their suicide ideation.
- 113 made an obvious su~cidal threat.
- Psychiatric patients are of 3 - 12 times greater risk than non Psychiatric
degree of risk which ~ar ies with age, sex, diagnosis, chronicity and
many other factors.
- Other Psychological disturbances such as anti-social personality, eg,
bullylng . stealing, truancy and other emotional symptoms or
"emot~onal instability".
- Family history: - high concordice rate for schizophrenic and manic
depress~ve illness.
- Alcoholism -- Alcohol use and alcoholism are high risk for suicide.
6- 20 percent alcoholics commit suicide.
- Physical and Psychological problems. Social deprivation and previous
parasulc ~ d e
The largest sub group of alcoholic are those with associcated antisocial
personality.
Alcoholrc who has fewest social, economic and interpersonal resources
to support are psychologically more disturbed than others.
The following factors increase alcoholic suicide risk rate at high level
Depressive illness is more common among females- relatives of
alcoholic
Self destructive and aggressive personality.
Sense of guilt feelings.
The alcoholic with a history of parasuicide has a poor prognosis,
impulsiveness and impaired capacity to cope with stress, recurrent
feelings of' failure, isolation, hopelessness depression and separation,
little orlentation to the future and some death might seem the relief with
a hangover or severe withdrawall symptoms
Alcoholics kequently threaten to commit suicide more than half first
talked it over a year before their death.
12% had communicated 6 weeks before the attempt.
The nature of interpersonal disruptions report in order of their
tiequency and they have more of marital separation or divorce, breakup
of an erotic relationship.
Several medical illness, cancer.
Suicide prone alcoholic will be Psychologically more disturbed than
others.
Alcoholic experience an increase anxiety and depression during
intoxicat~on
Other Psychopathology, alcoholic with dual Psychiatric diagnosis as
anti social personality disorde:r, boderline personality disorder, h/o
suicide attempts, generalised anxiety disorder and post tranautic stress
svndrome also contribute to suiciide
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- Aicohol~c ~mpulsivit); and low frustration tolerance on anxiety &
Psychtat~c complication
- H~dden suicide ideation.
- Alcohol~c homosexual or heterosexual activity may cause AIDS.
- Alcohol~sm affect family system. It is an important factor depression
and suicide in the family
- In addition social problems on increase.
Whai can we do he& them - Increase Support systems include the family , School, work place,
professionals, organisation etc.
- Identi6 h~gh risk group and refer to professionals.
- Physician assisted programme may help to prevent the high groups
attempt
Personality
Suicide attempters and suicide completers appears to differ in their personality
characteristic, and attempters have the more disturbed personality profiles.
- Attempters are usually women below 24 years, more often neurotic /
personality disorder
- Su~cide completers tend to be mare men and older age groups.
- Lowered or negative self esteem in both suicide & parasuicide.
- BIIPwith great self-destruction behaviour among most of the attempters
- Higher mortality in neurosis & Personality disordres
- Secondary depression related antisocial personality
- Antisoc~al personality disorder and criminology are predictors of
recurrent attempts.
- Attempters with "Psychopathic States" found that the majority of
attempters had previous attempts.
Hopelessness & He&lessness are closely associated with depression, the more
hopelessness people feel is their situation concerning the conditions in their life that
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burden them. So evaluators need to assess strengthen feelings, they are affected by
faulty perception . and glve more importance to negative aspects in life and ignore.
Positive element. Evaluators need to take note integrity of reality testing and whether
they are able to see anything good, hopeful or worthwhile in themselves,
hopelessness is an Important clue that should alter clinicians to long term suicide
potential.
Social support, soc~al support is the perceived support, a subjective evaluation that
significant others are caring and available in times of need and instrumental in
providing a sat~sfylng relationship,and stress reducing .
Experience of Loss, loss is the central issues in depression as the most cause of
suicide, loss of parent, divorce, separation, loss of viriginity, courmpt as sex, eiends
& lovers. The loss become more serious when it is interpreted as a rejection.
Unemployment, the incidence of unemployment is sured males dying by suicide, was
3 times, and the sulc~de rate of unemployment was 5 times in males. Psychiatric
disorders due to unemployment, lack of work are more risk for suicidal behaviour
History of prior suicide attempt People who have already attempted suicide atleast
once are far more likely to attempt it again
Schizophrenic depresswe symptoms response to hallucinations or delusion associated
with suicide as h~gh risk among young males, single, previous attempt , recent
discharge from hosp~tal.
Physical illness :-Many persons with chronic:, painful or terminal illness to end their
suffering prematurely by taking their own lives, such as rat~onal decisions to commit
suicide are relatively rare.
- Phvsical ~llness bring on a severe depression
- Suicide accounts only 0.5% of males and 0.2% females
- Prevalence varies from 25% to 70% T.B & Parkinsonism are
respectively 10 to 200 times.
- Cancer I5 times, reumatoid arthritics 5 to 7 times, Peptic ulcer 2-5.
- 30% Psychiatric Patients were physically ill before committing suicide.
- Higher incidence among epileptic.
Some of the physical disease are often contribure suicide attempt
- Disease of central nervous system.
- Epilepsy
- Multiple sclerosis
- Head injuries
- Cerebrovascular disease
- Huntington's Chorea
- Other disease of CNS, eg: Cerebral tumors, Dementia, Paralysis agitans
- Cancer
- Gastrointestinal disease
- Other gastrointestinal disease, eg, Cirrhosis of liver and
gallbladderdisease, hepatic cirrhosis.
- Urogenital disease
- Cardiovascular disease and hypertension
- Respiratory disease
- Musculoskeltal disease
- Endocrine disease
- Other conditions such as anorexianemosa, Klinefelter's syndrome, and
acute intermittant perphyris intermittent porphyris, other conditions to
control distress symptoms, particularly severe pain.
Genetic Factors
- Family hrstory of suicide
- First degree of relatives of Psychiatric Patients
- Hlg concordance rates for schizophrenic & Manic depressive illness
C1,ASSIFICA'TION OF SUICIDE
Classification is no use in the clinic where the task is saving lives but examine
how the Socio-Cultural context influence the risk of suicide
In 1967 Douglas classified according to six Eundamental dimentions of the initiation
of the act (that lead to death) the willing (of self destruction). , the loss (of will) the
motivation ( to be dead ) and knowledge ( ofthe death potential of the act). Some of
the classifications are:
- Altrusric Suicide -result from excessive integration is determined by
society. Egoistic: determined by a lack of meaningful family ties or social
interaction
- Eugostic- determined by a lack of meaningful family use or social
interaction
- Anomic-occurs when the relationship between and individual and society is
broken by social or economic adversity.
- Rational : to escape pain
- Reaction , following loss
- Vengefui to punish someone else
- Man~pulat~ve to thwart others pair1
- Psychot~c to hllfill delusuion
- Acc~dental re cons~dered too late
- Ludic referlng to games and play
- Man~cal due to halluc~nation or delusion escape from imaginary danger
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- Anx~ety su~c~de through out sad, depressed, w~th constant increasing
anxlety
- Others are dynamic orgeneratic, escapist, aggressive, oblative (obligatory)
Seasonal trend in suicide
Monthly peak occurance of suicide
More - May, April, June
Less - September, August, January
Spring and summer peaks for women
Common characteristics of features of committed suicide
In Millers iivmg system ment~on some common features of sulctde , each
s u ~ c ~ d e IS an ~diosynoratic event In some suwcrde these are no un~versals, absolutes,
and other features are
The common purpose of suicide is to seek Solution
The: common goai of suicide is cessat~on of consciousness
The common stimulus (or informatic on input) ia suicide is intolerable Psychological pain
The common stressors in suicide is iiustrated 1)sychological need
The common emotion in suicide is hopelessness - helplessness
The common internal attitude in suic~de is ambivalence
The common cognitive state in suicide is constriction
The common acuon of suicide is escape
The common interpersonal act in suicide is cornminication of intention (80% of
suicide)
The common consistency in suicide is with life long coping patterns.
OBSERVED BEHAVIOURAL PATTERNS
These symptoms must been present nearly every day for a period of at least two
weeks they may attempted suicide.
1 . Poor appetite or significant weight loss (when not dietient) or increased
appetite or significant weight gain.
2. Insomnia or hypersomnia
3. Psycho- motor agitation or retardation (but not merely subjective feelings of
restlessness or being slow down).
4. Loss of interest or pleasure in usual activities or decreased in sexual drive not
limited to a per~od. When delusional or hallucinating,
5. Loss of energy. .Fatigue
6. Feelings of worthlessness, sei6 repoach or excessive or in appropriate guilt
(either mav be delusional)
7 . Complaints or evidence of diminished ability to think or concentrate such as
slowed t'h~nking or indecisioness not associated with marked loosening of
associations or incoherence.
8. Recurrent thoughts of death, suicidal ideation wishes to dead, or suicide
attempt
They may be unable to recognise the signs or the association between
depressed feehngs and actual behaviour
Most studies describing depression and mania indicate ratio of depression
around 6 . 1
WHY DEPRESSED COMMIT SClCIDE :'
The mildly depressed persons suffers from feelings of poor self images,
inadequate and "the blue"
The person often concerned about having some medical illness and about dying.
These thoughts are frequent , repetitive and difficult to avoid for any significant
period of time
In most depressed feel more or more \vorthless and less and less hopeful. The
problems of mcreased slowness & sluggishness of movement (Some experience
opposite motor ag~tation of speech, sometimes to the point of muteness, inability to
think, to concentrate, to feel emotion and feeling that head is empty delusion such as
incurability, self blame, illness of a punishment for sin and hallucination are also
encountered. Two th~rd of suicide victim had seen by physician or psychiatrists in the
month before suicide
55% had glven a hind about the suicide: to someone at sometimes and one third
made an obvious suicidal threat and 113 received depressant adequate dosage.
Don't ignore if any one show the symptoms.
Early identification
Suicidal Signs
Threat of suicide : The belief that those who threaten suicide are less like to do, it is
supported that threats of suicide represent attention seeking behaviour ,
especially among the young, most adolescence who do make suicide attempts
have proceeded the act with some form of warning to others. Suicidal
communication are very significant in indicators Psychological distress. Some
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of them are less depressed quite happy but immediately commit attempt
suicide.
Depression : 1s the key sign of suicidal potential, depression becomes a critical
importance as a sign of suicide not by its mere presence, but by its severity and
its persistence
The follow~ng signs of behaviour changes, mood changes, loss of previous
interest, risk taking behaviour, changes in appearance and drug & alcohol use, poor
appetite due significant weight loss., insomnia or hypersomnia. Psychomotor agitation
or retardation, sublectlve feeling or restless or being slowed down, decreased sexual
desire, loss of energy, fatigue, feeling of worthlessness, self-reproach or excessive
inappropriate guilt complaint or dimmished ability to think or concentrate recurrent
thought of death.
Reckless behaviour : Keckless, potentially self-destructive behaviour has been noted
before su~cidal behaviour.
Drug and Alcohol use : substance abuse that consistently signals strong likelihood of