Suicideppt

SUICIDE

DR. YASHASREE POUDWALDEPT. OF PSYCHIATRY

K.J. SOMAIYA HOSPITAL

TERMS AND DEFINITIONS

SUICIDE: Death caused by self-directed injurious behavior with any intent to die as a result of the behavior.

LEGAL DEFINITION: INTENTIONAL act of self destruction committed by someone knowing what he is doing and the probable consequences of his action.

SUICIDE ATTEMPT: A non-fatal self-directed potentially injurious behavior with any intent to die as result of the behavior. A suicide attempt may or may not result in injury.

INDIRECT SUICIDE:

The act of setting out on an obviously fatal course without directly committing the act upon oneself. Indirect suicide is differentiated from legally defined suicide by the fact that the actor does not pull the figurative (or literal) trigger.

Examples of indirect suicide include a soldier enlisting in the army with the express intention and expectation of being killed in combat.

Another example would be "suicide by cop” in which a police officer is provoked into using lethal force against them.

High risk-taking behaviors and unhealthy lifestyles may reflect an intent to die. Studies have suggested that many more auto accidents are some form of indirect suicide than believed

PARA SUICIDE:

Suicide attempts or gestures and self-harm where there is no result in death. It is a non-fatal act in which a person deliberately causes injury to him/herself or ingests any prescribed or generally recognized therapeutic dose in excess. Studies have found that about half of those who commit suicide have a history of Para suicide.

SELF-HARM (SH) OR DELIBERATE SELF-HARM (DSH):The intentional, direct injuring of body tissue most often done without suicidal intentions. The person's primary intention is to relieve unbearable emotions, sensations of unreality, or feelings of numbness by injuring their body.

SUICIDAL GESTURESInclude cutting, whereby the cut is not deep enough to cause significant blood loss, or taking a non-lethal overdose of medication.

Suicidal gestures are typically done to alert others of the seriousness of the individual's clinical depression and suicidal ideation, and are usually treated as actual suicide attempts by hospital staff. Some suicidal gestures do lead to death, despite the individual not having the intention of dying.

SUICIDE THREAT:Any interpersonal action, verbal or nonverbal, stopping

short of a directly self-harmful act, that a reasonable person would interpret as communicating or suggesting that a suicidal act or other suicide-related behavior might occur in the near future.

SUICIDAL IDEATION:

Thoughts of suicide. These thoughts can range in severity from a vague wish to be dead to active suicidal ideation with a specific plan and intent. Although most people who undergo suicidal ideation do not commit suicide, some go on to make suicide attempts.

SUICIDE SURVIVOR:

A friend or family member who has experienced the suicide death of someone they cared about

Shneidman’s Ten Commonalities of Suicide (1985)

1. The common stimulus is unendurable psychological pain (i.e., psychache).

2. The common stressor in suicide is frustrated psychological needs.

3. The common purpose of suicide is to seek a solution.

4. The common goal of suicide is cessation of consciousness.

5. The common emotion in suicide is hopelessness-helplessness.

6. The common internal attitude toward suicide is ambivalence.

7. The common cognitive state in suicide is constriction.

8. The common interpersonal act in suicide is communication of intention.

9. The common action in suicide is egression (i.e., escape).

10. The common consistency in suicide is with life-long coping patterns.

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

EPIDEMIOLOGYGLOBAL SCENARIO

Over 1 million per yr

GLOBAL SUICIDE RATE – 16/100000

1.8% Deaths- due to suicide

2nd leading cause of death in youth after road traffic accidents

AGE

Comparatively rare before puberty

Males- more in 20-30yrs, after 65 yrs of age

Females- highest in middle age

Elderly & Late adolescence are at additional risk

Suicidal attempt - 20 times common than completed suicide and is more common in females (completed suicide is more common in males).

Suicidal thought - attempt – act= 100 : 10 : 1

Psychiatric illness (90%) –Depression ,Schizophrenia, Alcoholism , Drug addiction, Organic disorders (epilepsy, brain disease, mild dementia),Personality disorders

GENDER DIFFERENCES

MALES

Completed rates higher

More lethal and more violent methods used

More premeditation, depression

Substance use more common

Less likely to seek professional help with issues

FEMALES

Attempts higher

Less lethal and violent methods preferred

More impulsive, labile

Substance use less common

More likely to seek professional help with issues

China, India and Japan may account for 40% of all suicides (WHO estimates)

INDIAN SCENARIO > 10% OF SUICIDES IN THE WORLDSuicide rate 21.1 per 100000 (2012) (67%

increase over 1980 values) 1 SUICIDE EVERY 5 MIN, 1 ATTEMPT PER MIN. 242 males and 129 females commit suicide

daily on an average 275 below the age of 45

Southern states - Kerala, Karnataka, Andhra Pradesh, Tamil Nadu have a suicide rate of > 15

Northern States of Punjab, Uttar Pradesh, Bihar and Jammu-Kashmir, the suicide rate is < 3.

71 %- <44 yrs of agemale: female ratio of 1: 0.66

Poisoning (36.6%), hanging (32.1%) and self-immolation

(7.9%) most common methods

Males – more of socioeconomic causes

Females-more of emotional and personal causes

Presence of suicidal thought – 5 -10% in the Indian population.

India accounted for the highest estimated number of suicides in the world in 2012, according to a recent WHO report which found that one person commits suicide every 40 seconds globally.

According to the official data, reason for suicide is not known for about 43% of suicides, while illness and family problems contribute to about 44%

M:F = 64 :36

Boy : girl =48 : 52

More than 60% in age group 15-44yr.

37% in 15 - 29 yr.

34% in 30 to 44yr.

CLASSIFICATIONDURKHEIMS CLASSIFICATION

1. EGOISTIC

High isolation, excessive individuation, not strongly integrated into society

2. ALTRUISTIC

Excessive integration into group or society, insufficient individuation

3. ANOMIC

Experiences trauma, society changes. if bond between people loosened, with no regulation and norms of living in society.

4. FATALISTIC

Excessive regulation, no personal freedom and hope e.g. farmer suicide in India

COMMON METHODS

A asphyxiation

B blunt force trauma

C cuts, stabs

D drowning, drugs, chemicals, poisons

E electricity, explosives

F fire

G guns

H hanging, hypothermia

I intentional overdose

Pact/ cult suicides, suicide missions etc

Mass/Family suicide – 237 cases in 2006. Max. in Chhattisgarh,

then Kerala and Rajasthan.Govt. servant- 1.8% of total. Students 5.2%More than 20% – by housewives.47% married male, 25.3% married females72.2% married, 20.7% unmarried One-fifth of senior citizen suicide victims –

belong to Kerala.Max. child suicide – Andhra Pradesh 14.8%

(364 out of 2464)

ETIOLOGY

PSYCHOLOGICALFREUD – anger turned inwards against

introjected, ambivalently cathected love object

ZILBOORG – fantasies

MENINGER- wish to die, wish to kill, wish to be killed

KLEIN – defense mechanisms involved

GOMEZ- D/t illness

ROTJENBERG- Alternative to intense psychological pain

JAMISON, STYRON- utter hopelessness

BIOLOGICALGENETICS

Polymorphism- in genes for tryptophan hydroxylase, MAO-A

5-HT2A receptor, 5-HTT involved

FAMILY STUDIES- Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal subjects

TWIN STUDIES- Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins.

ADOPTION STUDIES- a greater risk of suicide among biologic rather than adoptive relatives.

NEUROCHEMICAL/ NEUROANATOMICAL

Low CSF 5HIAA

DECREASED 5HT transporter binding in PFC

INCREASED binding post synaptic 5HT1A,2A in PFC

INCREASED CRF conc. In CSF

DECREASED CRF binding sites in frontal cortex

Decreased NE transmission in locus cereleus, decreased neurons

Elevated 24-hour urinary cortisol production

significantly smaller 24-hour urinary output of the dopamine metabolite homovanillic acid (HVA) , increased plasma cortisol levels

Dexamethasone non suppression, HPA axis hyperactivity

Increased plasma AVP conc. Decreased cholesterol levels

Blunted TSH, Prolactin responses

BIOPSYCHOSOCIAL MODEL (STRESS-DIATHESIS MODEL)

These hold that individuals who are born with genetically modulated tendencies toward impulsivity (the diathesis), when stressed by external events later in life—particularly if they become depressed—are more likely to harm themselves than those not so predisposed.

Demographic male; widowed, divorced, single; increases with age; white

Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access

Psychiatric psychiatric diagnosis (es); comorbidity

Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system

Psychological Dimensions

hopelessness; psychic pain/anxiety; agitation; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism

Behavioral Dimensions

impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt

Cognitive Dimensions

thought constriction; polarized thinking; rigidity

Trauma sexual/physical abuse; neglect; parental loss; traumatic events

Genetic & Familial

family history of suicide, mental illness, or abuse

RISK FACTORS

Children in the home, except among those with postpartum psychosis

Pregnancy

Deterrent religious beliefs

Life satisfaction

Reality testing ability

Positive coping skills

Positive social support

Positive therapeutic relationship

PROTECTIVE FACTORS

PROTECTIVE FACTORS

Research has found that the following protective factors can counterbalance suicidal vulnerabilities:

having social supports

being cognitively flexible

obtaining treatment (especially psychotropic medications)

being a younger female

being physically healthy

being hopeful

They conclude that suicidal outcome is not only a joint product of risk, vulnerability, and psychiatric disorder, but also counterbalanced by protection, competency, and resilience.

Psychiatric Examination

Risk Factors Protective

Factors Specific Suicide

Inquiry

Modifiable Risk Factors

Risk Level:

Low, Med., High

DETERMINATION OF RISK

SUICIDE AND PSYCHIATRIC DISORDERS Mental disorders (mainly depression and substance abuse)

contribute to more than 90% causes of suicide

MOOD DISORDERS – Risk 6-15%

Bipolar pts. – nearly 10-20% risk of suicide. Rest 10%

patients with depressive disorders commit suicide early in the illness than later

more depressed men than women commit suicide;

single, separated, divorced, widowed, or recently bereaved.

middle-aged or older, Social isolation.

Suicide among depressed patients- likely at the onset or the end of a depressive episode esp. in months after

Inadequate treatment

Comorbid SUBSTANCE USE disorder, psychotic depression, +ve family history

SCHIZOPHRENIA AND SUICIDE10% risk. Esp. early on in the illness

Risk factors : young age, male gender, single marital status, a previous suicide attempt, a vulnerability to depressive symptoms, and a recent discharge from a hospital, Personal and family history, Living alone or not living with the family, Higher education ,Recent loss events

Agitation, Sense of worthlessness, hopelessness, Sleep disturbance, Fear of mental disintegration, Poor adherence to treatment, Comorbid Depression (recent or past), Substance dependence, Impulsivity

SUBSTANCE USE AND SUICIDE

7-15% RISK

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

Other axis 1 disorders – anxiety disorders, panic disorder, dysthymia, adjustment disorder, conduct disorder, dementia, delirium

AXIS II DISORDERS

BORDERLINE PD (8.5%)

ASPD (5%)

NARCISSISTIC PD

IMPULSIVITY

SUICIDE IN CHILDHOOD AND ADOLESCENCE

Rare in < 5 yrs. of age, increasing in pre-pubescence, adolescence

Ideation more common than attempts

Impulsivity, psychiatric disorders, substance use, aggression, poor problem solving

Copy cat suicides, internet suicides, “ werther syndrome”

Suicide more common in boys, attempts more common in girls

risk factors in suicide include a family history of suicidal behavior, exposure to family violence, impulsivity, substance abuse, and availability of lethal methods

SUICIDE IN ELDERLYMore in males, single, widowed, divorced,

living alone, chronic illness, mood disorder

High lethality, few warning signs, greater planning

TERMINALLY ILL

MIGRANT POPULATION

COMPONENTS OF SUICIDE ASSESSMENT

• Appreciate the complexity of suicide / multiple contributing factors

• Conduct a thorough psychiatric examination, identifying risk factors and protective factors and distinguishing risk factors which can be modified from those which cannot

• Ask directly about suicide; The Specific Suicide Inquiry

• Determine level of suicide risk: low, moderate, high• Determine treatment setting and plan• Document assessments

Psychiatric Illnesses

Comorbidity; Affective Disorders; Alcohol / Substance Abuse; Schizophrenia; Cluster B Personality disorders.

History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses; Family history of suicide / attempts / mental illness

Individual strengths / vulnerabilities

Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain

Psychosocial situation

Acute and chronic stressors; changes in status; quality of support; religious beliefs

Suicidality and Symptoms

Past and present suicidal ideation; plans, behaviors; intent; methods; hopelessness; anhedonia; anxiety symptoms; reasons for living; associated substance use; homicidal ideation

Areas to Evaluate in Suicide Assessment

Suicide Risk CategoriesI. Baseline – Absence of an acute (i.e., crisis) overlay, no

significant stressors not prominent symptomatology. Only appropriate for ideators and single attempters.

II. Acute – Presence of acute (i.e., crisis) overlay, significant stressor(s) and or prominent symptomatology. Only appropriate for ideators and single attempters.

III. Chronic high risk – Baseline risk for multiple attempters. Absence of an acute (i.e., crisis) overlay, no significant stressors not prominent symptomatology.

IV. Chronic high risk with acute exacerbation – Acute risk category for multiple attempters. Presence of acute (i.e., crisis) overlay, significant stressor(s) and/or prominent symptomatology.

PIERCE SUICIDE RISK SCORE

BECKS SUICIDAL INTENTION SCALE

BECKS HOPELESSNESS SCALE

MODIFIED SAD PERSONS SCALE

SUICIDE PROBABILITY SCALE

CALIFORNIA SUICIDE RISK ESTIMATION SCALE

WEISSMAN AND JORDAN RISK- RESCUE RATING SCALE

RATING SCALES

Elicit the presence of suicidal ideation

Elicit the presence of suicide plan

degree of suicidality including intent and lethality

SUICIDAL THOUGHTS, PLANS, BEHAVIOR

Consider assessing the patient's potential to harm others in addition to him- or herself

1. Establish a clear treatment plan with the client as to how suicidal thoughts, feelings, and behaviors will be managed on an outpatient basis.

2. Closely monitor and document ongoing suicidality until it resolves.

3. Consider and use all appropriate modalities (e.g., various therapies: CBT, DBT, EMDR, Behavioral Activation Therapy, journaling, exercise, couples counseling, bibliotherapy), vocational counseling, medication, etc.

4. Routinely seek professional consultation and document such.

5. Document the resolution of suicidality; monitor for any future reoccurrence.

GENERAL GUIDELINES FOR PRACTICE AND TREATMENT

ECT Evidence for short-term reduction of suicide

Benzodiazepines May reduce risk by treating anxiety

Antidepressants A mainstay treatment of suicidal patients with depressive illness / symptoms.

Lithium and Anti-convulsants

Lithium has a demonstrated anti-suicide effect; anticonvulsants not so much

Antipsychotics Evidence for Clozapine reducing suicidality in schizophrenia and schizo-affective disorders

SOMATIC TREATMENTS

PSYCHOTHERAPYCBT, PROBLEM SOLVING

DIALECTICAL

GROUP THERAPY

SHORT TERM

INTERPERSONAL

PSYCHOANALYTICAL

FOLLOW UP ESSENTIAL, DOCUMENTATION ESSENTIAL

LEGAL ASPECTS –

firearm control legislation, restrictions on pesticides, restrictions on the prescription and sale of barbiturates and other medications

SUICIDAL ATTEMPT ILLEGAL ( SEC 309 IPC)

ABETTMENT OF SUICIDE PUNISHABLE (SEC 306 IPC)

SUICIDE HELPLINES- AASRA, SAMARITAN, SNEHA

SUPPORT GROUPS, NO SELF HARM CONTRACTS

DECREASED MEDIA SENSATIONALISATION

WHEN A SUICIDE OCCURS

Despite best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice

Approximately, 12,000-14,000 suicides per year occur while in treatment.

To facilitate the aftercare process:

Ensure that the patient’s records are complete

Be available to assist grieving family members

Remember the medical record is still official and confidentiality still exists

Seek support from colleagues / supervisors

COLLABORATIVE ASSESSMENT & MANAGEMENT OF SUICIDALITY (CAMS) METHOD Developed by Dr. David Jobes (2006). A specific clinical approach and a philosophy of working with suicidal clients. The CAMS approach conceptualizes the assessment and treatment of suicidal

patients in a fundamentally different way than current conventional approaches.

CAMS is inherently designed to help shift clinicians’ attitudes and approaches by changing our conceptualization of suicide as a clinical problem and thereby changing how we assess and treat this problem.

CAMS approach does not focus on alleviating problems like depression, but rather concerns itself with suicidality. By maximizing alliance and motivation CAMS assists the client to develop coping and problem-solving skills to make suicide an unnecessary option.

The core multipurpose tool used in all phases of the CAMS is the Suicide Status Form (SSF).Use of the SSF within CAMS enables both parties to examine and work with the client’s suicidality in a relatively objective manner.

NOTE ON CONTRACTING FOR SAFETY!!!

The concept of contracting for safety (also known as no-suicide contracts or agreements, no-harm contracts, and suicide prevention contracts), although a popularly accepted method for managing suicidal patients for more than 30 years, has no scientific evidence to support its effectiveness.

At times, contracting is often the primary factor in clinical decision-making, justifying a lower level of intervention or concern.

The ultimate focus of suicide contracting is not on the safety agreement itself but on the process it engenders to engage staff and patient in a dynamic, meaningful relationship for identifying patient needs, encouraging disclosure of distress, and assuring consistent support and appropriate interventions.

PREVENTION OF SUICIDE

AREAS OF FOCUS• Education and awareness programs for the general

public and professionals

• Screening methods for high-risk persons

• Treatment of psychiatric disorders

• Restricting access to lethal means

• Media reporting of suicide.

•WHO DECLARED THE FIGHT AGAINST SUICIDE AS A PRIORITY FOR THE FIRST TIME IN THE YEAR 2000.

By WHO Dept. of Mental Health and Substance Abuse (1999).

Objectives-

1. To reduce mortality/morbidity due to suicidal behavior.

2. To break taboo surrounding suicide.

3. To bring together national authorities and public.

Suicide Prevention (SUPRE) Project -

WHO

WORLD SUICIDE PREVENTION DAY

• Efforts to prevent suicide have been celebrated on World Suicide Prevention Day – September 10th – each year since 2003.

• In 2014, the theme of World Suicide Prevention Day is 'Suicide Prevention: One World Connected.'

• The theme reflects the fact that connections are important at several levels if we are to combat suicide.

• World Suicide Prevention Day in 2014 is significant because it marks the release by the WHO of the World Suicide Report (WSR). The report follows the adoption of the Comprehensive Mental Health Action Plan 2013-2020 by the World Health Assembly, which commits all 194 member states to reducing their suicide rates by 10% by 2020.

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