special thanks and acknowledgement goes out to the contributors of the slide: meroshana, haziman fauzi, griselda pearl, widad ulya, atiqah shakira, halim latiffi, farith che man and marwan omar. Hopefully this is able to help medical students to understand about the psychiatry topic, suicide. This is made by students so if there are any mistakes, please do correct us. We are open to constructive criticism. thank you :)

1. SUICIDE
By Group B

2. INTRODUCTION

3. 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.

4. OTHER
DEFINITIONS

5. 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

6. 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

7. SUICIDAL ATTEMPT
• Non-fatal self inflicted destructive act with explicit or
inferred intent to die
ABORTED SUICIDAL ATTEMPT
• An event when an individual comes close to the
attempting suicide but he does not complete the act
• No injury

8. 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)

9. WARNING
SIGNS AND
RISK
ASSESSMENT

10. • Suicide is rarely a spur of the moment decision (Dr Suarn
Singh, Head of Psychiatry, Ministry of Health Malaysia).
• Usually there are clues leading to the actual attempt.

11. 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• Becoming withdrawn and depressed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.

13. • 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.

14. • 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.

15. 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

16. RISK FACTORS

17. 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

18. Scoring system:
1 point for each of the positive answers
Score Risk
0 - 2 No real problems, keep watch
3 - 4 Send home, but check frequently
5 - 6 Consider hospitalization involuntary or
1) Paterson, W, Dohn, H , Bird, J, Paterson, G. Psychsomatics, 1983, 24, 343349
2) Juhnke, G.E. “SAD PERSONS scale review.” Measurement & Evaluation in
Counseling & Development, 1994, 27, 325328
3) Juhnke, G.E. (“The adapted SAD PERSONS: As assessment scale designed for use
with children” Elementary School Guidance & Counesling, 1996, 252258
voluntary, depending on your level of
confidence in follow-up.
7 - 10 definitely hospitalize involuntarily or voluntarily

19. • 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)

20. • 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.

22. 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?

23. • 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.

24. 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).

25. 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.

26. 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).

27. 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.

28. 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.

29. 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

30. 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

31. • 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.

32. HISTORY TAKING

33. 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)

34. QUESTIONS TO ASK (CONTD.)
• Thoughts about life ?
• Optimism ?
• Judgement

35. 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

36. QUESTIONS TO ASK (CONTD.)
• Social history
(Marital status, family
relationship, occupation,
social support, stress level )

37. MENTAL STATUS
EXAMINATION

38. 1. Appearance and behaviour
2. Mood /affect
3. Thought -Form/Flow/Content/ Possession
4. Perception
5. Cognition - GOAL CRAMP
6. Judgement
7. Insight

39. THOUGHT
• Irrelevant form
• Normal flow
• Content of suicidal ideation
• Try to reveal pt's plan of suicide
• Suicidal idea can convert to homicidal

40. JUDGEMENT
Personal
• Ask, what pt would do when he leaves the hospital?
Social
• Is there anyone who cares about him?

41. LEGAL ISSUES

42. • Attempt to commit suicide
• 309. Whoever attempts to commit suicide, and does any act towards
the commission of such offence, shall be punished with imprisonment
for 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 the
death of her newly-born child, but at the time of the act or omission
she had not fully recovered from the effect of giving birth to such
child, and by reason thereof the balance of her mind was then
disturbed, she shall, notwithstanding that the circumstances were
such that but for this section the offence would have amounted to
murder, be guilty of the offence of infanticide.

43. 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.

44. 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.

45. MANAGEMENT

46. 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

47. 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.

48. 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.

49. 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.

50. 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.

51. 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

52. THANK YOU! 