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Psychiatry

1. Suicide – risk assessmemt and management By –Dr Rewa Sood

2. introduction The term suicide means a fatal self inflicted destructive act with explicit or inferred intent to die. In psychiatry ,suicide is the primary emergency It is almost always the result of mental illness, usually depression, and is amenable to psychological and pharmacological treatment.

3. Terms and definitions ABORTED SUICIDE ATTEMPT -potentially self injurious behavior with explicit or implicit evidence that the person intended to die but stopped the attempt before physical damage occurred DELIBERATE SELF HARM - willful self inflicting of painful, destructive, or injurious acts without intent to die LETHALITY OF SUICIDAL BEHAVIOR - objective danger to life associated with a suicide method or action

4. SUICIDAL IDEATION -Thought of serving as the agent of one’s own death SUICIDAL INTENT -Subjective expectation and desire for a self destructive act to end in death SUICIDE ATTEMPT -Self injurious behavior with a non fatal outcome accompanied by an explicit or implicit evidence that the person intended to die SUICIDE -Self inflicted death with explicit or implicit evidence that the person intended to die

5. PARASUICIDE - describes patients who injure themselves by self mutilation but who usually do not wish to die

6. epidemiology According to WHO(2014), global suicide rates have increased 60% over the past 45 years, and now more than 800,000 people die from suicide every year—roughly one death every 40 seconds. India  has the highest  suicide rate  in the South-East Asian region, according to the  World  Health Organization's  latest  report in 2019.   India's suicide rate  stands at 16.5  suicides  per 100,000 people. India also had the third-highest female suicide rate (14.7) in the world 

7. Suicide is the 15 th leading cause of death globally, accounts for 1.4 % of all deaths The global suicide rate is 10.6 per 100000 population-15 /100000 for males and 8 /100000 for females. For every 1 suicide 25 people make a suicide attempt 135 people are affected by each suicide death This equates to 108 million people bereaved by suicide worldwide every year

8. Etiology SOCIOLOGICAL FACTORS Durkheim’s theory- Divides suicide into 3 social categories- egoistic,altruistic and anomic PSYCHOLOGICAL FACTORS FREUD’S THEORY -suicide represents aggression turned inward against an introjected ,ambivalently cathected love object MENNINGER’S THEORY –suicide is an inverted homicide because of a patient’s anger towards himself

9. BIOLOGICAL FACTORS Decreased serotonin GENETIC FACTORS family history increases the risk

10. Risk Factors A)Gender Differences- Men commit suicide more than four times as often as women women attempt suicide or have suicidal thoughts three times as often as men B) Age- Among men, suicides peak after age 45; among women, the greatest number of completed suicides occurs after age 55. Rates of 29 per 100,000 population occur in men age 65 or older

11. C) Race. Suicide rates among white men and women are approximately two to three times as high as for African American men and women across the life cycle D) Religion. Historically, Protestants and Jews in the United States have had higher suicide rates than Catholics. Muslims have much lower rates

12. E)Marital Status. Marriage lessens the risk of suicide. Divorce increases suicide risk Widows and widowers also have high rates F)Occupation. The higher the person’s social status, the greater the risk of suicide, but a drop in social status also increases the risk

13. G)Physical Health. The relation of physical health and illness to suicide is significant. Previous medical care appears to be a positively correlated risk indicator of suicide: About one third of all persons who commit suicide have had medical attention within 6 months of death

14. H)Mental Illness . Almost 95 percent of all persons who commit or attempt suicide have a diagnosed mental disorder. Depressive disorders - 80% schizophrenia -10 % dementia or delirium - 5 %

15. I ) Psychiatric patients- 3-12 times that of non patients Depression – 20% Schizophrenia -10% Bipolar disorder - 15-20% Alcohol dependence- 15% Antisocial personality disorder-5%

16. Pooled Relative risk of suicide Disorder No of studies Pooled relative risk MDD 4 19.9 Anxiety disorder 7 2.7 Schizophrenia 4 12.6 Bipolar disorder 4 5.7 Anorexia nervosa 9 7.6 Alcohol dependence 12 9.8 Opioid dependence 21 6.9 Psychostimulant dependence 4 8.2 Amphetamine dependence 1 4.5 Cocaine dependence 3 16.9

17. J) A past suicide attempt is perhaps the best indicator that a patient is at increased risk of suicide. Studies show that about 40 percent of depressed patients who commit suicide have made a previous attempt. The risk of a second suicide attempt is highest within 3 months of the first attempt.

18. Foreseeability of Suicide The concept of imminent suicide imposes an illusory time frame on an unpredictable act ( Pokorny 1983). Suicide is typically impulsive in nature. As such, many patients remain uncertain to the last moment, with little premeditation, and are often ambivalent about dying

19. At risk individuals Previous suicide attempt Family h/o suicide Cultural sanctions for suicide Stressful events such as Relationship break up Loss of loved one Argument with family and friends Financial ,legal or work related problems Isolation

20. Amongst vulnerable groups- Refugees and migrants Bisexual or homosexual gender identity prisoners

21. Relatives and close friends of people (suicide survivors) who die by suicide are a high risk group for suicide due to The psychological trauma of a suicide loss Potential shared familial and environmental risk Suicide contagion through the process of social modelling The burden of stigma associated with this loss

22. Protective Factors Factors that have been associated with a decreased risk of suicide include the following: • Family cohesiveness • Parenthood • Pregnancy • Religious affiliation • Social support

23. Warning Signs Suicide is associated with a tetrad of warning signs 1. The wish to die (as a way to end suffering or facilitate a reunion with lost loved ones) 2. The wish to kill (the aim to cause the destruction of others, as well as oneself) 3. The wish to be killed (a form of reaction formation—i.e. “I don’t hate you; you hate me”) 4. The wish to be rescued (a sign of ambivalence; a desire to prove they are loved and desired)

24. The following signs are often present in suicidal patients. Talking about wanting to die or to kill oneself Looking for a way to kill oneself (e.g., searching online suicide sites, buying a gun) Talking about feeling hopeless or having no reason to live Talking about feeling trapped or in unbearable pain (physical or emotional) Talking about being a burden to others

25. Unwillingness to provide enough information for clinician to assess suicide risk Increasing use of alcohol or drugs Acting anxious or agitated Behaving recklessly Sleeping too little or too much Withdrawing or isolating oneself Showing rage or talking about seeking revenge Displaying extreme mood swings

26. Presentation Four types of suicide cases are commonly encountered in the emergency department 1. Patients who report suicidal ideation 2. Patients who just survived a suicide attempt 3. Patients presenting with other, usually somatic complaints but in whom suicidal thoughts are discovered during a comprehensive evaluation 4. Patients who deny suicidal ideation but whose behavior (or family’s report) suggests suicidal potential or risk

27. Components of suicide assessment 1. Conduct a thorough psychiatric evaluation a. Identify specific psychiatric signs and symptoms b. Assess past suicidal behavior, including intent of self-injurious acts c. Review past treatment history d. Identify familial history of suicide, mental illness, and dysfunction e. Identify current psychosocial situation and nature of crisis f. Identify patient’s psychological strengths and vulnerabilities

28. 2. INQUIRE ABOUT SUICIDAL THOUGHTS, PLANS, AND BEHAVIORS a. Elicit the presence or absence of suicidal ideation b. Elicit the presence or absence of a suicide plan c. Assess the degree of suicidality , including suicidal intent and lethality of plan d. Understand the relevance and limitations of suicide assessment scales

29. 3. Establish a diagnosis 4. Estimate the suicide risk 5. Develop and administer a treatment plan 6. Determine the most appropriate treatment setting 7. Provide education to patient and family

30. 8. Monitor the patient’s psychiatric status and response to treatment 9. Obtain consultation, if indicated 10. Reassess safety and suicide risk

31. 11. Ensure adequate documentation and risk management a. Detail general risk management plan and document issues specific to suicide b. Limit the use of suicide contracts c. Communicate with pertinent parties, especially patients’ clinicians and significant others d. Implement mental health interventions for surviving family and friends after suicide

32. Evaluation of attempt Suicidal communication before attempt Precaution taken to avoid discovery Intent to die Type of attempt(planned or impulsive) Was the method chosen dangerous Reaction to survival

33. scales Columbia suicide severity rating scale is a suicidal ideation and behavior rating scale Scale for assessment of lethality of suicide attempt(SALSA scale) Beck's  Suicide Intent Scale   is a risk assessment instrument using 15-items designed to examine both subjective and objective aspects of the  suicide  attempt, such as the circumstances at the time of the attempt and the patient's thoughts and feelings during the attempt

34. Treatment Most suicides among psychiatric patients are preventable, because evidence indicates that inadequate assessment or treatment is often associated with suicide. Some patients experience suffering so great and intense, or so chronic and unresponsive to treatment, that their eventual suicides may be perceived as inevitable

35. Primary Prevention PSYCHOEDUCATION AND TRAINING OF HEALTH CARE WORKERS Over 75% of patients who committed suicide had contact with primary care providers within the year of their death, but only one-third had contact with mental health services Therefore, caregivers should be trained in the recognition of conditions associated with high suicidal behavior, risk factors, warning signs, and basic knowledge of intervention modalities.

36. DIAGNOSING AND TREATING PEOPLE WITH MENTAL DISORDERS A thorough history of current and past psychiatric symptoms is necessary.

37. ADDRESSING SUBSTANCE USE DISORDERS Management of substance abuse and alcoholism is pertinent to primary prevention of suicide.

38. REDUCING ACCESS TO THE MEANS OF SUICIDE presence of firearms at home assorted medications or other lethal substances  instead of hanging the fan by a hook to the ceiling use of four springs hinged to the shaft of the fan and ceiling, such that it will allow an additional weight of 25kg. If a person tries to attempt suicide, the weight increases and the spring uncoils and the person will land safely.

39. Treatment Interventions RISK REDUCTION THROUGH HOSPITALIZATION Individuals at high risk of imminent suicide should be hospitalized . 1. Key issues regarding imminent suicide risk are intent and means, Severity of psychiatric illness, the presence of psychosis or hopelessness a lack of personal resources, older age among men

40. 2. Because interrupting a suicide has been proved effective, psychiatric holds are useful. The psychiatric hospitalization should allow for a more extended period of observation by trained personnel.

41. 3. Once hospitalized Monitor closely ensure the patient’s safety at all times, especially during the first few days One-to-one sitter supervision (especially if admitted to a medical floor for stabilization after a suicide attempt)

42. 4. Voluntary admission should first be offered, but if this is turned down, further assessment is required to determine the potential need for an involuntary hospitalization

43. Close Monitoring But No Hospitalization When patients have elevated but not imminent suicide risk, they can be discharged home with close observation by family or friends. 1.not a viable option for patients who lack a support structure, those too unstable or psychotic who have already exhibited dangerous or self-injurious behavior.

44. 2. If a patient is to be discharged home, all potential lethal means must haven been removed or secured. These include firearms, medications, and other potential methods to commit suicide. 3. Involvement of family, friends, or other support systems is imperative.

45. 4. A patient’s reluctance regarding clinical contact with care providers or support system is cause for concern

46. 5. Despite the extensive use of safety contracts in clinical practice, there is little evidence that such contracts actually reduce suicide a patient’s unwillingness to “contract for safety” should be an indication that the patient may not be safe in an outpatient setting and that hospitalization may be necessary.

47. Initiating Pharmacotherapy if Indicated Psychopharmacological treatment should be initiated (or restarted in nonadherent patients) It is important to educate the patient regarding the lag between medication initiation and symptom relief the possibility of adverse effect and the risk of sudden discontinuation of pharmacological agents (e.g. serotonin, benzodiazepines

48. Secondary Prevention Identification of High-Risk Patients Close Follow-Up and Ongoing Prevention of Suicide Adequate treatment of any underlying psychiatric disorder through pharmacological agents, psychotherapy, and family interventions is essential.

49. Patients should be discharged with a treatment plan, which includes appropriate referral for follow-up close monitoring of mental status and response to pharmacological treatment, including potential adverse effect involvement of family members and/or significant others, if appropriate and with the patient’s Consent

50. Regularly scheduled office visits may improve the patient’s medication continuation

51. Development of a Suicide Prevention Action Plan Review it with the patient or assist the patient in starting to develop one. The goal of this plan is to help guide the patient, or those within the patent’s support structure, through difficult moments of crisis.

52. Provision of Contact Information Important types of resources that can be provided to patients with current or a past history of suicidal ideation include outpatient mental health referrals and crisis/suicide hotline information

53. Psychoeducation An educational campaign should be directed at patients, their families, and physicians, with the objective of improving the psychiatric (e.g., antidepressant,mood -stabilizing, and/or antipsychotic) treatment they are receiving.

54. Responsible Media Reporting 1. Inform the audience without sensationalizing the suicide. 2. Use school, work, or family photographs, rather than graphic images of incidents. 3. Keep details of the suicide to a minimum.

55. 4. Use the reporting opportunity to educate the population about the warning signs of impending suicide, provide tips as to what a person should do if he or she suspects that someone may be suicidal, and provide information regarding assistance (e.g., suicide hotline number, crisis intervention contact information).

56. CLUSTERS OF SUICIDES The media sometimes gives intense publicity to “suicide clusters” - a series of suicides that occur mainly among young people in a small area within a short period of time. These have a contagious effect especially when they have been glamorized, provoking imitation or “ copycat suicides ”. A  copycat suicide  is defined as an emulation of another suicide that the person attempting suicide knows about either from local knowledge or due to accounts or depictions of the original suicide on television and in other media. A spike of emulation suicides after a widely publicized suicide is known as the Werther effect.

57. Emerging trends- Covid 19 pandemic

58. Widely reported studies modelling the effect of the covid-19 pandemic on suicide rates predicted increases ranging from 1% to 145%(ref . bmj 12 nov 2020), largely reflecting variation in underlying assumptions There has been an increase in self-harm and suicide ideation among people since the Covid-19 pandemic hit, says a study ‘ COVID 19 BLUES’ conducted by Bengaluru based Suicide Prevention India Foundation (SPIF)

59. A selective approach for subgroups at increased risk for suicide, for example, for individuals with a history of psychiatric disorders, persons with symptoms of significant emotional distress, COVID-19 survivors, frontline health care professionals and elderly people. Active outreach is necessary, especially for people with a history of psychiatric disorders, COVID-19 survivors and older adults.

60. People with psychiatric disorders should be advised to continue their treatment regimens and to stay in touch with their mental health professionals. Some psychiatric patients may need adjustments in their treatment and increased frequency of contact with their mental health clinicians.

61. TELEMEDICINE can improve accessibility of mental health care. Also, vulnerable individuals should be advised to limit watching, reading or listening to traditional and social media news stories.

62. Up-to-date and valid information regarding the COVID-19 outbreak can reduce these fears. Similarly, symptoms suggestive of COVID-19 infection are associated with psychological distress, and patients with such symptoms should be evaluated for features of anxiety and depression as well as for suicide risk

63. Elderly suicides in India: an emerging concern during COVID-19 pandemic These unprecedented times have put the mental health of the elderly at higher risk of relapse as they are already susceptible to melancholy and disquietude Susceptible to both the infection and its psychosocial implications

64. Family interventions with social cohesion may lead to improving the mental health of the elderly, which can be referred to as a phenomenon of resilience

65. Suicides in medical professionals Suicide among doctors is a complex, multi- factoral issue that has been plaguing the country for decades now. Studies from across the world indicate that suicide rates among doctors are higher than in the general population. Among physicians, psychiatrists are considered to be at greatest risk, followed by ophthalmologists and anesthesiologists, but all specialties are vulnerable.

66. Public health policies must aim at improving social work environment and contribute to screening, assessment, referral, and destigmatization of suicides in physicians Further, adequate quantity and quality supplies of PPE, COVID-19 compliant work practices and infection control measures are required to harmonize and reduce the burden of further stress and suicidal ideation

67. Steps by government DECRIMINALIZATION OF SUICIDE According to the Section 115 of Mental Healthcare Act (MHCA), 2017, suicide attempters are presumed to have severe stress, not to be punished and the government should have duty to provide care, treatment, and rehabilitation to reduce the risk of recurrence. Decriminalization might lead to openly seeking help, improvement in epidemiological data, better planning, and resource allocation

68. On August 27, 2020, the Central government, in a first, launched " KIRAN "— a mental health rehabilitation helpline number (1800-599-0019) — that intends to provide early screening, first-aid, psychological support, distress management, mental well-being and psychological crisis management. The helpline will be managed by the Department of Empowerment of Persons with Disabilities ( DEPwD ). The line is operational and open to calls on a trial basis

69. AASRA  is a Mumbai-based mental health  NGO  which is noted for operating a  24 HOUR Helpline  to cater to suicidal and emotionally distressed individuals. The service is an offshoot of  Befrienders Worldwide and Samaritans , whose India chapter was established in 1960.

70. Steps by himachal government Various webinars organised at IGMC - ‘ Working together to prevent suicide ’ on World Suicide Prevention Day, September 10 Focussed on getting help that can be sought at 104, the medical helpline of the state government. Facebook page named Stress / depression/addiction management by Department of psychiatry ,IGMC Helpline number provided by the Department of Psychiatry

71. Thank you