SUICIDE- RISK FACTORS,

ASSESSMENT,
METHODOLOGICAL PROBLEMS

Dr. Sneha
Table of contents
• Introduction
• Definitions
• Epidemiology
• Theories
• Risk factors
• Suicide and psychiatric conditions
• Assessment
• Methodological Issues
• Miscellaneous
• Future Guidelines
Introduction
• SUICIDE
• Self inflicted death with explicit or implicit evidence that
the person intended to die

• Derived From Latin Word

• Sui – Oneself, Cidium-killing
• Primary Emergency For Mental Health Professional
• Major Public Health Problem
Historical Perspective
• In ancient Greece and Rome, suicide was deemed to be an acceptable
method to deal with military defeat

• In ancient Athens – denied honours of normal burial

• ISLAM- Suicide is prohibited

• CHRISTIANITY- Suicide is considered a sin

• 19th century-Europe –act of suicide shifted from being viewed by

caused by sin to being caused by insanity
• Hinduism-Upanishads condemns suicide

• Vedas – permit suicide for religious reasons, consider

that the best sacrifice was that of one’s own life-
Sallekhana

• Sati-where a woman immolated herself on the pyre of

her husband rather than live the life of a widow

• Juhar- Rajput women- mass self immolation, primarily

to avoid capture, enslavement and rape by foreign
invaders

• Mass suicide of Jonestown November 18, 1978

Guyana –Jim Jones-over 900 deaths
Suicidal ideation occurrence of passive thoughts about wanting to be dead or active thoughts about
DEFENITIONS killing oneself

Suicidal intent Subjective expectation and desire for a self destructive act to end in death

Lethality of suicidal behaviour Objective danger of life associated with a suicide method or action

Suicide Attempt A self initiated sequence of behaviours by an individual who at the time of
initiation ,expected that the set of actions would lead to his or her own death

Self Harm Any forms of non fatal self poisoning or self injury, regardless of the motivation or the
degree of intention to die.

Deliberate self harm Willful self inflicting of painful, destructive or injurious acts without intent to die

Nonsuicidal self injury Self injury directed to the surface of the body undertaken to induce relief from a negative
feeling or cognitive state or to achieve a positive mood state
Predicament Suicide Suicide that occurs when the individual without mental disorder is in
unacceptable circumstances from which they cannot find an acceptable
alternative means of escape

Suicide threats Are utterances made to others that indicate an intent to commit suicide
NSSI
Within last 1 year on 5 or more days, engaged in intentional
self-inflicted damage to the surface of his or her body with the
expectation that the injury will lead to only minor or moderate
physical harm (i.e., there is no suicidal intent).
To relieve unbearable emotions by seeking to modify rather
than abolish the state of consciousness
Seeking emotional self regulation and relief from psychological
pain
Recourse to multiple methods of self injury
Intrapersonal: to seek relief from negative effects
Interpersonal: to communicate their malaise/ask for
help/escape difficult situation
Low risk of death
High frequency of acts
Suicidal Behaviour Disorder
Individual has made a suicide attempt within last 24 months
Involves conscious intention to die, through the abolition of
consciousness
Does not meet the criteria for non-suicidal self injury
Not initiated during a state of delirium or confusion
/not undertaken solely for a political or religious objective
Current:<12 months since last attempt
Early remission: >12 months since last attempt
Higher risk of death
Low frequency
ICD 10
• INTENTIONAL SELF HARM :X60-X84
• INCLUDES PURPOSELY SELF INFLICTED POISONING OR INJURY
ICD 11
• INTENTIONAL SELF HARM
• Intentional self-harm, person intended to die
• Intentional self-harm, person did not intend to die
• Intentional self-harm, not known or not determined if person
intended to die
 Epidemiology
• More than 800,000 lives worldwide are lost to suicide every year,
and Asia accounts for more than 60% of such deaths.

• Annual global age-standardized suicide rate of 11.4 per 100 000

population (15.0 for males and 8.0 for females)

• Globally, suicides account for 50% of all violent deaths in men and
71% in women.

• Globally suicide is the second leading cause of death in 15−29-

year-olds
 INDIAN SCENARIO
• India’s suicide rate at 20.9 per 100,000 of the population, compared with a
global rate of 11.4 per 100,000.

• A total of 1,34,516 suicides were reported in the country during 2018

showing an increase of 3.6% in comparison to 2017 and the rate of suicides
has increased by 0.3 during 2018 over 2017.

• Male : Female= 68.5:31.5

National Crime Records Bureau Suicide Statistics 20

National Crime Records Bureau Suicide Statistics 2018
National Crime Records Bureau Suicide Statistics 2018
National Crime Records Bureau Suicide Statistics 2018
 ETIOLOGY
• Sociological Theories of Suicide
• Durkheim's Typology of Suicide
• Social integration
• Egoistic
• Altruistic

• Social regulation
• Fatalistic
• Anomic
Family and genetic theory
• Twin and adoption studies have shown an elevated risk of suicidal behaviors
in monozygotic twins as compared to dizygotic twins (Roy et al., 1991)

• There is also consistent evidence to suggest that a family history of suicidal

behavior is associated with an increased risk of suicide attempt in young
people

• Heritability of impulsive aggression

• ??construct that is transmitted through families independently of the
established association with familial risk of depression, impulsivity, and
other psychopathology
BIOLOGICAL FACTORS
Neurobiological theory
Neuroprobe and biomarkers: • Receptor-linked signaling
Platelets mechanisms
Lymphocytes
• HPA axis function
Serotonin and its metabolite
increased serotonin receptor subtypes
and • Cytokines
decreased 5-hydroxyindoleacetic acid
Noradrenergic:
altered levels of NE and MHPG in
suicide subjects.
Adrenergic:
Alpha 2 receptors
Interpersonal theory

Capability for suicidal behavior emerges:

• Habituation

• Opponent processes

• response to repeated exposure to

physically painful and/or fear-
inducing experiences
 RISK FACTORS
• Trait dependent/ Distal factors:  Risk Factors:
1. Genetic loading 1. Demographic
2. Personality characteristic 2. Clinical
3. Perinatal circumstances 3. Diagnostic
4. Early traumatic life events 4. Miscellaneous
5. Neurobiological disturbances
• State dependent/ proximal:
1. Psychiatric disorder
2. Physical disorder
3. Psychosocial crisis
4. Availability of means
5. Exposure to models
PROTECTIVE FACTORS
SELF
•Coping strategies /
problem solving
•Personality
•Self confidence and self
esteem
•Religion
• fear of social disapproval
• fear of act of suicide
INTERPERSONAL
•Family support
•Children in the home
•Good peer relations
ENVIRONMENTAL
•Good relation with
neighbour/Friends
•Connectedness with
cultural group and
community
Suicide and its association with various
Psychiatric conditions
• Prevalence ~ 90% as determined by psychological autopsy

• Comorbidity has been associated with increasing risk of suicide attempt

• Kessler et al. (1999) found that those with more disorders, regardless of
type of disorder, were more likely to attempt suicide

• Psychological autopsy studies from India, China and other eastern

countries have reported considerably lower rates of diagnoses among
suicides than those reported in western countries (Yang et al., 2005)
 Prevalence of the illness Percentage of suicide Standardised suicide ratio

Depression 5.25 35% 20.4

Schizophrenia 1.41 8% 8.5

Alcoholism 4.65 18% (OR 8.25) 5.9

Bipolar Affective Disorder 0.50 20%(lsr*)

Phobic anxiety disorder 1.91

Panic disorder 0.50 10

Obsessive Compulsive 0.76

Disorder
 Suicide in Child and
Suicide In
Suicide InWomen
Women Adolescent Population
Risk factors
RISK FACTORS
• Stressful Life Events
• Mental Disorders • Mental disorders
• Hormonal Factors • Previous suicide attempts
• Protective factors • Personality characteristics
• Pregnancy • Family factors
• Motherhood • Specific life events-traits
• More willing to ask for, and more likely to be • Contagion-imitation*
offered, help for emotional problems.
• The choice of less lethal means to suicide
• Availability of means
increases their chance of survival.
Assessment of Suicide Risk and Immediate
Management
Suicide risk Suicide risk
assessment formulation

Risk and protective Judgement about

factors – from foreseeable risk
history, psychiatric +
interview, scales and Triage decisions,
tools safety and
+ treatment plans
Observable and
reported symptoms
and behaviors
(ideation + intent)

(Shea et al, 2009; Silverman et al, 2014)

Clinical difficulty:
Young
Stated intent people’s
ambivalence +
fluctuating
Real mood states =
Reflected
suicidal ? Clarity of
intent
intent information

Withheld
intent
Stabilization and Safety

• Stabilization of medical condition

• Should not be allowed to leave ED prior to a full evaluation

• Assess risk of harm to self/others

• If needed, restrain chemically or physically

• The physician and medical staff must be cognizant of their own safety
• Ensure that the area of patient observation is safe and that there are
no available means for self-harm

• All sharp objects, belts, drugs, and medical equipment should be

isolated from the patient

• The patient should be easily observable from the nurses' station

• An attendant should accompany the patient to all procedures and tests

While eliciting history….

• Set the appropriate environment

• Remain calm, nonjudgmental, and nonthreatening
• Ensure confidentiality
• Use of basic interviewing techniques: expressing empathic curiosity,
active engagement, and morally nonjudgmental relatedness with the
patient*
• Assessment of suicide risk
ASSESSMENT OF SUICIDE RISK
• Isolation • Alleged purpose or intent

• Timing • Expectations of fatality

• Precautions against • Conception of method’s

discovery/ intervention lethality

• Acting to get help • Seriousness of attempt

during/after attempt
• Final acts in anticipation of • Attitude towards living/dying
death

• Conception of medical
• Active preparation for rescueability
attempt

• Degree of premeditation
• Suicide note

• Overt communication of
intent before attempt
Mental Status and Physical Examination

• Physical examination including vital signs*

• Establish the patient's level of alertness and orientation.
• Observation of appearance, level of attention, affect, dress,
grooming, and hygiene.
• Look for needle marks, unusual odors, or excoriations suggestive of
past abuse or injury.
• Mental status examination: ?Comorbid Psychiatric Condition
• Observe interactions of the patient with family, friends, and hospital
staff.
• Investigations
 ACTION TAKEN

• Admission
• Sent home: Alone/ With relative/friend
• Referred to: other hospital/GP/ Psychiatrist

ADMISSION

• The patient should be placed on suicide precautions

• Maintain a high index of suspicion for occult overdose and should be prepared to
use reversal agents
• Document the encounter, including the assessment (based on the interview and the
collateral information), differential diagnosis, working diagnosis, and treatment plan
• The treatment plan should include evaluation by a Psychiatrist, preferably while in
the hospital
Role of Medications and Psychotherapy
PHARMACOLOGICAL NON PHARMACOLOGICAL

Pharmacological management of underlying Address depressive cognitions, anxiety and guilt,

Psychiatric condition – use appropriate medications problem solving, coping, stress reduction, inter-
Pharmacological management of
as per the need personal issues etc.

underlying psychiatric condition Various Psychotherapeutic approaches may be used

Antidepressants Duration of treatment – may depend on how and
when the patient is stabilized and is back to his
normal life

Lithium, other mood stabilizers

Antidepressants CBT, IPT, PST,
Individual MI,DBT
therapy

Antipsychotic medications including Clozapine Involvement of significant others– awareness,

Lithium,other mood stabilisers support, earlyMI
CBT, IPT, PST, recognition of worsening of problems
etc.

Sedative-Hypnotics etc.
• IN CASE OF DISCHARGE

• Establish follow-up plan

• Antisuicide contract

• Explain regarding high risk suicide precautions to be taken

• Involve the patient's family and support system

• Monitoring the patient and provide support by family member

or close contact.
Conventional risk assessment scales
SCALE SENSITIVITY SPECIFICITY PPV
Beck hopelessness scale 78-80% 42% 1%
Beck depression inventory 2%
Beck scale for suicidal ideation 3%
Suicide intent scale 59% 77% 10%
SAD PERSONS scale 23% 89%
Suicide assessment scale 75% 86% 19%
Karolinska interpersonal violence 88% 60% 14%
scale
 SAD PERSONS Scale - Patterson, Jhunke
Item Points
S Sex 1
A Age 1
D Depression or Hopelessness 2
P Prior History 1
E Ethanol (Alcohol) use 1
R Rational thinking loss (i.e., psychosis) 2
S Support system loss (single/widowed/divorced) 1
O Organized plan 2
N No significant other (no social support) 1
S Stated future intent (determined to repeat or ambivalent) 2
INDIAN GUIDELINES/ PROGRAMS
National Mental Health Policy 2014

• Address stigma and discrimination

• Access to Rx

• Reduce alcohol access

• Reduce access to means
• Responsible media reporting
• Train community leaders to identify risk factors
• Crisis intervention, helplines - DMHP
• Section 309 of the Indian Penal Code (IPC) clearly states as follows: “Whoever
attempts to commit suicide and does any act towards the commission of such
offence, shall be punished with simple imprisonment for a term which may
extend to one year or with fine or both.”

• 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," the Mental Healthcare Bill 2016

• Mental Healthcare Act (MHCA), 2017

Other relevant areas

• Mass suicide The Burari deaths, also "Burari case" and "Burari kand",
refers to the deaths of eleven family members of the
• Student suicide Chundawat family from Burari, India, in 2018.

• Family suicide
• Pact suicide
• Farmer suicide
• Contagion of suicide behaviour
• Imitation (celebrity suicide)
• Internet facilitated suicide
• Blue Whale Game- ? began in Russia in 2013
• First alleged case – Mumbai, a 14yr old jumped from7th floor to death
• India-around 7 suspected cases were reported
• Worldwide around 130 cases were reported
• Reportedly spread over various countries like- Russia, US, China, Saudi
Arabia, Bangladesh etc.
Role of media
• Reporting guidelines
• Training for media staff
• Werther Effect
• Papageno Effect
• Irresponsible reporting to be made a punishable offence
Suicide prevention
Matrix Of Intervention
BIO PSYCHOSOCIAL ENVIRONMENTAL SOCIO CULTURAL

UNIVERSAL • SCREENING ALCOHOLISM • REDUCE ACCESS TO • POSITIVE PORTRAYAL

PESTICIDES / OF WOMEN IN MEDIA
ALCOHOL

SELECTIVE • IMPROVED RECOGNITION • PREVENT DOMESTIC • PRE\POST EXAM

AND REFERRAL OF VIOLENCE COUNSELLING
MENTAL DISORDERS BY
CRISIS WORKERS • ASSERTIVENESS

• INTERGENERATIONAL
CONFLICT RESOLUTION

INDICATED • ANDIDEPRESSANT IN • SAFE HAVEN • COMMUNITY SUPPORT

PRIMARY HEALTH CENTRE FOR THOSE BEREAVED
BY OR THOSE WHO
• MANAGEMENT OF ATTEMPTED SUICIDE
POISONING
REFERENCES
1.Kaplan and Sadock’s Comprehensive Textbook of Psychatry, 9th ed.
2.PSYCHIATRY by Allan Tasman 4th edition
3.Suicide risk assessment and intervention in people with mental illness, James M Bolton, David Gunnell, Gustavo Turecki. BMJ
2015;351:h4978
4.Suicide: An Indian perspective, Radhakrishnan R, Andrade C; Indian J Psychiatry. 2012 Oct-Dec; 54(4)
5.Suicide in South India: A community-based study in Kerala. C. R. Soman, S. Safraj, V. Raman Kutty, K. Vijayakumar, K. Ajayan. Indian J
Psychiatry 51(4), Oct-Dec 2009
6.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.
7.Researching suicidal behaviour: Sarah Payne and Rachel Lart
8.Methodological issues and their impacts on suicide studies, Mohsen Rezaeian. MIDDLE EAST JOURNAL OF BUSINESS - VOLUME 7, ISSUE 2
9.Shea, S. C. (2004). Suicidal Ideation: Clear understanding and use of an interviewing strategy such as the Chronological Assessment of
Suicide Events (CASE Approach) can help clarify intent and immediate danger to the patient. Psychiatric Annals, 34(5), 385-400.
National Crime Records Bureau Suicide Statistics 2018
10.
Joiner, T., Van Orden, K., Witte, T., Selby, E., Ribeiro, J., Lewis, R., & Rudd, M.D. (in press). Main predictions of the interpersonal-
11.
psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of Abnormal Psychology.
Khan, F. A., Anand, B., Devi, M. G., & Murthy, K. K. (2005). Psychological autopsy of suicide-a cross-sectional study. Indian journal of
12.
psychiatry, 47(2), 73–78. https://doi.org/10.4103/0019-5545.55935
13. National mental health survey of India 2016
14. Vadlamani, L. N., & Gowda, M. (2019). Practical implications of Mental Healthcare Act 2017: Suicide and suicide attempt. Indian journal
of psychiatry, 61(Suppl 4), S750–S755. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_116_19