suicide - a public health problem history, global scenario, Indian scenario, etiology, risk factors. protective factors, suicide in adolescents, treatment, prevention, recommendations

1. PRESENTER: Dr. Suhasini K.
Dec 3 2014

2. Introduction
Historical perspective
Global & Indian scenario
Etiology
Risk factors
Protective factors
Common methods
Stages
Warning signs
Treatment
Prevention
Recommendations 12/03/14 2

3.  Suicide – defined as an act with a fatal outcome
that is deliberately initiated and performed by the
person in the knowledge or expectation of its fatal
outcome.
It’s a complex phenomenon
Insurmountable disparity between expectations and
outcomes, real or imagined – tremendous pressure on
mind, blinding its logic, forcing it a conclusion of escape
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4. Derived from Latin word
sui = oneself , cidium = a killing
Primary emergency for mental health professional
Major public health problem
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5. The story of suicide is probably as old as that of man
himself
Suicide has variously been glorified, romanticized,
bemoaned, and even condemned
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6. In ancient Athens, a person who committed suicide
without the approval of the state was denied the
honours of a normal burial
In ancient Greece & Rome suicide was deemed to be an
acceptable method to deal with military defeat
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7. ISLAM: suicide is PROHIBITED
CHRISTIANITY: suicide is considered a sin
In 19th-century in Europe the act of suicide shifted
from being viewed as caused by sin to being caused
by insanity.
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8. Hinduism:
When Lord Sri Ram died, there was an epidemic of
suicide in his kingdom, Ayodhya
The Bhagavad Gita - condemns suicide
Upanishads, the Holy Scriptures - condemn suicide
‘he who takes his own life will enter the sunless
areas covered by impenetrable darkness after
death’
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9. 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
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10. More than 8,00,000 people die by suicide every year
Estimated annual mortality is 14·5 deaths per
1,00,000 people
Around one person every 40 seconds
75% of suicides occur in low- and middle-income
countries
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11. Suicide worldwide was estimated to represent 1.8% of
the total global burden of disease in 1998
 By 2020 - projected to be 2.4%
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12. Tenth leading cause of death worldwide
It is the second leading cause of death in 15-29 year-olds
globally
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13. 12/03/14 13

14. Suicide belt – (25 per 100,000) Scandinavia,
Switzerland, Germany, Austria, eastern European
countries (Belarus, Estonia, Lithuania, and the
Russian Federation) and Japan
Prime suicide site of the world – Golden Gate Bridge in
San Francisco
Japan- reported to have highest number of cases
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15. India ranks 43rd in descending order of rates of suicide
with a rate of 10.6/100,000 reported in 2009
About one-third of suicides over the world happen in
India
According to 2012 WHO data –
males -25.8/100,000population/year
females- 16.4/100,000
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16. According to NCRB : In 1989- 8.47/100,000
population/year
1999 – 11.21
2006 – 10.5
Under-reporting
• Pondicherry, Andaman & Nicobar Islands –
30/100,000
• Kerala, Sikkim, Tripura, Karnataka also have reported
high rates of suicide
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17. Sociological Factors
 Durkheim’s Theory:
Emile Durkheim ( French Sociologist )
suicide
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18. Egoistic - This type of suicide occurs when the degree of
social integration is low
Altruistic - degree of social integration too high
Anomic – Integration into society is disturbed
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19. Psychological Factors
 Freud’s theory: “ Mourning and Melancholia”
Menninger’s theory: suicide as inverted homicide
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20. Biological Factors
Serotonergic system: low concentration of
5-HIAA (metabolite of serotonin)
Nonadrenergic system: stress-diathesis model
HPA axis: Dexamethasone suppression test- non-suppressors
( suicide is more common in groups with low cholesterol
levels) 12/03/14 20

21. Genetic factors
Molecular biology – polymorphism in TPH gene
(tryptophan hydroxylase enzyme)
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22. Gender differences- Men 4 times > Women
Exceptions – India and China , ratio is 1.3:1
Age- Increase with age
men peak age- after 45 years
women – 55years
Race- Two out of every three suicides are White males
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23. Religion- degree of orthodoxy and integration
Marital status- lessens the risk
Occupation- higher social status greater the risk
unemployed > employed
Physician suicides - physicians particularly females are
at greater risk
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24. Climate – no significant variation
Physical health- loss of motility
disfigurement
chronic intractable pain
patients on hemodialysis
alcohol related illnesses
Drugs : Reserpine, corticosteroids, anti-cancer agents
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25. • Mental illness- 90- 95% have a diagnosed mental
disorder
Psychiatric patients- depressive disorder- 80%
alcohol related disorders – 4-60%
schizophrenic disorder- 3-10%
personality disorder- 5-44%
organic mental disorder- 2-7%
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26. Depression
Schizophrenia
Addiction disorder
Family history
& past history of
suicidality
Dysregulated
serotonergic system
Early parental
loss
Isolation
Unemployment
Acute life
events
Older age
Male sex
Vulnerable
periods
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27. Strong connections to family and community support
 Skills in problem solving, conflict resolution, and non-violent
handling of disputes
 Personal, social, cultural and religious beliefs that
discourage suicide and support self-preservation
Restricted access to means of suicide
 Seeking help and easy access to quality care for
mental and physical illnesses
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28. Pesticide poisoning(30%)
 Hanging
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29. Firearms
Drug overdose
Fatal injuries
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30. Exsanguinations
 Suffocation
Drowning
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31. STAGES OF SUICIDE
Ideation
Threatening
Attempting
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Intervention

32. Parasuicide : injures themselves by self
mutilation but do not wish to die
Cyber-suicide : suicide pact made between
individuals who meet on the internet
Copycat suicide : a suicide within a peer
group/publicized suicide can serve as a model for
next suicide in absence of sufficient protective
factors (Werther syndrome)
Anniversary suicide: persons take their lives on
the day a member of their family did
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33. IPC S. 309 Attempt to Commit Suicide
S.306 Abetment of Suicide
• S.305 Abetment in Special Cases
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34. Suicide in adolescents:
Highly vulnerable group
Living in violent & abusive environment
Lack of support network
They are usually successive in their attempt to suicide
Male : female ratio almost equal
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35.  Causes- mental illness
school difficulties
broken romance
separation
rejection
physical/ sexual abuse
Children –bullying /being bullied
(NOTE: Direct questioning about suicidal thoughts is
necessary)
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36. Trouble coping with recent losses, death, divorce,
moving, break-ups, etc.
Feelings of hopelessness and despair
Making final arrangements: writing a will or
eulogy, or taking care of details (i.e. closing a bank
account).
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37. Gathering of lethal weapons
Giving away prized possessions
Preoccupation with death, such as death and/or
'dark' themes in writing, art, music lyrics, etc.
Sudden changes in personality or attitude,
appearance, chemical use, or school behavior.
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38. “I can't go on anymore"
"I wish I was never born"
"I wish I were dead"
"I won't need this anymore"
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39. "My parents won't have to worry about me anymore"
“Everyone would be better off if I was dead”
“Nobody cares if I live or die”
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40. Treatment of suicide attempters
For every completed case of suicide there are about 20
non fatal attempts
Repetition – 15-25% within a year
Poor problem solving skills
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41. Psychosocial treatment
a)Problem-solving
b)Psychotherapy
c)Distress-tolerance skills
d)Outreach
e)Provision of emergency cards
f) Family therapy
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42. Pharmacological treatment
a)Antidepressants- fluoxetine, should be always
combined with other therapies
b)Neuroleptics- flupenthixol 20mg for 6 months
c)Lithium
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43. 1) Assessment- ( SAD PERSON’S scale – high specificity
but low sensitivity so not used anymore)
2) Treatment:
a)Psychiatric disorders to be treated
b)Community therapy- problem solving and outreach
c) Adolescents – family therapy, group therapy
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45. General principles
Population strategies
High-risk strategies
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46. Population strategies
Intervention at community level:
1. Increasing public awareness
2. Campaign to reduce stigma
3. Guidelines for the mass media
4. Regulating formulations, packaging and sale of
pesticides
5. Regulation of over-the-counter medication
6. Gender-related legislation and action
7. Introducing alcohol policies
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47. Interventions at institutional and organizational
levels:
1. Establishing sentinel centres and developing an
information system
2. Training of personnel working in high risk settings
3. Establishing crisis intervention and counselling centres
and telephone hotlines
4. Increase in specific clinical training programmes for lay
counsellors
5. Redesigning the curriculum for medical and nursing
personnel
6. Intervention programmes for high schools
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48. High-risk strategies
1. Patients with psychiatric disorder
a) Risk identification
b) Preventive strategies- active treatment of individuals
and psychological therapy
2. Elderly people- care and support
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49. 3. Suicide attempters
4. High-risk occupational groups- all these groups have
easy access to methods of suicide – removing the
access
5. Prisoners- young males held at remand
Ensuring that prison cells are safe in terms of absence of
structures favorable for suicide
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51.  Key Gatekeepers
o Primary health care providers
o Mental health care providers
o Emergency health care providers
o Teachers and other school staff
o Community leaders
o Police officers and other first responders
o Military officers
o Social welfare workers
o Spiritual and religious leaders
o Traditional healers
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54. In the WHO Mental Health Action Plan 2013-2020 - the
global target of reducing the suicide rate in countries
by 10% by 2020.
WHO’s Mental Health Gap Action Programme,
launched in 2008, includes suicide prevention as a
priority and provides evidence-based technical
guidance to expand service provision in countries
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56. Model for developing countries in public health
low IMR
MMR
High life expectancy
Marched forward in physical health, neglected mental
health
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57. Evidenced by high suicide rates
32/100,000 population/ year
KRISIS (Kerala Integrated Scheme for Intervention in
Suicide)- launched in 2004
In 2008- 26/100,000 population/yr
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58. Public awareness
Integration of mental health and general health in
suicide prevention approaches
At MBBS level – making it a compulsory subject of
study and a examination paper
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59. Foundations providing services in prevention of suicide
Prerana group- Mumbai
Sneha NGO – Chennai based
Maithri -Ernakulam
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60. When someone is suicidal , he or she will always
remain suicidal
Heightened suicide risk is often short-term and
situation-specific.
While suicidal thoughts may return, they are not
permanent and individual with previously suicidal
thoughts and attempts can go on to live a long life
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61. Talking about suicide is a bad idea and can be
interpreted as encouragement
Given the widespread stigma around suicide, most
people who are contemplating suicide do not know
who to speak to.
Rather than encouraging suicidal behaviour, talking
openly can give an individual other options or the time
to rethink his/her decision, thereby preventing
suicide.
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62. Only people with mental disorders are suicidal
Suicidal behaviour indicates deep unhappiness but not
necessarily mental disorder.
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63. Most suicides happen suddenly without warning
The majority of suicides have been preceded by
warning signs, whether verbal or behavioural.
 Of course there are some suicides that occur without
warning
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64. Someone who is suicidal is determined to die
On the contrary, suicidal people are often ambivalent
about living or dying
 Someone may act impulsively by drinking pesticides,
and die a few days later, even though they would have
liked to live on
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65. People who talks about suicide do not
mean to do it
People who talk about suicide may be reaching out for
help or support
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68.  Kaplan & Sadock’s Synopsis of Psychiatry (10th edi)
 New Oxford Textbook of Psychiatry ; Michael Gelder, Nancy Andreasen
(2nd edition)
 Community Mental Health in India; B. Chavan, Nithin Gupta
 Essentials of Psychiatry; Jerald Kay, Allan Tasman
 A hand book on Suicide Prevention Strategies, KRISIS
 World Health Organization. World Health Report 2001. Mental health:
New understanding, new hope. Geneva
 S.Manoranjitham;Towards a National Strategy to Reduce Suicide in
India; The National Medical Journal of India vol. 18, no. 3, 2005
 Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad ; Suicides in
young people in rural southern India Lancet; 2004;363:1117–18
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