By

ALI ABD
ALLAH
“No one ever lacks a good
reason to suicide”
Cesare Pavese
 ‫و يرحل العمر عنى‬
‫و أغدو أسافر بين السنين‬
‫و تبحث عنى دروب القدر‬
‫رحيل و عودة و عمر يضيع‬
‫و يهرب منى رحيق الحياة‬
‫و تسقط عنى غصون الشجر‬
‫دعونى أهاجر عنكم و عنى‬
‫فما أجمل البعد عنكم‬
‫و ما أروع أن أنــــتــحـــــــــــــــــــر‬
 Definition:
 Suicide is derived from the Latin word for
self-murder.
 It is a fatal act that represents the person's
wish to die.
 Chronic suicides for example, death through
alcohol and other substance abuse and
consciously poor adherence to medical
regimens for addiction, obesity, and
hypertension.
 Epidemiology
 In 2013 36,909 people in the United States
died by suicide. About every 14.2 minutes
someone in this country intentionally ends his
life.

 Suicide is the second leading cause of death

for people aged 15-34.

 Suicide is the third leading cause of death for

people aged 10-24.

 Suicide is the fourth leading cause of death

for adults over 65.
 Epidemiology
 Suicide is highest in white males over 85
more than female .
 The suicide rate was 12 /100,000 in 2015.

 It greatly exceeds the rate of homicide.

(6/100,000)

 From 2000-2013, 901,180 people died by

suicide, whereas 463,942 died from AIDS and
HIV-related diseases.
Myths Versus
Facts About
Suicide
MYTH:
People who talk about suicide don't
complete suicide.

FACT:
Many people who die by suicide
have given definite warnings to
family and friends of their intentions.
Always take any comment about
suicide seriously.
MYTH:
Suicide happens without
warning.

FACT:
Most suicidal people give
clues and signs regarding
their suicidal intentions.
MYTH:
Suicidal people are fully intent
on dying.

FACT:
Most suicidal people are
undecided about living or dying,
which is called “suicidal
ambivalence.” A part of them
wants to live; however, death
seems like the only way out of
their pain and suffering. They
may allow themselves to
"gamble with death," leaving it
up to others to save them.
MYTH:
Men are more likely to be
suicidal.

FACT:
Men are four times more
likely to kill themselves
than women. Women
attempt suicide three
times more often than
men do.
MYTH:
Asking a depressed
person about suicide will
push him/her to
complete suicide.

FACT:
Studies have shown that
patients with depression
have these ideas and
talking about them does
not increase the risk of
them taking their own
life.
MYTH:
Improvement following a suicide
attempt or crisis means that the risk is
over.

FACT:
Most suicides occur within days or
weeks of "improvement," when the
individual has the energy and
motivation to actually follow through
with his/her suicidal thoughts. The
highest suicide rates are immediately
after a hospitalization for a suicide
attempt. (Hoyer et al, 2004)
MYTH:
Once a person attempts
suicide, the pain and shame
they experience afterward will
keep them from trying again.

FACT:
The most common psychiatric
illness that ends in suicide is
Major Depression
Every time a patient gets
depressed, the risk of suicide
returns.
 Suicide
Suicide correlates
correlates

1. Personal correlates 2. Physical Health

3. Mental health 4. Drugs
5. Suicidal behavior
6. Neurobiological correlates
7. Psychodynamic correlates
8. sociological correlates
Personal
Personal correlates
correlates
* Sex Men : women
Suicide: 3 : 1
Attempt suicide: 1 : 4
 Personal
Personal correlates
correlates
* Methods:

Men: Firearms, hanging, & jumping.

Women: Psychoactive overdose, but
nowadays , firearms increase as a
method for suicide.
Personal
Personal correlates
correlates
* Age:
Suicide rates increase with age.
# For men, suicide peaks after age 45; &
after age 55 for women.
# Above 65 rates increased to 40/100.000.
Personal
Personal correlates
correlates
* Age:
Suicide rates increase with age.
# For men, suicide peaks after age 45; &
after age 55 for women.
# Above 65 rates increased to 40/100.000.
Personal
Personal correlates
correlates

# Elderly accounts for 25% of the suicides,

& suicide above 75 ys is 3 times more than
younger population.
# The suicide rate is rising rapidly in young
people, Suicide is the third leading cause of
death in 15-24 ys old group after accidents
& homicides in the United States.
 Personal
Personal correlates
correlates
* Religion:
The faith in GOD, & increased
religiosity decrease the risk of suicide.
* Marital status:
Married < Single < Divorced <
Separated
 Personal
Personal correlates
correlates

* Occupation:
Regular employment protect against suicide.
Professionals esp.. physicians, high social class
& fall in social status increase suicidal risk.
Psychiatrists & ophthalmologists showed
higher incidence .
 Physical
Physical health
health
• 25-75% of all suicide victims had a physical
illness.
• Physical illnesses contribute in 11-50% of
suicides & this increase with age.
• CNS disorders highly correlated with suicide are:
Epilepsy, MS, CVS, HIV infection, Head injury,
Huntington chorea, & dementia.
Physical
Physical health
health
* Physical morbidity especially
disfigurement, and intractable pain increase
the risk.
E.g. 50% of patients with cancer who
commit suicide do so within one year of
verifying the diagnosis.
Mental
Mental health
health
 95% of suicidal had a mental disorder
diagnosis.
 Suicidal: 80% had depression esp..
delusional depression, 10% had
schizophrenia, 5% had dementia &
delirium, and 25% were drug abusers, &
did have a dual diagnosis.
Mental
Mental health
health
 15% of depressed patient are at a very
high risk of committing suicide
400/100.000.
 Panic disorder patients are at 7 times more
risk of committing suicide than general
population.
Mental
Mental health
health
* Schizophrenia:
10% died out of suicide, mainly due to
depression in 2/3 of patients, delusions &
hallucinations might be the cause.
* Antisocial personality disorder:
5% of them commit suicide.
Mental
Mental health
health
* Drug dependence:
15% of alcoholics committed suicide,
& heroin abusers has 20 times increased
risk, esp.. with antisocial PD. This is
usually due to dysphoric or depressed
mood, chaotic life style and drug
intoxication.
 Suicidal
Suicidal Behavior
Behavior
 Past suicidal attempt -----> high risk of
suicide esp.. in the next 3 - 6 months.
 Around 1% of attempters died by suicide
within one year of last attempt. This
represents a risk approximately 100 times
that of the general population risk of suicide.
 40% of persons who commit suicide had a
previous suicidal attempt.
 Neurobiological
Neurobiological correlates
correlates
Suicide runs in family
* Family History of 1st degree relative ---->
8 times increased risk.
* Monozygotic twins have a higher concordance rate for
suicide and attempted suicide than dizygotic twins.
• Adoption studies showed high rates among biological
families of those who commit suicide.
(Mann,1995)
 Neurobiological correlates
 Genetic factors account for 45% of suicidal
thoughts and behaviors: 7 types of genes have
been focused on serotonin transporter(SERT),
tryptophan hydroxylase (TPH) 1 and 2, three
serotonin receptors (5-HTR1A, 5-HTR2A,
and 5-HTR1B), and the monoamine oxidase
promoter(MAOA)
 Neurobiological correlates
 Post-mortem studies have shown changes in
central neurotransmission of serotonin, nor-
adrenaline and post-synaptic signal
transduction

 Dysfunction of Hypothalamic-pituitary-
adrenal axis (stress response) predicts suicide
in depressed patients
 Neurobiological correlates

 Increased suicide risk associated with low

cholesterol levels

 Reduced 5-HIAA levels in CSF of depressed

patients who suicide
 Psychoanalytical
Psychoanalytical
correlates
correlates
* Freud: Thanatos - Eros
Aggression turned inward
Suicide is a repressed desire to kill some one else.
* Meningier’s theory:
Man against himself (Inverted homicide)
“ The wish to kill, to be killed & the wish to die”
 sociological correlates
Durkeim Theory
Egoistic suicide applies to those who are not
strongly integrated into any social group. The lack
of family integration explains why unmarried
persons are more vulnerable to suicide than married
ones and why couples with children are the best
protected group. Rural communities have more
social integration than urban areas and, thus, fewer
suicides. Protestantism is a less cohesive religion
than Roman Catholicism, and so Protestants have a
higher suicide rate than Catholics.
 sociological correlates
Durkeim Theory
Altruistic: Too much integration. The
person sacrifices their life for the benefit of
others. For example suicide bombers or a
recent case in the UK was that a family was set
to be deported due to immigration however if
the mother was a widow then they could stay
so the father killed himself for the family's
benefit.
 sociological correlates
Durkeim Theory
Anomic suicide applies to persons whose
integration into society is disturbed so that
they cannot follow customary norms of
behavior. Anomie explains why a drastic
change in economic situation makes persons
more vulnerable than they were before their
change in fortune. In Durkheim's theory,
anomie also refers to social instability, and a
general breakdown of society's standards and
values.
 sociological correlates
Durkeim Theory

Fatalistic-Too much regulation. The

individual has little freedom as a result of the
control of society. For example slaves.
Assessment &Prediction
 Assessment Questions
Have you ever thought about hurting yourself?
Have you thought about a way (plan)?
Do you have a way? (means)
Can you resist the feeling?
Specific Questions to Ask about
Suicidal Ideation:
• When did you begin to have suicidal
thoughts?
• Did anything precipitate them?
• How often do you have them?
• What makes you feel better?
• What makes you feel worse?
• Do you have a plan to end your life?
• How much control of these ideas do you
have?
• What stops you from killing yourself?
 Questions About Plans
• Do you have a gun or access to
one?
• Do you have access to harmful
medications?
• Have you practiced your suicide?
• Have you changed your will or life
insurance or given away your
posessions?
Level of concern about Suicide risk factor groups:
potential suicidal
behavior: 1. Any history of a suicide attempt
2. Long-standing tendency to lose temper or
become aggressive
3. Living alone, chronic severe pain, or recent
1. 0: Lowest concern (within 3 months) significant loss
4. Recent psychiatric admission/discharge or
2. 1-2: Some concern first diagnosis of MDD, bipolar disorder or
schizophrenia
3. 3-4: Increased 5. Recent increase in alcohol abuse or
concern worsening of depressive symptoms
6. Current (within last week) preoccupation
4. 5-7: High concern with, or plans for, suicide
7. Current psychomotor agitation, marked
anxiety or prominent feelings of
hopelessness
Warning Signs
 Observable signs of serious depression
 Depressed mood
 anhedonia
 Hopelessness
 Desperation
 Anxiety, psychic pain, inner tension
 Withdrawal
 Sleep problems
 Increased alcohol and/or other drug use
 Recent impulsiveness and taking unnecessary risks
 Threatening suicide or expressing strong wish to die
 Making a plan
 Purchasing a firearm
 Obtaining other means of killing oneself
 Unexpected rage or anger
Management
 Show your care
 Take ALL talk of suicide seriously
 If you are concerned that someone may take their
life, trust your judgment!
 Listen Carefully
 Reflect what you hear
 Let the person know you really care. ask about
his feelings .
 "I'm concerned about you… how do you feel?"
 "Tell me about your pain."
 "You mean a lot to me and I want to help."
 "I care about you, about how you're sufferring."
 "I'm on your side…we'll get through this."
 To Hospitalize or Not…?
• Access to means
• Poor social support
• Poor judgment
• Cannot make a contract for safety
 Outpatient?
• No intent nor plan

• No means, has social support and

good judgment

• Can contract for safety

 Legal Issues
• If in imminent danger,
confidentiality can be breached

• Involuntary hospitalization in most

states

• Unsure? Call a crisis center.

Suicidality has legal implications;
you should document every step
of management
 PSYCHOTROPICS
Antidepressants
 Adequate prescription treatment and monitoring
 Only 20% of medicated depressed patients are
adequately treated with antidepressants – possibly
due to:
 Side effects
 Lack of improvement
 High anxiety not treated
 Fear of drug dependency
 Concomitant substance use
 Didn't combine with psychotherapy
 Dose not high enough
 Didn't add adjunct therapy such as lithium or other
medication(s)
 Didn't explore all options including: ECT
 Psychotherapy
 Research shows that when it comes to treating
depression, all therapy is NOT created equal.

 Study shows applying correct techniques reduce

suicide attempts by 50% over 18 month period

 To be effective, psychotherapy must be:

 Specifically designed to treat depression (CBT).

 Relatively short-term (10-16 weeks)
 Means Restrictions

 Firearm safety
 Construction of barriers at jumping sites
 Restrictions on pesticides
 Reduce lethality or toxicity of prescriptions
– Use of lower toxicity antidepressants
– Restrict sales of lethal hypnotics (i.e.
Barbiturates)
Variants of Suicide
 Indirect Self – Destructive
Behaviors
* They are behaviors in which there is neither
suicidal intention nor awareness or expectation of
any suicidal outcome.
Smoking alochol & drug abuse,
risky sports dangerous occupations
sexual disorders eating disorders,
drug addiction medical non compliance
chronic overwork Pathological gambling
 Parasuicide
* It is a non fatal act in which an individual
deliberately causes self injury or ingests a
substance in excess of any prescribed or
generally recognized dosage.
Kreitman, 1977
 Continuum of
Suicidality
Highest - Completed suicide
- Serious (high lethality) suicide attempt
- Non serious (low lethality) suicide attempt
- Suicide plan (specific, lethal)
- Suicide plan (vague, non lethal)
- Diffuse risky life style
- Suicide like gesture
- Suicide ideations (chronic)
- Suicide ideation (fleeting)
Lowest - Totally non suicidal
 Victim-Precipitated Homicide

Suicide by cop is a suicide method in which a

suicidal individual deliberately acts in a
threatening way, provoking a lethal response from
a law enforcement officer or other legitimately
shot to death armed individual, such as being
 Murder-Suicides
• A murder–suicide is an act in which an
individual kills one or more other persons
before, or at the same time as, killing
oneself. The combination of murder and
suicide can take various forms, including:
Murder before suicide with the intent of preventing future
pain and suffering of others including family members
and oneself, such as a parent killing their children before
ending their own life;
 Copycat suicide
• The well-known suicide serves as a model, in the absence of protective
factors, for the next suicide. This is referred to as suicide contagion.
They occasionally spread through a school system, through a
community, or in terms of a celebrity suicide wave, nationally. This is
called a suicide cluster. Suicide clusters are caused by the social
learning of suicide related behaviors, or "copycat suicides". Point clusters
are clusters of suicides in both time and space, and have been linked to
direct social learning from nearby individuals. Mass clusters are clusters
of suicides in time but not space, and have been linked to the
broadcasting of information concerning celebrity suicides via the mass
media. Examples of celebrities whose suicides have inspired suicide
clusters include Ruan Lingyu, the Japanese musicians Yukiko Okada
andhide, and Marilyn Monroe, whose death was followed by an increase
of 200 more suicides than average for that August month.
• Another famous case is the self-immolation of Mohamed Bouazizi, a
Tunisian street vendor who set himself on fire on December 17, 2010, an
act that was a catalyst for the Tunisian Revolution and sparked the
Arab Spring, including several men who emulated Bouazizi's act.
 Euthanasia
Euthanasia
(Assisted
(Assisted suicide)
suicide)
* It is the act of killing a hopelessly ill or injured
person for reasons of mercy.
*61% of United States’ primary care
physicians believed suicide could be rational
under some circumstances.
31% supported the concept of legalization of
assisted suicide under certain circumstances.
(Duberstein et al, 1995)
 Euthanasia
Euthanasia
(assisted
(assisted suicide)
suicide)
* Jack kevorkian, a physician in Michigan, is the
first physician who committed assisted suicide at
1990, by helping a demented patient to comit
suicide after her own request.
* Final Exit, is written by the founder of the
Helmock society for Euthanasia, Derek
Humphery, has been the best seller in the U.S. It
gives explicit directions on suicide techniques.
 Euthanasia
Euthanasia
(assisted
(assisted suicide)
suicide)
* Active Euthanasia is allowed in Netherlands: if,
1. the patient makes repeated well informed and
enduring requests.
2. the patient’s mental and physical condition are
considered incurable.
3 .all other options for care have been exhausted.
4. Assisting physician must have the agreement of
another physician.
 ‫الدنيا أودة كبيرة لألنتظار‬
‫فيها أبن آدم زيه زى الحمار‬
‫الهم واحدو الملل مشترك‬
‫و مفيش حمار بيحاول األنتحار‬
‫عجبى !!!!‬

‫صالح جاهين‬
] Dr. Abd El Nasser Omar Suicide 65