Suicide

SUICIDE:
Latin suicidium, from sui caedere, "to kill oneself"
A fatal act that represents the person's wish to die.

ABORTED SUICIDE ATTEMPT: Potentially self-injurious behaviour with explicit or implicit evidence that the person intended to die but stopped the attempt before physical damage occurred.

DELIBERATE SELF-HARM: Wilful self-inflicting of painful, destructive, or injurious acts without intent to die.

LETHALITY OF SUICIDAL BEHAVIOR: Objective danger to life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual's expectation of what is medically dangerous.

SUICIDAL IDEATION: Thought of serving as the agent of one's own death. Seriousness may vary depending on the specificity of suicidal plans and the degree of suicidal intent.

SUICIDAL INTENT: Subjective expectation and desire for a self-destructive act to end in death.

SUICIDE ATTEMPT: Self-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die.

SUICIDE: Self-inflicted death with explicit or implicit evidence that the person intended to die.

CHRONIC SUICIDE: (e.g., deaths through alcohol and substance abuse and consciously poor adherence to medical regimens for addiction, obesity, and hypertension).

PARASUICIDE: Patients who injure themselves by self-mutilation (e.g., cutting the skin), but who usually do not wish to die. Female: male ratio is almost 3: 1. These patients are usually in their 20s and may be single or married. Most cut delicately, not coarsely. Most claim to experience no pain. Reasons: anger at themselves or others, relief of tension. Personality disorder is common. They are significantly more introverted, neurotic, and hostile.

The World Health Organization (WHO) estimates that of the nearly 800,000 people who die from suicide globally every year (World Health Organisation WHO; 2015):

• Suicide accounted for 1.4% of all deaths worldwide. (WHO 2015)
• 78% of global suicides occur in low and middle-income countries. (WHO 2015)

GENDER:

• M:F 4:1
• Women attempt suicide or have suicidal thoughts three times as often as men.
• Men commit suicide using firearms, hanging, or jumping from high places.
• Women more commonly take an overdose of psychoactive substances or poison.
• Globally, the most common method of suicide is hanging.

AGE:

• Rare before puberty.
• Bimodal- in young adulthood and also in the elderly
• Suicides in the 3rd decade of life (20-29 years) account for 41% to 62%.
• Among older adults, the age-specific suicide rate increases with age.
• Among children under 18 years of age, suicide rates increase with age.
• Among men, suicides peak after age 45 years and in women peak after age 55.
• Older persons attempt suicide less often than younger persons but are more often successful.

RACE: white > black

MARITAL STATUS:

• Unmarried > married - 2:1
• Divorce increases suicide risk (M:F 3:1)
• Marriage is a protective factor
• Homosexual men and women appear to have higher rates of suicide than heterosexuals

ANNIVERSARY SUICIDES: Take their lives on the day a member of their family did.

OCCUPATION:

• Higher the person's social status, the greater the risk of suicide, but a drop in social status also increases the risk.
• Suicide is higher among the unemployed than among employed persons.
• Among occupational rankings, professionals, particularly physicians, have traditionally been considered to be at the greatest risk.

PHYSICIAN SUICIDES:

• 2-3 times more in physicians.
• Most often depressive disorder, substance dependence, or both.
• Among physicians, psychiatrists are considered to be at the greatest risk, followed by ophthalmologists and anaesthesiologists.

PHYSICAL HEALTH:

• Loss of mobility, disfigurement (particularly among women), and chronic, intractable pain, seizure disorder.
• Patients on hemodialysis are at high risk drugs like reserpine, corticosteroids, antihypertensive, and some anticancer agents.
• Alcohol-related illnesses, such as cirrhosis, are associated with higher suicide rates.

• Almost 90% of all persons who commit or attempt suicide have a diagnosed mental disorder. (Centre for Suicide Prevention, 2007)
• Depressive disorders account for 80% of this figure, schizophrenia accounts for 10%, and dementia or delirium for 5%.
• 25% are also alcohol dependent and have dual diagnoses.
• Persons with delusional depression are at highest risk.
• A history of impulsive behavior or violent acts increases the risk of suicide.
• Risk of suicide - psychiatric patient : non-patient 3-12:1
• Most of them are of a younger age group.
• The first three months after discharge are the highest risk for suicide.

MOOD DISORDERS:

• Approximately 60-70% of suicide victims suffered a significant depression at the time of their deaths. (CTP)
• The lifetime risk of death by suicide among individuals with bipolar disorder is approximately 15 to 20%.
• They commit suicide early in the illness rather than later.
• More depressed men than women commit suicide.
• Risk increases if single, separated, divorced, widowed, recently bereaved, or on inadequate treatment.

SCHIZOPHRENIA:

• Up to 10% die by committing suicide.
• Maximum suicide occurs during the first few years of illness.
• Only a small percentage commit suicide because of hallucinated instructions or a need to escape persecutory delusions.
• Risk factors: Young age, male gender, single marital status, previous suicide attempt, vulnerability to depressive symptoms, recent discharge from a hospital, personal and family history, living alone or not living with the family, higher education, recent loss events.
• In those with chronic schizophrenia, greater risk is associated with: Hopelessness, Insight into illness, Higher cognitive function.

SUBSTANCE USE:

• Up to 15% of all alcohol-dependent persons commit suicide.
• 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.
• Number rather than type of substances is more important for predicting suicide attempts (Borges et al., 2000).

Antisocial personality disorder:

• 5% of patients with antisocial personality disorder commit suicide.

BORDERLINE PD (10%):

• Uncompleted suicide attempts are made by almost 20% of patients with panic disorder and social phobia.

PTSD:

• PTSD has been associated with eight times greater risk of suicide attempt than that in non-PTSD populations.
• Hopelessness and impulsivity are considered risk factors for suicide ideation.

DEMOGRAPHIC AND SOCIAL PROFILE

HEALTH

SUICIDAL ACTIVITY

PREDICTING SUICIDE

• Attempted suicide is at least 20 times more common than completed suicide
• Hopelessness Scale and pessimism items on the Beck Depressive Inventory predicted suicides more accurately
• SAD PERSONS scale
• Beck Suicidal Intent Scale
• Suicidal Intent Questionnaire (SIQ)
• The Columbia-suicide severity rating scale (C-SSRS)
• Suicide trigger scale (STS)
• Suicide probability scale (SPS)

1. SOCIOLOGICAL FACTORS:
   • DURKHEIM’S THEORY
   • Emile Durkheim (French Sociologist)
   • Each society has a specific tendency toward suicide

   DURKHEIM’S THEORY

   • EGOISTIC - bounds which unite groups weaken, and individuality increases. Too little integration
   • ALTRUISTIC - bonds between groups too strong. So individuals sacrifice themselves.
   • ANOMIC - Integration into society is disturbed
   • FATALISTIC - Luck & Slavery Excessive regulations
2. PSYCHOLOGICAL FACTORS:
   • FREUD’S THEORY: “Mourning and Melancholia”
   • Aggression turned inward against an introjected, ambivalently, cathected love objects.
   • MENNINGER'S THEORY: In “Man against Himself” conceived of suicide as inverted homicide because of a patient's anger toward another person.
3. BIOLOGICAL FACTORS:
   • Serotonergic system: low concentration of 5-HIAA (metabolite of serotonin).
   • Dysfunction of Hypothalamic-pituitary-adrenal axis (stress response) predicts suicide in depressed patients.
   • Increased suicide risk associated with low cholesterol levels.
4. GENETIC FACTORS:
   • Family history of suicide increases the risk two-fold especially in women and children independent of family psychiatric history.
   • Concordance rates of suicide higher among monozygotic twins
   • Adoption studies: A greater risk of suicide among biologic rather than adoptive relatives.
   • Genetic factors account for 45% of suicidal thoughts and behaviors.
   • Polymorphism of Tryptophan hydroxylase (TPH) 1 and 2, three serotonin receptors (5-HTR1A, 5-HTR2A, and 5-HTR1B), and the monoamine oxidase promoter(MAOA)

STRESS-DIATHESIS MODEL

• STRESS: A force that disrupts the equilibrium or normal functioning of an individual’s mental or physical state. Different types of stressors may precipitate suicidal behavior.
  • Negative Life events
  • Acute substance intoxication
  • Acute psychiatric condition
• DIATHESIS: Innate vulnerability or predisposition (in the form of traits) for developing the suicidal state.
  • Familial / genetic influences
  • Chronic multiple psychiatric problems
  • Hopelessness
  • Being male / loneliness

Most suicides among psychiatric patients are preventable.

The evaluation for suicide potential involves:

• Complete psychiatric history
• Thorough examination of the patient's mental state
• Inquiry about depressive symptoms
• Suicidal thoughts, intents, plans, and attempts
• A lack of future plans

GUIDELINES FOR ADMISSION

Admission generally indicated:

• High risk of suicide

After a suicide attempt or aborted suicide attempt if:

• Patient is psychotic
• Attempt was violent, near-lethal, or premeditated
• Persistent plan and/or intent is present
• Distress is increased or patient regrets surviving
• Patient is male, >45 years of age, especially with new onset of psychiatric illness or suicidal thinking
• Current impulsive behavior, severe agitation
• Patient has change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting
• In the presence of suicidal ideation with: Specific plan with high lethality, High suicidal intent

From the Practice Guidelines for Assessment and Treatment of the Suicidal Patient, 2nd ed. The American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders Compendium.

Admission may be necessary:

• Moderate risk of suicide

After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated, in the presence of suicidal ideation with:

• Psychosis
• Post attempts, particularly if medically serious
• Need for supervised setting for medication trial or electroconvulsive therapy
• Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting
• In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk

Lesser Risk

• Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient's view of the situation has changed since coming to the emergency department
• Plan/method and intent have low lethality
• Patient has a stable and supportive living situation
• Patient is able to cooperate with recommendations for follow-up
• Outpatient treatment may be more beneficial than hospitalization: lesser risk of suicide
• Patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts, if a safe and supportive living situation is available and outpatient psychiatric care is ongoing