Document Sample
Dr Victor Makanjuola
Dept. of psychiatry
University of Ibadan
   Suicide: defined as the act of deliberately
    killing one self.

   Suicide is a major public health problem
    approximately 0.9 percent of all deaths are the result of suicide.
    About 1000 persons are estimated to commit suicide each day
   In the United States suicide ranks as the eighth leading cause of
    death, and there are approximately 75 suicides per day, or one
    every 20 minutes, and more than 30,000 each year.
   The number one suicide site in the world is the Golden Gate Bridge
    in San Francisco.
   In general the suicide rate is low in less prosperous countries and
    higher in more affluent countries; it is high in all Eastern European
    nations. The United States has a rate in the middle range, around 12
    per 100,000.
Risk factors

   Age: Suicide rates increase with age. The elderly
    attempt suicide less often than do younger people but
    are successful more often. The elderly account for 25
    percent of the suicides, although they make up only 10
    percent of the total population. The rate of suicide for
    those 75 or older is more than three times the rate
    among the young.
   Sex: Males at all ages commit suicide more often than
    females and male-to-female suicide ratios range from 2
    to 1 to 7 to 1.
   Race: Ethnic and minority groups tend to be more
    cohesive and have lower suicide rates. In the United
    States, blacks have lower suicide rates than whites.
    Suicide among immigrants is higher than in the native-
    born population.
   Marital Status: Married persons have the lowest suicide
    rates. The suicide rate for single persons is twice that of
    married persons and that of the divorced, separated, or
    widowed, four to five times higher.
   Social Integration: Neighbourhood and families ties and
    religious affiliations affect the risk of suicide. Suicide
    rates are lower among Jews and Catholics than among
   Employment: Work, in general, protects against suicide.
    The unemployed have higher suicide rates, probably
    owing to an interaction of socioeconomic circumstances,
    psychological vulnerability, and stressful life events.
Causes of Suicide

Social Factors
 Emile Durkheim
 Egoistic suicide is determined by a lack of
  meaningful family ties or social interactions.
  Such suicide occurs in individuals who had lost
  their sense of integration within their social
  group, hence no longer felt subject to its social,
  family and religious control.
   Anomic suicide occurs when the relationship
    between an individual and society is broken by
    social or economic adversity.
    It occurs in individuals living in a society that
    lacked “collective order”.e.g suicide rates rose
    during the Great Depression of the 1930s and
    fell in nearly all European countries during both
    world wars.
   Altruistic suicide results from excessive
    integration in society (e.g., harakiri, sati).
Psychological Factors

   Freud: Freud stated that suicide represented aggression turned
    inward against an introjected, ambivalently cathected love object.
    Freud doubted that there would be a suicide without the earlier
    repressed desire to kill someone else.

   Menninger: Karl Menninger in “Man Against Himself” conceived of
    suicide as a retroflexed murder, an inverted homicide, as a result of
    the patient's anger toward another person, which is either turned
    inward or used as an excuse for punishment. He described three
    components of hostility in suicide: the wish to kill, the wish to be
    killed, and the wish to die.

   Recent Theories: Aaron Beck has demonstrated the importance of
    hopelessness while Edward Shneidman has observed cognitive
    constriction of choices among the suicidal.
Biological Factors
 Diminished central serotonin plays a role
  in suicidal behavior. Low concentrations of
  CSF 5-HIAA also predicts future suicidal
 Recent studies also report some changes
  in the noradrenergic system of suicide
Genetic Factors
 Suicidal behaviour, like other psychiatric
  disorders, tends to run in families. For example,
  Margaux Hemingway's 1997 suicide was the fifth
  suicide among four generations of Ernest
  Hemingway's family.
 In psychiatric patients a family history of suicide
  increases the risk both of attempted suicide and
  of completed suicide in most diagnostic groups.
Medical factors
Mental disorders
Mental disorders are a most important cause of suicide.

   Depressive disorders: rates of suicide are increased among
    depressed patient. (paradoxical suicide)
   Alcohol Abuse: is the second most frequent psychiatric disorder
    among those who die by suicide being present in 25% of cases
   Other Drug Dependent: patients also have an increased suicide
   Personality disorders: is detected in a third to half of people who
    commit suicide
   Schizophrenia: account for only about 3% of suicides hence the
    risk must be borne in mind.
Physical Disorder
 Post-mortem studies show that a physical
  illness is present in 25 to 75 percent of all
  suicide victims; a physical illness is
  estimated to be an important contributing
  factor in 11 to 51 percent of suicides.
 In each instance, the percentage
  increases with age.
   Rational suicide: suicide occasionally is
    the rational act of mentally healthy person

   Suicide pacts: two people agree that at
    the same time each will take his or her
    own life
Assessing suicidal risk

   All general risk factors are to be enquired about
   Interview must be conducted in an unhurried
    and sympathetic manner that allows the patient
    to admit any despair or self destructive
   Current problems must be enquired about
   Mental state examination should be particularly
    thorough and cognitive functions must not be
    overlooked. The mood must also be examined
    and homicidal ideas should be enquired about.

Management in the community
 Full assessment of patient and relatives including review
  of suicidal risk
 Organisation of adequate social support
 Regular review
 Full dosage of safe psychiatric treatment
       Choose less toxic drugs
       Small prescriptions
       Involve relatives in care of tablets
 Arrange immediate access to extra help for patient and
In the presence of significant suicidal risk, inpatient care is nearly
    always required
Management in the hospital
 Safe ward environment
 Adequate well trained staff with good working relationship
 Clear policies for assessment, review, and observation
 On admission
 Asses risk
 Agree level of observation
 Remove objects which might be used as a means of suicide
 Discus plans with patient
 Agree policy for visitor
   During admission
       Regular review of risks and plans
       Clear plans for leave
       If patient leaves the ward without notice, take
       Immediate action
   Discharge
       Plan and agree in advance
       Prescribe adequate but non-dangerous
       amount of drugs
       Early follow up
Suicide Prevention

Primary Prevention
 Better and more available psychiatric services
 Restricting the means of suicide
 Educational programmes
 Restricting opportunities for imitations
Secondary Prevention
 Better and more available psychiatric care
 Crisis centres and “hotlines”
Deliberate Self Harm (attempted
suicide or Parasuicide)

   Deliberate self poisoning: Accounts for about
    90% of DSH and usually involve a drug
    overdose. Most commonly used drugs are non
    opiate analgesics such as paracetamol and
   Deliberate self injury: Accounts for about 5 –
    15% of DSH. Methods include lacerations
    (usually of the fore arm or wrists). Others
    including jumping from heights or in front of a
    train or motor vehicle, shooting, and drowning

   In England and Wales, self-poisoning is
    the most common diagnosis of admitted
    patients under 50 years of age; among
    women it is the most common reason for
    emergency medical admission whereas
    among men it is second only to heart
Risk Factors

   Age: commoner among the young people with rates
    declining sharply in the middle ages
   Sex: commoner among females, about 1.3 to 1.5 times
   Socioeconomic class: Prevalence higher in the lower
    socioeconomic class
   Marital status: Highest rates are found among the
    divorced. High rates are also recorded among teenage
    wives, younger single men and women.
   Other social factors: high rates in areas with high
    unemployment, overcrowding, etc
Causes of deliberate self harm

Precipitating factors
 Stressful life events: compared with the
  general population, people with DSH
  experience 4 times as many stressful life
  problems in the six months before the act.
Predisposing factors
 Marital difficulties
 Unemployment
 A background of poor physical health: epileptics are six
  times more likely to carry out DSH than the general
 Early parental loss
 Poor skills in solving interpersonal problems and in
  planning for the future
 Psychiatric disorders: few have psychiatric disorders
  though affective symptoms are common. Depressive
  disorder and alcohol dependence are the two
  commonest disorders associated with DSH.
   NB: The risk of completed suicide is
    increased about 100 times over that of the
    general population
Assessment of patients after
 Circumstances suggesting high suicidal
 Planning in advance
 Precautions to avoid discovery
 No attempts to obtain help afterwards
 Dangerous methods
 „Final acts‟
Factors predicting suicide after
deliberate self harm
   evidence of serious intent
   depressive disorder
   alcoholism or drug abuse
   antisocial personality disorder
   previous suicide attempts
   social isolation
   unemployment
   older age group ( female only)
   male sex
Factors predicting the repetition
of non fatal deliberate self
 Previous deliberate self harm
 Previous psychiatric treatment
 Antisocial personality disorder
 Alcohol or drug abuse
 Criminal records
 Low social class
 Unemployment

   About 5 – 10 % require immediate in patient
    treatment in psychiatric facility, about
    25%require no special treatment because their
    self harm is a response to temporary difficulties
    and carried little risk of repetition.
    The rest may require some outpatient
   The treatment is mainly psychological and
    social. Drugs may be needed in a small minority
    to treat depression.