Class presentation

On
Suicide

SUBMITTED TO: SUBMITTED BY:

MADAM MITA MANDAL PRICILA MINJ

CLINICAL INSTRUCTOR 2 ND YEAR M.SC. NURSING

CON NRSMCH CON NRSMCH

 INTRODUCTION
Suicide is not a diagnosis or a disorder; it is a behaviour. The judeo-christian belief has been
that life is gift from god and taking it is strictly forbidden. In the United States, suicide is the
third leading cause of death among adolescents, topped by accidental death and homicide. In
all countries, suicide rarely occurs in children who have not reached puberty. In the last 15
years, the rates of both completed suicide and suicidal ideation rates have decreased among
adolescents. This decrease appears to coincide with the increase in SSRI medications
prescribed to adolescents with mood and behavioural disturbance. Suicidal ideation, gestures,
and attempts are frequently, but not always, associated with depressive disorders. Reports
indicate that as many as half of suicidal individuals express suicidal intentions to a friend or a
relative within 24 hours before enacting suicidal behaviour. In psychiatry suicidal threat is
considered as one of the commonest emergencies. More than 90 percent of all persons who
commit or attempt suicide have diagnosed as mental disorder.

DEFINITION

Suicide is defined as the intentional taking of one’s own life in a culturally non-endorsed
manner.

According to Valente (1983) suicide is an intentional self-inflicted death’. The term suicide
originates from the Latin word Sui which means ‘of oneself ’and Cida (derived from
Caedere) which means to kill’

According to Shneidman (1985), suicide is the conscious act of self-induced annihilation,

best understood as a multi-dimensional malaise in a needful individual who defines an issue
for which the act is perceived as the best solution.

Attempted suicide ( para suicide, pseudocide, nonfatal deliberate self-harm) is defined as

any act of self-damage carried out with apparent intention of self-destruction, however half
hearted, vague, and ineffective.

Suicidal ideation: suicidal ideation are thoughts of injury or the minds of self but not
necessarily a plan intent, or a means for example, ‘I want to kill myself’
Suicidal threat: It is a statement of intent to commit suicide. There the individual threatens
one of imminent self-destructive action that, if carried out has a high probability of leading to
death. For example ‘I am going to kill myself ’

EPIDEMIOLOGICAL FACTOR

 More than 38000 people committed suicide in 2010, the latest year for which
statistics have been reported. This is highest rate of suicide in 15 years, these
statistics has established suicide as third leading cause of death among young
American age 15 to 24 years,4th leading cause among ages 25 to 44, 8th leading
cause among 45 to 64 and tenth leading cause of death among all.

AETIOLOGY

a) Predisposing factor: attempted suicide

 Disrupted home circumstances: Broken homes, marital discord and death have a
tendency to lead to contemplate suicide
 Family history of psychiatric illness: when there is family history of psychiatric
disorder, mainly alcohol or drug abuse, depression and other emotional disorder, it
lead to suicide and self-harm.
 History of psychiatric disorder: among older teenagers, the retrospective
assessment by means of psychological autopsies suggest that over 90% had some
of psychiatric disorder, with and affective disorder commonly in both the sexes.
 Models of successful and attempted suicide: children are influenced by the
incidence of successful or attempted suicide as a means of escape from stressful
life situations. Most of the model are family, friends, media, and books.
 Previous suicidal threat or behaviour: Roughly half of all the cases have had a
history of previous suicidal attempt or threats.
 Availability of highly lethal means: The availability of means such as fire arms,
coal gas, drugs acts as predisposing factor for attempted suicide.
b) Predisposing factor: deliberate self-harm
 Lack of supportive family relationships: The lack of support in a family
relationship is associated with broken homes, placement of children in children’s
homes and disharmonious family environment with low affection.
 Family members with psychiatric disorder: Alcohol abuse is common in parents
particularly father.
 History of physical and sexual abuse: Person with the history of being abused both
physically and sexually end up particularly liable to hate themselves. This leads to
deliberate self- harm.
 School or work problems: When academic attainments are typically below average
and there have been problems relating to teachers and peers, the adolescents resorts
to deliberate self-harm.
 Role modelling: when family members, friends or media reports have provided
models for imitation, the adolescent may attempt deliberate self-harm.
 History of previous attempt: Many of the person with deliberate self –harm have
had a previous history of a similar attempt. This accounts for almost 20%
 Impulsive behaviour: Most of the attempted self- harm is on the spur of the
moment, impulsive and most likely to be acted on when they have immediate
access to prescribe or over-the-counter medication.
c) Precipitating factor ---suicidal attempt
 Disciplinary crisis: when young person has got into trouble with the school or the
police, there is a chance of the parents getting to know about it, the adolescent
tends to attempt suicide as an easy way out.
 Problem with psychotic parents: when the child face chronic stress due to the
illness in one of his/her parents, there is a tendency to opt for suicide.
 Quarrel with parents, friends, or boy/girlfriend: Trying to escape from the
crisis of a disrupted interpersonal relationship, could lead the adolescent to
suicide.
 Lack of support: If the child is out of school away from home having to fend for
himself, and happens to face a crisis, he tends to consider suicide as an option.
d) Precipitating factors—Deliberate self-harm
 Relatively minor additional stress seems to be the last straw for a vulnerable
adolescent.
  Quarrel with family, friends, or boy/girlfriends
 Episode of physical or sexual abuse
 Feeling of hopelessness
 Worry about the future
 Anger towards
 Feeling of loneliness and being unwanted
e) Psychiatric disorders
 Major depression
 Schizophrenia
 Drug or alcohol abuse
 Dementia
 Delirium
 Personality disorder

f) Physical disorder
 Patient with incurable or painful physical disorder like cancer and AIDS.
g) Psychosocial factor
 Failure in examination
 Dowry harassment
 Marital problems
 Loss of loved ones
 Isolation and alienation from social groups
 Financial and occupational difficulties

CAUSATIVE FACTOR OF SUICIDE ACROSS THE LIFE SPAN

Developmental Prevalence Causative factor

period
Childhood Unknown (some accident may be suicide). It is  Affective disorder
predicted to increase to 13% for age group of mainly depression
10-14 years by 2000 AD  Family developmental
Adolescence 6-13% have attempted suicide. It is predicted as  Affective disorder
94% for ages 15-19 years by 2000AD
Developmental Prevalence Causative factor
period
 Conduct disorder and
antisocial disorder
 Substance abuse
 family disorganisation
Early and 15% of those with major depression commit  Depression,
middle suicide. 15%of those with schizophrenia schizophrenia, previous
adulthood commit suicide. 80% of those who commit attempts, lack of
suicide have made previous attempts. 15% of psycho-social resources,
alcoholics commit suicide. alcoholism, substance
abuse, major psychiatric
and physical health
problems
Older adulthood 17% have attempted suicide  Loss, feeling of isolation
and poor physical health
status.

RISK FACTORS

I. Marital status: The suicide rate for single person is twice that of married persons.
Divorced, separated, or widowed persons have rates four or five times greater than
those of married
II. Gender: women attempt suicide more than men, and men succeed more often.
Successful suicide numbers about 70 percent for men and 30 percent for women.
Women tend to over dose, men use more lethal means such as firearms. Women may
have a tendency to seek and accept help from friends or professionals whereas men
often view help seeking as a sign of a weakness.
III. Age: suicide risk and age are positively correlated. This is particularly true for men.
Although rates among women remain fairly constant throughout life, rates among
men show a higher age correlation. The rate rises sharply during adolescence, peak
between 40 and 50 level off until age 65, when rate rises again for the remaining year.
IV. Religion: Historically suicide rate among Roman Catholic populations have been
lower than the rates among protestant and Jew. According to study its say that men
and women who consider themselves affiliated with a religion are less likely to
attempt suicide than their non-counter parts.
V. Socio economic status: Individuals in very highest and lowest social class have higher
suicide rate than those in the middle classes. With regard to occupation, suicide rate
are higher among physicians artists, dentist, law enforcement officers lawyersand
insurance agents.
VI. Ethnicity: with regard to ethnicity, statistics show that whites are at higher risk for
suicide followed by Native American, African Americans, Hispanic American and
Asian Americans.
VII. Other risk factor: more than 90 percent of suicide or people who kill themselves have
a diagnosable mental disorder, mostly mood disorder etc.

PREDISPOSING FACTORS: THEORIES OF SUICIDE

1) Psychological theories
a) Anger turned inward: Freud (1957) believed that suicide was a response to intense
self-hatred that an individual possessed. The anger had originated toward a love
object but was ultimately turned inward against the self. Freud believed that
suicide occurred as a result of an earlier repressed desire to kill someone else. He
interpreted suicide to be an aggressive act towards the self that often was really
directed toward other.
b) Hopelessness: Carroll-Ghosh and associates (2003) identified hopelessness as a
central underlying factor in the predisposition to suicide. Beck, Brown, and
Berchick(1990) also found a high correlation between hopelessness and suicide.
c) Desperation and guilt: Hendin (1991) identified desperation as another important
factor in suicide. With desperation, an individual feel helpless to change, but heor
she also feels that life is impossible without such change. Guilt and self-
recrimination are other aspect of desperation. These affective components were
found to be prominent in Vietnam veterans with post-traumatic stress disorder
exhibiting suicidal behaviour(Carrol-Ghosh)
 d) History of aggression and violence: Some studies have indicated that violent
behaviour often goes hand in hand with suicidal behaviour (Carrol-Ghosh). These
studies correlate the suicidal behaviour in violent individuals to conscious rage,
therefore citing rage as an important psychological factor underlying the suicidal
behaviour.
e) Shame and humiliation: Some individuals have viewed suicide as a face-saving
mechanism a way to prevent public humiliation following a social defeat such as a
sudden loss of status or income. Often these individuals are too embarrassed to
seek treatment or other support system.
f) Development stress: Rich, Wasradt, and Nemiroff (1991) have associated
developmental level with certain life stressor and their correlation to suicide. The
stressor of conflict separation and rejection are associated with suicidal behaviour
in adolescence and early adulthood. The principal stressor associated with suicidal
behaviour in the 40-to 60 years old group is economic problems. Medical illness
play an increasing significant role after 60 year of age and become the leading
predisposing factor to suicidal behaviour in individual older than age 80.
2) Sociological theory
Durkheim (1951) studied the individual’s interaction with society in which he or she
lived. He believed that the more cohesive the society, and the more that the individual
felt an integrated part of the society, the less likely he or she was commit suicide.
Durkheim described three social categories of suicide:
a. Egoistic suicide: Egoistic suicide is the response of the individual who feels
separate and apart from the mainstream of the society. Integration is lacking
and the individual does not feel a part of any cohesive group (such as a family
or a church).
b. Altruistic suicide: Altruistic suicide is the opposite of egoistic suicide. The
individual who is prone to altruistic suicide is excessively integrated into
group. The group is often governed by cultural, religious, or political, and
allegiance is so strong that the individual will sacrifice his or her life for the
group.
c. Anomic suicide: Anomic suicide occurs in response to changes that occur in
an individual’s life (e.g., divorce, loss of job) that disrupt feeling of
relatedness to the group. An interruption in the customary norms of behaviour
 instils feeling of “separateness” and fears of being without support from the
formerly cohesive group.
3) Biological theories
a. Genetics: Twin studies have shown a much higher concordance rate for
monozygotic twins than dizygotic twins. Some studies with suicide
attempters have focused on the genotypic variations in the gene for
tryptophan hydroxylase with result indicating significant association top
suicidality (Abbar etal., 2001). These results suggest a possible existence of
genetic predisposition towards suicidal behaviour.
b. Neurochemical factor: A number of studies have been conducted to
determine if there is a correlation between neurochemical functioning in the
central nervous system and suicidal behaviour. Some studies have revealed a
deficiency of serotonin (measure as a decrease in the levels of 5-
hydroxyindole acetic acid [5-HIAA] of the cerebrospinal fluid) in depressed
client who attempted suicide. Some changes in the noradrenergic system of
suicide victims have also been reported.

SUICIDAL TENDECNY IN PSYCHIATRIC PATIENT

Certain psychiatric disorder where the patient may develop suicidal tendencies include:

a. Major depression
 This is one of the commonest conditions associated with high risk of suicide.
Suicide in a major depressive episode is due to pervasive and persistent
sadness, pessimistic cognitions concerning the past, present and future;
delusions of guilt, helplessness, hopelessness and worthlessness, derogatory
voices urging him to take his life.
 The risk for suicide is more when acute phase has passed and the
characteristic psychomotor retardation has improved. This is so because the
patient has more energy to carry out his suicidal plan now, though he might
have been harbouring them for some quite time.
b. Schizophrenia
 The major risk factor among schizophrenics include the presence of
associated depression, young age and high levels of premorbid functioning
(especially during college education).
  People in this risk group are more likely to realize the devastating
significance of their illness more than other groups of schizophrenic patient
do, and see suicide as a reasonable alternatives.
c. Mania
 Mania patient may occasionally commit suicide. This is usually the result of
grandiose ideation. The patient may believe that he is great person or wish to
prove his supernatural powers. With this intend in mind hey may carry out
some dangerous activity that can cost him his life.
d. Drug or alcohol abuse
 Suicide among alcoholics can be due to depression in the withdrawal phase.
Also, the loss friends and family, self –respect, status and a general realization
of havoc alcohol has created in his life can cause the individual to wish to die.
e. Personality disorder
 Individuals with histrionic and borderline traits may occasionally attempt
suicide.
f. Organic conditions
 Conditions such as delirium and dementia due to changes of mood like
anxiety and depression may also induce suicidal tendency.

MANAGEMENT OF SUICIDE

A. ASSESSMENT: The following items should be considered when conducting a

suicidal assessment: demographics, presenting symptoms/medical-psychiatric
diagnosis, suicidal ideas or acts, interpersonal support system, analysis of the suicidal
crisis, psychiatric/medical/family history, and coping strategies.
a. Demographics: The following demographics are assessed:
 Age. Suicide is highest in persons older than 50 years of age. Adolescents are
also at high risk.
 Gender. Males are at higher risk than females.
 Ethnicity. Caucasians are at higher risk than are Native Americans, who are
at higher risk than African Americans.
 Marital status. Single, divorced, and widowed persons are at higher risk than
married persons.
  Socioeconomic status. Individuals in the highest and lowest socioeconomic
classes are at higher risk than those in the middle classes.
 Occupation. Professional health care personnel and business executives are
at highest risk.
 Method. Use of firearms presents a significantly higher risk than overdose of
substances.
 Religion. Protestants are at greater risk than Catholics or Jews.
 Family history. Higher risk exists if the individual has a family history of
suicide.
b. Presenting Symptoms/ Medical-Psychiatric Diagnosis: Assessment data must be
gathered regarding any psychiatric or physical condition for which the client is
being treated. Mood disorders (major depression and bipolar disorders) are the most
common disorders that precede suicide. Individuals with substance use disorders are
also at high risk. Other psychiatric disorders in which suicide may be a risk include
anxiety disorders, schizophrenia, and borderline and antisocial personality
disorders. Other chronic and terminal physical illnesses have also precipitated
suicidal acts.
c. Suicidal ideas or acts: How serious is the intent? Does the person have a plan? If
so, does he or she have the means? How lethal are the means? Has the individual
ever attempted suicide before? These are all questions that must be answered by the
person conducting the suicidal assessment. Individuals may leave both behavioural
and verbal clues as to the intent of their act. Examples of behavioural clues include
giving away prized possessions, getting financial affairs in order, writing suicide
notes, or sudden lifts in mood (may indicate a decision to carry out the intent).
d. Interpersonal support system: Does the individual have support persons on whom
he or she can rely during a crisis? Lack of a meaningful network of satisfactory
relationships may implicate an individual at high risk for suicide during an
emotional crisis.
e. Analysis of suicidal crisis

 The precipitating stressor: Adverse life events in combination with other risk
factors such as depression may lead to suicide (NIMH, 2006). Life stresses
accompanied by an increase in emotional disturbance include the loss of a loved
 person either by death or by divorce, problems in major relationships, changes in
roles, or serious physical illness.

 Relevant history: Has the individual experienced numerous failures or rejections

that would increase his or her vulnerability for a dysfunctional response to the
current situation?

 Life-stage issues: The ability to tolerate losses and disappointments is often

compromised if those losses and disappointments occur during various stages of
life in which the individual struggles with developmental issues (e.g., adolescence,
midlife).
f. Psychiatric/medical/family history
The individual should be assessed with regard to previous psychiatric treatment for
depression, alcoholism, or for previous suicide attempts. Medical history should be
obtained to determine presence of chronic, debilitating, or terminal illness. Is there a
history of depressive disorder in the family, and has a close relative committed
suicide in the past?
g. Coping strategies
How has the individual handled previous crises? How does this situation differ from
previous ones?

Diagnosis/Outcome Identification

Nursing diagnoses for the suicidal client may include the following:
● Risk for suicide related to feelings of hopelessness and desperation.
● Hopelessness related to absence of support systems and perception of
worthlessness.

Intervention with the Outpatient Suicidal Client (or Following Discharge

from Inpatient Care)
In some instances, it may be determined that suicidal intent is low and that hospitalization is
not required. Instead, the client with suicidal ideation may be treated in an outpatient setting.
Guidelines for treatment of the suicidal client on an outpatient basis include the following:

● The person should not be left alone. Arrangements must be made for the client to stay with
family or friends. If this is not possible, hospitalization should be reconsidered.

● Establish a no-suicide contract with the client. Formulate a written contract that the client
will not harm himself or herself in a stated period of time. For example, the client writes, “I
will not harm myself in any way between now and the time of our next counselling session,”
or “I will call the suicide hotline (or go to the emergency room) if I start to feel like harming
myself.” When the time period of this short-term contract has lapsed, a new contract is
negotiated.

● Enlist the help of family or friends to ensure that the home environment is safe from
dangerous items, such as firearms or stockpiled drugs. Give support persons the telephone
number of counsellor or emergency contact person in the event that the counsellor is not
available.
Appointments may need to be scheduled daily or every other day at first until the immediate
suicidal crisis has subsided.
● Establish rapport and promote a trusting relationship. It is important for the suicide
counsellor to become a key person in the client’s support system at this time.
● Be direct. Talk openly and matter-of-factly about suicide. Listen actively and encourage
expression of feelings, including anger. Accept the client’s feelings in a non-judgmental
manner.
● Discuss the current crisis in the client’s life. Use the problem-solving approach. Offer
alternatives to suicide.
● Help the client identify areas of life situation that are within his or her control and those
that client does not have the ability to control. Discuss feelings associated with these control
issues. It is important for the client to feel some control over his or her life situation in order
to perceive a measure of self-worth.
● The physician may prescribe antidepressants for an individual who is experiencing suicidal
depression. It is wise to prescribe no more than a 3-day supply of the medication with no
refills. The prescription can then be renewed at the client’s next counselling session.
Macnab (1993) suggests the following steps in crisis counselling with the suicidal client:
 Focus on the current crisis and how it can be alleviated. Identify the client’s appraisals
of how things are, and how things will be. Note how these appraisals change in
changing contexts.
 Note the client’s reactivity to the crisis and how this can be changed. Discuss
strategies and procedures for the management of anxiety, anger, and frustration.
 Work toward restoration of the client’s self-worth, status, morale, and control.
Introduce alternatives to suicide.
 Rehearse cognitive reconstruction—more positive ways of thinking about the self,
events, the past, the present, and the future.
 Identify experiences and actions that affirm self-worth and self-efficacy.
 Encourage movement toward the new reality, with the coping skills required to
manage adaptively.
 Be available for ongoing therapeutic support and growth.
Intervention with Families and Friends of Suicide Victims
 Encourage the clients to talk about the suicide, each responding to the others’
viewpoints, and reconstructing of events. Share memories.
 Be aware of any blaming or scapegoating of specific family members. Discuss how
each person fits into the family situation, both before and after the suicide.
 Listen to feelings of guilt and self-persecution. Gently move the individuals toward
the reality of the situation.
 Encourage the family members to discuss individual relationships with the lost loved
one. Focus on both positive and negative aspects of the relationships. Gradually, point
out the irrationality of any idealized concepts of the deceased person. The family must
be able to recognize both positive and negative aspects about the person before grief
can be resolved.
 No two people grieve in the same way. It may appear that some family members are
“getting over” the grief faster than others.
 All family members must be made to understand that if this occurs, it is not because
they “care less,” just that they “grieve differently.” Variables that enter into this
phenomenon include individual past experiences, personal relationship with the
deceased person, and individual temperament and coping abilities.
  Recognize how the suicide has caused disorganization in family coping. Reassess
interpersonal relationships in the context of the event. Discuss coping strategies that
have been successful in times of stress in the past, and work to re-establish these
within the family. Identify new adaptive coping strategies that can be incorporated.
 Identify resources that provide support: religious beliefs and spiritual counsellors,
close friends and relatives, survivors of suicide support groups.

MANAGEMENT OF IMMEDIATE SUICIDE ATTEMPT

 Be aware of certain sign which may indicate that the individual may commit suicide
such as:
 Suicidal threat
 Writing farewell letters
 Giving away treasured articles
 Making will
 Closing bank accounts
 Appearing peaceful and happy after a period of depression
 Refusing to eat and drink
 Monitoring the patient safety needs
 Take all suicidal threat or attempt seriously and notify psychiatrist
 Search for toxic agents such as drugs/ alcohol
 Do not leave the drug tray within the reach of the patient, make sure that the
daily medication is swallowed
 Remove sharp instruments such as razor, blades, knifes, glass bottles from his
environment.
 Remove straps and clothing such as belts, neckties
 Do not allow the patient to bolt his door on the inside, make sure that
somebody accompanies him to the bathroom
 Patient should be kept in constant observation and should never be left alone.
 Have a good vigilance especially during morning hours
 Spend times with him talk to him and allow him to ventilate his feelings
 Encourage him to talk about suicidal plans/methods
  If suicidal tendency are very severe sedation should be given as prescribed.
 Encourage the verbal communication of suicidal ideas as well as his/her fear and
depressive thought. A no suicidal pact must be signed which is a written agreement
between a nurse and patient, that patient will not act on suicidal impulses but will
approach the nurse to talk about them
 Enhance self-esteem of the patient by focussing on hid strength rather than weakness.
His positive qualities should be emphasized with realistic praise and appreciation.
This foster a sense of self- worth and enables him to take control of his life situation.

MANAGEMNET OF ATTEMPTED SUICIDE IN THE IN PATINET UNIT

 Assess for vital signs, check airway, if necessary clear airway
 If pulse is weak, start IV fluids
 Turns patient’s head and neck to one side to prevent regurgitation and swallowing of
vomitus
 Emergency measures to be instituted in case of self-inflicted injuries

CONCLUSION
One of the most demanding and perplexing challenges in psychiatric nursing is the
prevention of suicide. Suicide is the behaviour and not a diagnoses or a disorder. In the past
based on the Christian belief suicide was considered a crime. But currently the world view
suicide with the most secular view and therefore there is growing support for individuals who
were psychiatric or clinically ill at the time of suicide.