Suicide and suicide risk assessment

SUICIDE AND SUICIDE RISK
ASSESSMENT
BY MARIAM ABAYOMI.

WHAT IS SUICIDE?
Originally, the word
suicide, founded on Latin
language ‘sui’ (oneself)
and ‘caedes’ (killing)
Suicide is a type of
deliberate self harm and is
defined as a human act of
self-intentioned and self
inflicted cessation (death).
suicide constitutes all
cases of death directly or
indirectly resulting from
act of a person who is
aware of the
consequences of the
behavior.

Asking a patient about suicide makes them
want to commit.

FALSE
In fact an opportunity to discuss it with them may
itself provide relief

TERMINOLOGIES
Parasuicide: 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 parasuicide.
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.

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. 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.

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. Some individuals habitually think of suicide, or use
thoughts of suicide when in stressful situations, to enable them to
feel better and more in control of a situation (in that they always have
an escape).

DID YOU KNOW?
Suicide is the tenth most frequent cause of
death for adults and the third
leading cause of death for persons between
ages 15 and 24.
Over 34,000 suicides occur each year in the
United States—about one every 18 minutes.
In Jamaica, Abel et al found that Jamaica's
suicide rate is among the lowest in the world
aver- aging at 2.26 per 100 000 with the 5–
14-year age group recording the lowest
suicide rate [0.3 per 100 000]
Every 17 minutes someone dies by suicide;
Every 42 seconds someone attempts suicide.

SUICIDE RATE VARIES AGE, SEX AND
RACE

THEORIES OF SUICIDE
Psychological theory: suicide depends on one’s attitude and how one
copes with the challenges of life.
Freud’s theory: “mourning and melancholia” 1917
Aggression turned inward against an introjected, cathected love
objects.
(loss of a love object (figuratively or literally), unpleasant situations
makes a person angry, this anger is then internalized manifested into
low self esteem and depression and revealed as suicide)
Menninger’s theory: In “man against himself” conceived suicide as
inverted homicide because of a patient’s anger toward’s another
person.

THEORIES OF SUICIDE
Imitation theory: why and how people commit suicide.
Gabriel Tarde suicide was seen as an outcome of changeable ideas
found in processes of innovation and imitation among creatively
receptive individuals.
E.g when a celebrity commit suicide, fans might want to commit
suicide.
AKA: group thinking, trending effect.

Suicide and suicide risk assessment

DURKHEIM’S THEORY
Durkheim’s book suicide was published in
1897.’Suggests that suicide is a social factor and
not a psychological one
a) Egoistic suicide
b) Altruistic suicide social breakdown
c) Anomic suicide.

Egoistic suicide is a product of relative weak
group integration.
 It takes place as a result of excess
individualism.
When men become ‘detached from society’
Durkheim's belief that lack of integration of the
individual into the social group is the main
cause for egoistic suicide.
These people find it difficult to take cope with
social alienation and feel impelled to commit
suicide.
EGOISTIC SUICIDE

ALTRUISTIC SUICIDE
This kind of suicide takes place in the form of sacrifice in which an
individual ends his life by heroic mean so as to promote a cause or an
ideal which is very dear to him.
Example- Soldiers who volunteer for a dangerous mission, in which
they are likely to lose their lives, out of zeal for and devotion to their
country.

ANOMIC SUICIDE
 This type of suicide is concerned with social
disorganization and imbalance and Lack of
moral regulation.
 If the change is sudden, adjustment
becomes difficult
and those who don’t get adjusted to changes
commit suicide.
 Acc. To Durkheim Not only economic
disaster and industrial crisis but even sudden
economic prosperity can causes disruption
and deregulation and finally suicide.

FATALISTIC SUICIDE
 This is as a result of too much regulations by rules
of society.
Durkheim described those who commit fatalistic
suicide as “persons with futures pitilessly blocked
and passions violently choked”
One classic example of a fatalistic suicide is that of
a slave who takes his life.
Contemporary examples includes a childless
married woman, a prisoner commits suicide due to
feeling oppressed by the prison system.

ETIOLOGY
Biological factors:
Serotonergic system: low concentration of 5HIAA
(serotonin)
Dysfunction of hypothalamic-pituitary-adrenal axis
(stress
response).
Increased suicide risk associated with low cholesterol
levels

RISK FACTORS
Epidemiologic factors
 Age: increases after age 14, second most common cause of death for
ages 15-24, highest rates of completion in persons >65 yr
 Sex: male
 Race/ethnic background: white or Native Canadians
 Marital status: widowed/divorced
past history
 Prior suicide attempt
 Family history of suicide attempt/completion

 psychiatric disorders
 Mood disorders (15% lifetime risk in depression; higher in bipolar)
 Anxiety disorders (especially panic disorder)
 Schizophrenia (10-15% risk)
 Substance abuse (especially alcohol – 15% lifetime risk)
 Eating disorders (5% lifetime risk)
 Adjustment disorder
 Conduct disorder
 Personality disorders (borderline, antisocial)

 HEALTH FACTORS
- Mental health conditions
• Depression
• Bipolar (manic-depressive) disorder
• Schizophrenia
• Borderline or antisocial personality disorder
• Anxiety disorders
• Substance abuse disorders Serious or chronic health condition

 ENVIRONMENTAL FACTORS
• Stressful life events which may include a death, divorce, or job loss
• Prolonged stress
• Access to lethal means including firearms and drugs
• Exposure to another person’s suicide
• Isolation and lack of social support

 HISTORICAL FACTORS
Previous suicide attempts A history of a suicide attempt is a major
risk factor for both repeated nonfatal suicidal behavior and suicide.
Family history of suicide attempts
The best predictor of completed suicide is a history of
attempted suicide

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SUICIDE METHODS:
Firearm
Drug overdose/poisioning
Hanging
Cutting
Jumping
Drowning

CLINICAL PRESENTATION:
symptoms associated with suicide
Hopelessness
Anhedonia
Insomnia
Severe anxiety
Impaired concentration
Psychomotor agitation
Panic attacks

SUICIDE (RISK) ASSESSMENT
This refers to the establishment of a clinical judgment of risk in the
very near future, based on the weighing of a very large mass of
available clinical detail.
 Risk assessment carried out in a systematic, disciplined way, it is
more than a guess or intuition – it is a reasoned, inductive process,
and a necessary exercise in estimating probability over short periods.

SUICIDE ASSESSMENT RISK
EVALUATE
IDEATION
EVALUATE
INTENT
EVALUATE
PLAN

Evaluate ideation
Ask every patient – e.g. “Have you had any thoughts of wanting to harm or kill
yourself?”
• Classify ideation
Passive ideation: would rather not be alive but has no active plan for suicide
e.g. “I’d rather not wake up” or “I would not mind if a car hit me”
Active ideation
e.g. “I think about killing myself”
• Onset and frequency of thoughts: “When did this start?” or “How often do you
have these thoughts?”
• Control over suicidal ideation: “How do you cope when you have these
thoughts?” “Could you call
someone for help?”
•Provoking factors
• Duration

EVALUATE INTENT
• Intention: “Do you want to end your life?” or “Do you wish to kill yourself?”
• Intended lethality: “What do you think would happen if you actually took those
pills?”
• Stated intent: what is directly told to the physician.
• Reflected intent: how much thinking, planning or behaviors related to suicidal
ideation
• Withheld intent: purposefully or unconsciously withholding information
concerning harming themselves.
• Assess their non verbal behavior and demeanor.
• Assess self control : Impulsivity is linked to suicide risk
“Do you feel worried that you might lose control and try to kill
yourself?”
“what stopped you when you lost control?”

EVALUATE PLAN
• Assess for specificity : some plans are vague while others can be very
specific
• Lethality: high vs low
• Availability: access to weapons, pills
• Proximity (time) : when the patient wants to act on the plan
• Likelihood of rescue

MANAGEMENT
The physician should approach the topic of suicide in a slow and tactful manner,
after having developed rapport with the patient. Because suicidal thoughts may
fluctuate, physicians should reassess suicide risk at each contact with the
patient.
 Patients with well-developed plans and the means to carry them out require
protection, usually in a hospital on a locked psychiatric unit. When the suicidal
patient refuses admission, it may be necessary to obtain a court order requiring
hospitalization.
Suicidal patients may plead with the doctor, family, or friends to stay out of the
hospital, but few people are adequately prepared to protect a suicidal person
around the clock. Hospitalization is the best way for a physician to ensure the
patient’s safety.

MANAGEMENT
proper documentation of the clinical encounter for management is essential
Higher risk (hospitalization needs to be strongly
considered)
 Patients with a plan and intention to act on the plan, access to lethal means,
recent social stressors
 Symptoms suggestive of a psychiatric disorder
 Do not leave patient alone; remove potentially dangerous objects from room
 If patient refuses to be hospitalized, complete form for involuntary admission
Lower risk
 Patients who are not actively suicidal, with no plan or access to lethal means
 Discuss protective factors and supports in their life, remind them of what they
live for,

Make a safety plan that could include an agreement that they will:
◆ not harm themselves
◆ avoid alcohol, drugs, and situations that may trigger suicidal thoughts
◆ follow-up with you at a designated time
◆ contact a health care worker, call a crisis line, or go to an emergency
department if they feel unsafe or if their suicidal feelings return or intensify
• Depression: consider hospitalization if symptoms severe or if psychotic
features are present; otherwise outpatient treatment with good supports and
SSRIs/SNRIs.
• Personality disorders: crisis intervention, may or may not hospitalize
• Schizophrenia/psychosis: hospitalization might be necessary
• Parasuicide/self-mutilation: long-term psychotherapy with brief crisis
intervention when necessary

JAMAICANS ARE ENCOURAGED TO PAY KEEN
ATTENTION TO THEIR FAMILY MEMBERS &
NEIGHBOURS. THE ONGOING COVID-19 PANDEMIC
HAS IMPACTED THE MENTAL HEALTH OF MANY

Suicide and suicide risk assessment

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