SUICIDE: RISK FACTORS, ASSESSMENT,

METHODOLOGICAL PROBLEMS

SWETA SHETH
CHAIR: DR. RAJESH GOPALAKRISHNAN
 OVERVIEW
 DEFINITION AND THEORIES
 EPIDEMIOLOGY
 AETIOLOGY AND RISK FACTORS
 ASSESSMENT OF SUICIDE
 RESEARCH INTO SUICIDE
 INDIAN SCENARIO- LEGAL STATUS,
 METHODOLOGICAL ISSUES AND CONTROVERSIES
 MEDIA PORTRAYALS
 CYBER SUICIDE
 PREVENTION
 CONCLUSION
 DEFINITIONS
Suicide: self inflicted death with evidence that the person
intended to die
Suicide attempt: self injurious behavior with a nonfatal
outcome and evidence that the person intended to die
Aborted suicide: attempt-potentially self injurious behavior
with evidence that the person intended to die but stopped
before physical damage occurred
Suicide ideation: thoughts of serving as the agent of one’s own
death
 DEFINITONS (contd.)
Suicidal intent: subjective expectation and desire for self-
destructive act to end in death
Lethality objective: danger to life associated with suicide
action or method
Deliberate self harm: wilful self-infliction of painful,
destructive or injurious acts without intent to die

APA PRACTICE GUIDELINE FOR ASSESSMENT AND TREATMENT OF PATIENTS WITH SUICIDAL
BEHAVIOUR, 2006
 AETIOLOGICAL THEORIES OF SUICIDE

1. PSYCHOLOGICAL
2. NEUROBIOLOGICAL FACTORS
 PSYCHOLOGICAL THEORIES
 Émile Durkheim divided suicide into “egoistic, anomic and
altruistic” types.
 Edwin Schneidman : the victim suffers unbearable mental pain,
“psychache,” and terminally, his or her perceptions narrow
(“tunnel vision”) and he or she can see only one solution—his or
her death.
 Sigmund Freud, in Mourning and Melancholia, wrote of
aggression turned inward when one internalizes a lost object and
then turns this rage on oneself.
 Karl Menninger added to this when he wrote of the suicidal triad:
A wish to die, a wish to kill, and a wish to be killed—as
components of all suicides
INTERPERSONAL THEORY (Van Orden et al): People die by suicide because they can and
because they want to. The theory has 3 central constructs
Hypotheses of the Interpersonal Theory
1. Thwarted belongingness and perceived burdensomeness are proximal and
sufficient causes of passive suicidal ideation.
2. The simultaneous presence of thwarted belongingness and perceived
burdensomeness, when perceived as stable and unchanging (i.e.,
hopelessness regarding these states), is a proximal and sufficient cause of
active suicidal desire.
3. The simultaneous presence of suicidal desire and lowered fear of death
serves as the condition under which suicidal desire will transform into
suicidal intent.
4. The outcome of serious suicidal behavior (i.e., lethal or near lethal suicide
attempts) is most likely to occur in the context of thwarted belongingness,
perceived burdensomeness (and hopelessness regarding both), reduced fear
of suicide, and elevated physical pain
 BIOLOGICAL THEORIES
 Most biological theories are focused on depression and the
amines associated with depressive disorder
 Numerous studies have found a decreased level of serotonin
(5-HT) in the brains of depressed decedents and of 5-hydroxy
indoleatic acid (5-HIAA), CSF of living depressed patients.
 In addition, depressed individuals who have made suicide
attempts or completed suicide have lower levels of 5-HT
than depressed patients who are not suicidal.
 Furthermore, those who have made more violent suicide
attempts or completions have lower levels than those
employing less violent means
 The relation between risk factors can be described in
explanatory models of suicide, such as the stress– diathesis
model

Adapted from Mann; 2003

GLOBAL EPIDEMIOLOGY- RECENT TRENDS
 WHO 2011 data:
• Globally: one suicidal death every 40 seconds and one attempt
every 3 seconds, on average
• global mortality rate of 16 per 100,000
• India ranks 43rd in descending order of rates of suicide with a
rate of 10.6/100,000
 Suicide rates increased by 60% worldwide from 1950 to 1995
 The rate of suicide is highest in Eastern European countries
 Low rates are found mainly in Latin America
 86% of all suicides occurred in the low and middle-income
countries
 INDIAN SCENARIO
 The suicide rate in India: the increasing rates
during recent decades is consistent with the
global trend.
 Data on suicide in India are available from the
National Crime Records Bureau (NCRB; Ministry
of Home Affairs).
 Consistent increase in suicide rates over the
decades, current rate of 11.4% per 100000
population
 RISK FACTORS FOR SUICIDE
1. SOCIO-DEMOGRAPHIC
2. PSYCHIATRIC ILLNESS
3. OTHER FACTORS
 RISK FACTORS
 Numerous factors contribute to suicide, which is never the
consequence of one single cause or stressor. These factors can
be categorised as state-dependent or trait-dependent, or as
distal or proximal factors
 RISK FACTORS
1. SOCIO-DEMOGRAPHIC
i. GENDER:
 Females 3 times more likely to attempt, males 3
times more likely to complete
 In India: suicide rates nearly equal for men and
women (Mayer P, Crisis. 2002)
 The male: female suicide ratio was 1.78 in India in
2008 and 2009 (NCRB, 2009)
 Differences reflective of socio-cultural factors
ii. AGE:
 Suicide is rare before puberty
 Young adults are a particularly vulnerable group and
currently show the highest rates of suicide the world
over.
 NCRB 2009:Youth in the age group 15-29 years
accounted for the largest proportion (34.5%)
 Developed countries show a second peak of increased
suicide rate in the elderly
 In India: lower incidence of suicide in the elderly
iii. MARITAL STATUS
 In the West, marriage is generally protective against suicide;
this empirical regularity is referred to as the “coefficient of
preservation”
 Divorced, separated, widowed, and single people are more
likely to commit suicide than married people. Persons living
alone are at particular risk.
 Marriage is not a strong protective factor for suicide
attempts in developing countries
 In 2009, 70.4% of all suicide victims in India were married
and 21.9% were unmarried.
iv. EDUCATION
 Low intelligence results in a 2-3-fold increased
risk of suicide.
 In one study of attempted suicide in India,
55.5% were uneducated
 Women attempting suicide tended to have a
lower educational status compared to men.
v. FAMILY SUPPORT
 People who are well integrated with their families and community have a
good support system during crises, protecting them against suicide.
 Risk factors related to the family include
• parenting style: “Affectionless control” is associated with a three-fold
increase in the risk of suicidal behavior.
• family history of mental illness and suicide, and
• physical and sexual abuse in childhood.
 India : changing family- effect of this change on suicide rate has not been
systematically studied
• Majority of attempters from joint families
• Marital and interpersonal conflict a risk factor
• Issue of dowry deaths
vi. OCCUPATION
 Unemployment may drive up the suicide risk through factors
such as poverty, social deprivation, domestic difficulties, and
hopelessness.
 Furthermore, persons with psychiatric disorders are at
higher risk of suicide and are also more likely to be
unemployed
 recent loss of employment vs long-term unemployment; the
former is associated with greater risk.
 The association between unemployment and suicide may
also be more significant for young adults
 RISK FACTORS (contd.)
2. PSYCHIATRIC ILLNESS
 Psychiatric disorders are present in about 90% of
people who kill themselves and contribute 47–74%
of population risk of suicide
 Such studies have mostly been done in developed
countries.
 Similar findings have come from India (Vijayakumar
L, Rajkumar S. Acta Psychiatr Scand 1999; 99)
 Other studies have shown contrary results
i. DEPRESSION:
 >50% of completed suicide: depression
 Clinical predictors of suicide in people with major depressive disorder
also include a
• Male gender
• history of attempted suicide,
• high levels of hopelessness, and
• high ratings of suicidal tendencies.
• most likely to occur during the first episode,
• alcohol misuse and impulsive- aggressive personality traits.
• The effect of impulsive-aggressive traits is present in child and
adolescent suicide and decreases with age
ii. BIPOLAR ILLNESS:
 10–15% of patients with bipolar disorder die by suicide, commonly
early in the illness course.
 Risk factors for suicidal behaviour include
• previous self-harm,
• family history of suicide,
• early onset and increasing severity of the disorder,
• depressive symptoms (including hopelessness),
• mixed affective states,
• rapid cycling,
• comorbid psychiatric disorder
• misuse of alcohol or drugs.
iii. SCHIZOPHRENIA
 Lifetime suicide risk in schizophrenia is 4–5%, the risk being
highest relatively early after onset of the disorder.
 Risk factors:
• Less risk with the core symptoms of schizophrenia, such as
delusions and hallucinations, but more with depression and
specific affective symptoms (eg, agitation, sense of
worthlessness, and hopelessness).
• Other factors include previous suicide attempts, drug
misuse, fear of mental disintegration, recent loss, and poor
adherence to treatment
iv. SUBSTANCE USE:
 Alcohol misuse, particularly dependence, is
strongly associated with suicide risk
 The severity of the disorder, aggression,
impulsivity, and hopelessness seem to
predispose to suicide.
 Key precipitating factors are depression and
stressful life events, particularly disruption of
personal relationships
v. OTHER PSYCHIATRIC ILLNESS
 Suicide is a common cause of death in people with eating
disorders, in particular anorexia nervosa.
 The risk of suicide is increased in adjustment disorder, and
anxiety disorders and panic disorder are also associated with
increased risk.
 30–40% of people who die by suicide have personality disorders,
especially borderline and anti-social personality disorder
 ADHD: increases the risk of suicide in males via increasing
severity of comorbidities, in particular conduct disorder and
depression.
 RISK FACTORS (contd.)
3. OTHER FACTORS
i. PHYSICAL ILLNESS:
 Suicide is associated with poor physical health and
disabilities.
 Increased risk of suicide is associated with smoking.
 Suicide is also associated with several physical
disorders, including cancer (head and neck cancers in
particular), HIV/AIDS, Huntington’s disease, multiple
sclerosis, epilepsy, peptic ulcer, renal disease, spinal-
cord injury, systemic lupus erythematosus, and pain
ii. PRECIPITATING FACTOR
 Suicide is commonly preceded by notable life events, in particular
interpersonal or health-related events
 The relationship of suicide to negative life events, stress, object
loss, and negative interaction needs to be understood in the
framework of a model of vulnerability, support, coping, and
problem-solving.
 In India: Marital conflict is the commonest cause of suicide among
women, while interpersonal conflict is the commonest cause
among men (NCRB 2008,; Ghosh et al, IJP 1990)
 Other suicide triggers include physical illness, bankruptcy, illicit
relationships, and drug intoxication.
 SUICIDE RESEARCH FROM VELLORE-
DISPROVING WESTERN STATISTICS
1. Risk factors for suicide in rural south India
 matched case–control design and psychological autopsy to assess 100
consecutive suicides and 100 living controls matched for age, gender and
neighbourhood
 (37%) of those who died by suicide had a DSM–III–R psychiatric diagnosis.
 Alcohol dependence (16%) and adjustment disorders (15%) were the most
common categories.
 The prevalence rates for schizophrenia, major depressive episode and
dysthymia were 2% each.
 On-going stress and chronic pain heightened the risk of suicide. Living alone
and a break in a steady relationship within the past year were also significantly
associated with suicide
 Psychosocial stress and social isolation, rather than psychiatric morbidity, are
risk factors for suicide in rural south India.
2. Perceptions about suicide: A qualitative study from southern India
 Focus group discussions were conducted with community health
workers (1 group) and members of the public (6 groups).
 In-depth interviews were also conducted with 5 people who had
attempted suicide and survived
 The most common causes for suicide were interpersonal and family
problems, and financial difficulties.
 Mental illness was also reported as causal. All 5 subjects who had
attempted suicide mentioned marital and family discord as the cause.
 The majority of the general population and all the subjects who had
attempted suicide were not aware of any community and support
services for the prevention of suicide
 ASSESSMENT OF SUCIDAL RISK
CLINICAL ASSESSMENT: RED FLAGS:
1. Sociodemographic Older single male,
profile Substance use
2. Past attempts Psychiatric illness
3. Current state Recent stressor
4. Psychosocial state Previous suicide
attempts
Presence of note
Involvement in a pact
 ASSESSMENT OF SUICIDE RISK
 In a 10-year prospective study of patients
admitted with suicidal ideation, Beck et al.
found that only the Hopelessness Scale and
pessimism items on the Beck Depressive
Inventory predicted suicides.
 A score of 10 or more on the Hopelessness Scale
correctly identified 91% of eventual suicides.
Hopelessness has been found to have a positive
correlation with degree of suicidal intent
 SADPERSONS SCALE
Originally described by Patterson et al
and has been reviewed by Juhnke 
1. S: Sex.
2. A: Age
3. D: Depression
4. P: Prior History
5. E: Alcohol (Ethanol) use
6. R: Rational thinking loss, i.e.,
psychosis
7. S: Support system loss
8. O: Organised plan
9. N: No significant other
10. S: Sickness
 OTHE SCALES FOR MEASURING SUICIDAL
INTENT
1. Beck Depression Inventory (BDI).
2. Beck Hopelessness Scale (BHS).
3. Suicidal Ideas Questionnaire (SIQ)
4. Suicidal Behaviour Questionnaire (SBQ)
 PROTECTIVE FACTORS
1. Age
2. Marital status
3. Having children
4. Having a stable job
5. Good family support
6. Religious or spiritual beliefs
 RESEARCH IN SUICIDE
1. Incidence and Prevalence studies
2. Identifying and profiling risk factors
3. Suicide and suicide behaviour in specific
communities
4. Studies on non fatal deliberate self harm
5. Suicide prevention strategies
 METHODOLOGICAL ISSUES WITH SUICIDE
RESEARCH
 Difficulties arise with both suicide in terms of
the meaning ascribed to acts and the question
of intent.
 Thus figures for suicide mortality may be
unreliable, in that suicide deaths may be
recorded as suicide, or as ‘undetermined
deaths’, or in some circumstances as accidental
death.
 Reporting of parasuicide/DSH attempts
 Further difficulties arise in research which aims to assess the underlying
motivations or causes of suicidal behaviour
 Two major approaches to research in this area have been used.
• One method explores relationships between different sets of data - for
example, national or regional statistics on suicide may be compared
with figures for the same area for marital breakdown, unemployment,
indicators of poverty, or female labour force participation.
• Such research may suggest relationships, but cannot prove causal
relationships
• This problem - the ‘ecological fallacy’ - is less open to more complex
statistical approaches such as multi-level modelling due to the relatively
small numbers involved - particularly with completed suicide.
 The second major approach - ‘psychological autopsy’,
 It allows a closer analysis of the factors that may have led to the act itself,
but suffers from other problems.
 More complex issues - including the impact of unemployment or divorce,
as well as questions of mental health - are largely reported retrospectively,
and are inevitably open to influence by the suicidal act itself
 People reporting the death by suicide of a family member are likely to have
a number of conflicting, and very difficult, emotions, which may increase
the likelihood of attributing the act to preceding depression or a factor
such as loss of paid employment or the breakdown of a relationship.
 Alternatively, however, they may wish to put less emphasis on factors such
as relationships and more on other factors which can be seen as immutable
and somehow less blameworthy for the survivor
 Cultural stereotypes influence the assignment of particular
deaths to the category of suicide,
 traditional classifications are inherently gendered; women
are seen as 'attempting' suicide more often, but failing more
often, than men.
 This, is linked to the underlying explanations for suicidal
behaviour attributed to each sex; that women attempt
suicide because of problems in their personal relationships,
while men do so because of threats to their public persona.
 Women's suicides are seen as irrational and emotional
responses, while men's are seen as rational choices.
STUDY DESIGNS FOR SUICIDE RESERACH
1. CASE CONTROL:
• Suited to study risk factors for a statistically rare outcome such as
suicide
• Problems of retrospective data collection
2. LONGITUDINAL STUDIES
• Minimal recall bias
• However, statistically not sound unless large populations studied
3. FOLLOW UP STUDIES:
• Useful in documenting long term prognosis
• Sample selection may be biased due to potential selection of
severe cases
 MEDIA PORTRAYAL OF SUICIDE
 The media and internet have been identified
as playing a crucial role in the dispersion of
information about novel suicide methods.
 Guidelines for media reporting?- study by
Ramdas et al.
 Werther vs. Papageno effects of media
reporting
 SUICIDE AND THE INTERNET
 The first known Internet-related suicide pact
occurred in Japan in October 2000
 Current trend of Internet suicide pacts (Canterbury
Suicide Project, 2005)
• they involve young people almost exclusively;
• tend to be between complete strangers or individuals
with platonic friendship-type relationships;
• and the common characteristic between them would
seem to be clinical depression.
 Suicide-risk individuals who went online for suicide-related
purposes, compared with online users who did not,
reported greater suicide-risk symptoms, were less likely to
seek help, and perceived less social support (Harris et al;
Arch Suicide Res Jul 2009)
 Certain suicide methods described on the Internet, that
can be easily found by searching for certain terms, and lead
to more lethal attempts (Biddle at al, BMJ 2008)
 In 2008 police in the United Kingdom expressed concern
that "Internet cults" and the desire for achieving prestige
via online memorials may encourage suicides
LEGAL STATUS OF SUICIDE IN INDIA
 Suicide was a criminal offence under Sec 309
of IPC
 Fasting to death as a means of political protest
 Sec 309 repealed in 2014
 What will be the repercussions of this
decision?
 PREVENTION
 Suicide is an important, largely preventable
public health problem
 In 2000, the WHO launched the multisite
intervention study on suicidal behaviors
(SUPRE-MISS) which aimed to increase
knowledge about suicidal behaviors and about
the effectiveness of interventions for suicide
attempters in culturally diverse places around
the world
The problem is however a difficult one; as aptly expressed
by Gajalakshmi et al as “a complex array of factors such as
poverty, low literacy level, unemployment, family
violence, breakdown of the joint family system, unfulfilled
romantic ideals, inter-generational conflicts, loss of job or
loved one, failure of crops, growing costs of cultivation,
huge debt burden, unhappy marriages, harassment by in-
laws and husbands, dowry disputes, depression, chronic
physical illness, alcoholism/drug addiction, and easy
access to means of suicide.
 POSSIBLE STRATEGIES?
1. Early detection and adequate treatment of a primary
psychiatric disorder
 Lithium, clozapine olanzapine, antidepressants, and
behavioural interventions such as dialectical behaviour
therapy, DBT have been shown to have anti-suicidal effects
2. Interventions aimed at suicide attempters may be the most
effective in reducing suicide rates.
 Vijayakumar et al., 2011 : efficacy of brief intervention and
regular contact in a randomized controlled trial in suicide
attempters and found that it did reduce rates of completed
suicide over an 18-month period.
3. The early identification and treatment of
vulnerable populations with risk factors for
suicide across the life-span is another
strategy.
 Populations that have been exposed to
traumatic childhood experiences, such as
sexual/physical abuse and parental domestic
violence
 Primary prevention strategies include
• promoting positive health and instilling adaptive coping
stategies among children;
• improving awareness among parents, teachers and
healthcare professionals regarding child-rearing practices
• early intervention for maldaptive coping styles.
 At the community level the establishment of social
programs such as child and family support programs and
programs aimed at achieving gender and socio-economic
equality maybe prove useful
 NATIONAL LEVEL STRATEGIES
 Strategies with empirical evidence in western literature such
as the Universal, Selective, Indicated (USI) model, ‘gatekeeper
training’ and outpatient follow-up and emergency outreach
may also be relevant to India.
 The USI model outlines
• ‘universal’ preventive strategies for the population as a whole
(eg., restricted access to lethal means),
• ‘selective’ strategies targeting at-risk individuals (eg.
psychiatrically ill, homeless, socially-excluded groups) and
• ‘indicated prevention’ strategies targeting suicide attempters
(eg. outpatient contact and emergency outreach).
 Gatekeeper training focuses on skill
development to enable community members
such as teachers, coaches and others in the
community to identify signs of depression and
suicide-related behaviors among youth.
 Interventions aimed at restricting access to
means- Sri Lanka’s success story
 SUICIDE HELPLINES
 Several NGOs dedicated to suicide prevention
• SNEHA
• AASRA
• MAITREYI
• LIFELINE FOUNDATION
 Lack of a central govt. sponsored initiatives
 The evidence?
 THE WAY FORWARD
 Engage key stakeholders
 Restrict access to means
 Surveillance and improve data quality
 Raise awareness
 Engage the media
 Mobilize the health system and train health workers
 Change attitudes and beliefs
 Develop and implement a comprehensive national
suicide prevention strategy
Preventing suicide: A global imperative WHO 2014
 CONCLUSIONS
 Suicide is a complex issue
 Continuum from ideation to attempt
 Need to identify risk factors, which vary across
culture and countries
 Need to look beyond psychiatric morbidity as
a risk factor
 Need to develop an inter-disciplinary, multi
sectorial coordinated effort to prevent suicide
 REFERENCES
1. Kaplan and Sadock’s Comprehensive Textbook of Psychatry, 9 th ed.
2. Suicide: An Indian perspective, Radhakrishnan R, Andrade C;
Indian J Psychiatry. 2012 Oct-Dec; 54(4)
3. Role of media reports in completed and prevented suicide:
Werther v. Papageno effects. The British Journal of Psychiatry
(2010) 197, 234–243
4. Risk factors for suicide in rural south India: S. D. Manoranjitham,
A. P. Rajkumar, P. Thangadurai, J. Prasad, R. Jayakaran, K. S. Jacob.
The British Journal of Psychiatry (2010) 196, 26–30.
5. Researching suicidal behaviour: Sarah Payne and Rachel Lart
6. Suicide Prevention: Meeting the Challenge Together