SUICIDE

By Group B

INTRODUCTION

SUICIDE

• Latin word: self-murder

• Fatal act that represents the person’s wish to die

• Suicide is an irrational desire to die.

• Suicide is a symptom and sign of serious depression.

• Sometimes, when we give antidepressant medication to depressed person, they will still feel depressed, but have more energy. It is during this time many people tend to make suicidal acts.

OTHER DEFINITIONS

SUICIDAL IDEATION

Suicidal ideation

With intention

Without intension

• Suicidal ideation, thoughts or act of killing own self and does not include the final act of killing oneself.

• Suicidal intent is to have suicide as one's purpose

• Intent refers to the aim, purpose, or goal of the behavior

PARASUICIDE

• Term used to describe patients who injured themselves by self-mutilation but usually do not wish to die

• Usually they do not feel pain

• Do it due to anger and release tension

• Having personality disorders and usually more introverted, neurotic and hostile

• Female : male ratio 3:1

SUICIDAL ATTEMPT• Non-fatal self inflicted destructive act with explicit or

inferred intent to die

• An event when an individual comes close to the

attempting suicide but he does not complete the act

• No injury

ABORTED SUICIDAL ATTEMPT

LETHALITY TO SUICIDE BEHAVIOR

• Objective danger to life associated with a suicide method or action

(eg: jumping from heights is highly lethal, while cutting wrist is less lethal)

WARNING SIGNS AND RISK ASSESSMENT

• Suicide is rarely a spur of the moment decision (Dr SuarnSingh, Head of Psychiatry, Ministry of Health Malaysia).

• Usually there are clues leading to the actual attempt.

WARNING SIGNS

• Constantly saying- 'l can't go on', Nothing matters any more', 'I want to end it all'

• Becoming withdrawn and depressed

• Behaving recklessly, such as crossing the road without looking or driving carelessly

• A marked change in behaviour, attitudes or appearance, such as not grooming or shaving

• Getting things in order, such as writing a will, and giving away valued possession

• These may be accompanied by erratic mood swings and behaviours, including constant crying, impulsiveness, self-mutilation and impulsiveness.

• The irony is that people harbouring suicidal thoughts often find to hard to talk to anyone about their problems because they cannot pinpoint what is wrong with themselves.

• The loneliness adds on to the emotional pressure.

• They feel that they are trapped in their own world.

• Experts in suicide studies have also voiced concern for the increasing number of websites and internet chat rooms dedicated to suicide.

• These sites promote the act of self-destruction and the taking of one's own life, with detailed descriptions of lethal methods to use and doses of everyday medications that can kill.

COMMON MYTHS ABOUT SUICIDE:

1) People who talk about suicide won't do it

2) People who commit suicide are unwilling to seek help

3) If someone wants to kill himself, nothing can stop him

4} Discussing suicide will give someone the idea of doing it

5) Suicide indicates a lack of religious faith

6) It only happens to others, not myself or someone I know

Quoted from Professor Mohamed Hussain Habil, the President of the Malaysian Psychiatric Association

RISK FACTORS

SUICIDE RISK SCALE (SAD PERSONS)

• Sex – Men 3x> women (although women attempt suicide 4x more)

• Age – greater risk among 19 years or younger, and 45 years or older

• Depressed – 30x more than non-depressed (depression and hopelessness – close tie to suicide)

• Previous Attempters – 64x that of general population

• Ethanol Abuser – about 15% of alcoholics commit suicide

• Rational Thinking Loss – Psychosis (“I heard a voice saying I should kill myself”), mania, depression

• Social Support Lacking – recent loss of support (deaths, divorce, break-ups, etc)

• Organized Plan – having a method in mind creates more risk

• No spouse – single, divorced, widowed or separated

• Sickness – terminal illnesses carry 20x chance for suicide

1) Paterson, W, Dohn, H , Bird, J, Paterson, G. Psychsomatics, 1983, 24, 3433492) Juhnke, G.E. “SAD PERSONS scale review.” Measurement & Evaluation inCounseling & Development, 1994, 27, 3253283) Juhnke, G.E. (“The adapted SAD PERSONS: As assessment scale designed for usewith children” Elementary School Guidance & Counesling, 1996, 252258

Score Risk

0 - 2 No real problems, keep watch

3 - 4 Send home, but check frequently

5 - 6 Consider hospitalization involuntary or

voluntary, depending on your level of

confidence in follow-up.

7 - 10 definitely hospitalize involuntarily or voluntarily

Scoring system:

1 point for each of the positive answers

• SAD PERSONS can be modified to “SAD PERSONAS”, with the second ‘A’ representing “Availability of lethal means”.

• This modification reminds the clinician to ask about lethal means when assessing suicidality.

• If lethal means are available, the clinician can then take whatever action is reasonably indicated to reduce the likelihood of a suicide.

• Eliminate scoring (William H. Campbell, Current Psychiatry Interactive Journal, Revised ‘SAD PERSONS’ helps assess suicide risk, Vol. 3, No. 3 / March 2004)

• In SAD PERSONS, one point is scored for each risk factor. Consider these two patients:

1. A 30 year old single man who is depressed and has an organized plan to shoot himself with his handgun

2. A widower who has dementia and is physically ill.

• Both men would score a 4, but the risk of suicide would be substantially greater in the first case.

• Suicide risk factors are qualitative—not quantitative—measures and should be considered within the overall context of the clinical presentation.

ASSOCIATED RISK FACTORS-CONTINUATION

1. Gender

Men kill themselves three times more frequently than women. (National Suicide Registry Malaysia, 2009)

However,

Women attempt suicide four times more than men.

Why?

• Methods

• Men’s higher rate of successful suicide is related to the methods they use. (eg: firearms, hanging)

• While women more commonly take an overdose of psychoactive substances or poison.

AGE

- The highest rate of suicide was in the 35-44 age group, followed by the 75+ age group.

Why?

- The youngest case was 14 years of age

and the oldest was 94 years old

(N.H. Ali et al (2012).

ETHNICITY- Indians had the highest suicide rate at 3.67/100,000 Indian

population(70 deaths)(NRSM 2009). This was consistent with findings from other studies in Malaysia (Maniam 1995) and Singapore (World Health Organization 2010).

Why?

- followed by the Chinese at 2.44/100,000 Chinese population (156 deaths).

- The Malays and the Bumiputera of Sabah and Sarawak had lower rates of 0.32/100,000 Malay population (44 deaths) and 0.37/100,000 Bumiputera Sabah and Sarawak population (11 deaths) respectively.

RELIGION- The highest rate of suicide was among the Hindus followed

by the Buddhists. The lowest rate of suicide was among the Muslims (N.H. Ali et al (2012).

- In Muslim countries, where committing suicide is strictly forbidden, suicide rates were close to zero (Jose 2002).

MARITAL STATUS- The highest rate of suicides was in the divorced/separated

group (18.33/100,000) .

- followed by the widowed group (1.92/100, 000) (N.H. Ali et al (2012). Why?

This may indicate that in Malaysia, marriage could perhaps serve as a protective factor from suicide behavior consistent with findings by Lorant et al and Nisbet.

PHYSICAL HEALTH

- Medical or surgical illness is a high risk factor, especially if associated with pain, chronic or terminal illness (Conwell et al). Why?

- Brown et al found that one every four people expressed the desire of ending his/her own life, among 44 terminal elderly patients.

MENTAL ILLNESS• One thousand and seven (17%) suicide attempters were

diagnosed with some form of mental illness ranging from adjustment disorder to schizophrenia. (NRSM 2009)

1) Depressive disorders

2) Schizophrenia

3) Alcohol and substance dependence

4) Personality disorders

5) Dementia and delirium

6) Anxiety disorder

OTHERS• Unambiguous wish to die

• Unemployment

• Sense of hopelessness

• Access to lethal agents or firearms

• Fantasies of reunion with deceased loves ones

• Previous suicide attempts

• History of childhood or physical abuse

• History of impulsive or aggressive behaviour

• Nizam et al 1995 , for example, found that 74% of the suicide attempters in his study did not know how to access counseling services even when 53% of them have heard about such services from the media.

• Zuraida et al 2000 focused on poor social network as a risk factor for suicidal behavior, emphasizing the importance of evaluating a patient’s social support system as part of the management plan for suicide attempter

• Meanwhile, Ainsah et al 2008 studied the relationship between the menstrual cycles and deliberate self-harm.

HISTORY TAKING

QUESTIONS TO ASK• Onset of suicidal thoughts

• Ideas of nihilism ?

• Depression/Angry/Tired with life ?

• Hallucinations ? Delusions ?

• Aggressive behaviours ?

• Substance dependence ?

• Acces of firearms ?

• Any previous attempted suicides ?

• Any psychiatric disorders ?

(ie; Schizophrenia, personality disorders, dementia, anxiety disorder)

QUESTIONS TO ASK (CONTD.)

• Thoughts about life ?

• Optimism ?

• Judgement

QUESTIONS TO ASK (CONTD.)• Past medical history

• Family & Social history

( Who is patient living with, family relationships, occupation, stress level, history of childhood abuse )

- Fantasies of Reunion with the deceased one

QUESTIONS TO ASK (CONTD.)

• Social history

(Marital status, family relationship, occupation, social support, stress level )

MENTAL STATUS EXAMINATION

1. Appearance and behaviour

2. Mood /affect

3. Thought -Form/Flow/Content/ Possession

4. Perception

5. Cognition - GOAL CRAMP

6. Judgement

7. Insight

THOUGHT

• Irrelevant form

• Normal flow

• Content of suicidal ideation

• Try to reveal pt's plan of suicide

• Suicidal idea can convert to homicidal

JUDGEMENT

Personal

• Ask, what pt would do when he leaves the hospital?

Social

• Is there anyone who cares about him?

LEGAL ISSUES

• Attempt to commit suicide

• 309. Whoever attempts to commit suicide, and does any act towardsthe commission of such offence, shall be punished with imprisonmentfor a term which may extend to one year or with fine or with both.

• Infanticide

• 309A. When any woman by any wilful act or omission causes thedeath of her newly-born child, but at the time of the act or omissionshe had not fully recovered from the effect of giving birth to suchchild, and by reason thereof the balance of her mind was thendisturbed, she shall, notwithstanding that the circumstances weresuch that but for this section the offence would have amounted tomurder, be guilty of the offence of infanticide.

CONT…

• Punishment for infanticide

• 309B. Whoever commits the offence of infanticide shall be punished at the discretion of the Court, with imprisonment for a term which may extend to twenty years, and shall also be liable to fine.

CONT…• Abetment of suicide of child or insane person

• 305. If any person under eighteen years of age, any insane person, any delirious person, any idiot, or any person in a state of intoxication, commits suicide, whoever abets the commission of such suicide shall be punished with death or imprisonment for a term which may extend to twenty years, and shall also be liable to fine.

• Abetment of suicide

• 306. If any person commits suicide, whoever abets the commission of such suicide shall be punished with imprisonment for a term which may extend to ten years, and shall also be liable to fine.

MANAGEMENT

Patient with suicidal

risk/behavior

1. Hospitalization or outpatient monitoring

2. Psychotherapy

3. Psychosocial interventions

4. Treatment of physical injury if suicidal attempt

1st

Line

With bipolar disorder

With schizoaffective

disorder

With personality disorder

With substance abuse

1st line + mood stabilizer

1st line + antipsychotic and/or mood stabilizer

1st line + selective serotonin-reuptake inhibitor (SSRI)

With depression 1st line + selective serotonin-reuptake inhibitor (SSRI)

Detoxification and monitoring

1. Do not leave a suicidal patient alone. Remove any potentially dangerous items from the room.

2. Assess whether attempt was planned or impulsive. • Determine the lethality of the method, the chances of discovery

(whether patient was alone, or notified someone)

• The reaction to being saved (whether patient is disappointed or relieved).

• whether the factors that lead to the attempt have changed.

3. Patients with severe depression may be treated on an outpatient basis if their families can supervise them closely and if treatment can be initiated rapidly. Otherwise hospitalization is necessary.

4. Suicidal ideas in schizophrenic patients must be taken seriously because they tend to use violent, highly lethal and sometimes bizarre methods.

5. The suicidal ideation of alcoholic patients generally remits with abstinence in a few days.

If depression persists after the physiologic signs of alcohol withdrawal have resolved, a high suspicion of major depression is warranted. All suicidal patients who are intoxicated by alcohol or drugs must be reassessed when they are sober.

IN SUMMARY

• Mitigate, eliminate risk factors

• Strengthen barriers and reasons for not committing suicide –proper counselling and support

• Develop outpatient safety plans, including a family support plan

• Establish a therapeutic alliance

• Treat underlying disorders

• Address any abuse of substances.

PREVENTION IS BETTER THAN CURE

• Malaysian Organizations

The Befrienders Kuala Lumpur

Helpline 1: (03) 7956 8144

Helpline 2: (03) 7956 8145

Website: www.befrienders.org.my

Email Helpline: sam@befrienders.org.my

Lifeline Association of Malaysia

Helpline 1: (603) 92850039

Helpline 2: (603) 92850279

Helpline 3: (603) 92850049

THANK YOU!