Embed Size (px)
Citation preview
.IXAININ<; R1ODUI.E FOR SOCIAL WORKERS1
MENTAL HEALTH PROFESSIONALS
CONTENTS
SEC:TION - 1 . TIlE NATURE OF Sl!ICIDE Concept of Suicide Terminologies and Purpose Causes Risk E>aluation
. . Classification of Suicide Characteristics of Suicide Early identification Observed behavioral patterns Assessment Treatment Management Strategies
SECTION - XI. THE ROLE O F PROFESSIONALS IN PREVENTION Physician's role Psychiatrist's role Psychologist's role Educationalist's role Social worker's role
SECTION - I l l .SOCIETIES ROLE TO \\.'ORE3 PREVENTION Cornmuni~ '~ role National Policy Media's role
SECTION - IV. MYTHS AND FACTS General iLl) ths Common facts Myths rols to contribute to suicide ( Role of myth in Suicide)
SECTION - V REHAVIOIIIWL hlETHODS IN PREVENTION
This training module is developed with the aim of understanding concept,
risk, assessment, intervention and rehabilitation of suicide attempters. This training
module development is through adopting three strategies: The three strategic adapted
are ( I ) based on the literature(2) consultation with experts on these field and(3) based
on the present study findings.
Suicide is a global tragedy., taking away 50,00,000 lives every year. Every
seven minutes there is a suicide. As it is under reported because of social stigma
attached it, the actual figure is more than estimated. it occurs among all groups.
Suicide is a major Public health problem, 10,000 people killing themselves in world
every year, 10% of all deaths is due to suicide. It has been observed that among the
Indian states, the highest suicide rate is in Kerala during the last few decades. 55%
had given a hint about their suicide 113 had made obvious suncide threats, and 113 had
received adequate antidepressant in adequate dosage.
This manual is intended to guide the professional social workers in early
identification and management of suicidal behaviour.This manuel is useful to
ProFessionals working in the area of suicidologist, such as clinician, educators,
priests, epidemiologists. Its major focus is on the information on suicidal behaviour.
Concepts of Suicide.
On completion of this section, the social workers will be able to answer the
following questions.
1. What is suicnde"
2 . What are the nature and prevention of Suicide?
3 . What are the main causes of su~cide?
4. What are the main approaches to management?
The three broad categories of Suicide
Completed Su~cide (CS)
Attempted Su~cide (AS)
Suicidal Ideation (SI)
Completed Suic~de (CS) includes all deaths in which a willfull, self- inflicted, life
threatening act has resulted in death.
Para-suicide or suzczdal attempt 1s as "Every act of self injury consciouly aiming at
self- destructton
Suicidal ldeatlon 1s frequent intense, or proiclnged thought about suicide in one who
has not attempted suiclde ever, but only nourished the idea about suicide.
Suicide intent is the seriousness or intensity of the wish of a patients to terminate his
life.
Suicidal behaviour include completed suicide, non fatal deliberate self-harm (eg:
attempt. gestures, Para suicide, self injury, self poisoning, suicide
communication including su~cide threats, and suicidal Ideation.
Causative factors:
Suicide does occur Not a single factors, it due to Multifactors. So
Multidisciplinary approach is essential for prevention, treatment & rehabilitation.
Psycho-social factor may be directly or indirectly related to suicidal
behaviours in any of three ways
- Predisposing
- Prec~prtating
- Psycho-social factors
A person or mediating agent suicidal behaviour under certain conditions, early
loss and certain Personality characteristic such as neuroticism and impulsivity are
generally viewed as predisposing.
Psychological factors may act as precipitating or direct causal factors in suicidal
behaviour eg. Llfe events.
3
Third, Psycho-social factors may be epiphenomena1 in other words they may be
related to phenomenon such as depression.
RISK EVALUATION
Risk factors can be helphl in identi@ing suicide risk. If intervention can be
started early we can prevent suicide to some extent. The major risk groups are:-
- Life events especially recent events and early loss such as that of a
parent during childhood due to death, divorce or legal separation.
- Bereavement, a prominent stress which precedes suicide.
- Depression ,6 - 15% (MDP approximately 30 times risk) most of them
during first 10 years. Several studies indicate that in many depressives
who committed suicide there had been inadequate assessment,
treatment or both.
It is responded that 2i3 of suicide victims had seen a physician or
Psychiatrist in the month before suicide.
55% had given a hint about their suicide ideation.
- 113 made an obvious su~cidal threat.
- Psychiatric patients are of 3 - 12 times greater risk than non Psychiatric
degree of risk which ~ar ies with age, sex, diagnosis, chronicity and
many other factors.
- Other Psychological disturbances such as anti-social personality, eg,
bullylng . stealing, truancy and other emotional symptoms or
"emot~onal instability".
- Family history: - high concordice rate for schizophrenic and manic
depress~ve illness.
- Alcoholism -- Alcohol use and alcoholism are high risk for suicide.
6- 20 percent alcoholics commit suicide.
- Physical and Psychological problems. Social deprivation and previous
parasulc ~ d e
The largest sub group of alcoholic are those with associcated antisocial
personality.
Alcoholrc who has fewest social, economic and interpersonal resources
to support are psychologically more disturbed than others.
The following factors increase alcoholic suicide risk rate at high level
Depressive illness is more common among females- relatives of
alcoholic
Self destructive and aggressive personality.
Sense of guilt feelings.
The alcoholic with a history of parasuicide has a poor prognosis,
impulsiveness and impaired capacity to cope with stress, recurrent
feelings of' failure, isolation, hopelessness depression and separation,
little orlentation to the future and some death might seem the relief with
a hangover or severe withdrawall symptoms
Alcoholics kequently threaten to commit suicide more than half first
talked it over a year before their death.
12% had communicated 6 weeks before the attempt.
The nature of interpersonal disruptions report in order of their
tiequency and they have more of marital separation or divorce, breakup
of an erotic relationship.
Several medical illness, cancer.
Suicide prone alcoholic will be Psychologically more disturbed than
others.
Alcoholic experience an increase anxiety and depression during
intoxicat~on
Other Psychopathology, alcoholic with dual Psychiatric diagnosis as
anti social personality disorde:r, boderline personality disorder, h/o
suicide attempts, generalised anxiety disorder and post tranautic stress
svndrome also contribute to suiciide
5
- Aicohol~c ~mpulsivit); and low frustration tolerance on anxiety &
Psychtat~c complication
- H~dden suicide ideation.
- Alcohol~c homosexual or heterosexual activity may cause AIDS.
- Alcohol~sm affect family system. It is an important factor depression
and suicide in the family
- In addition social problems on increase.
Whai can we do he& them - Increase Support systems include the family , School, work place,
professionals, organisation etc.
- Identi6 h~gh risk group and refer to professionals.
- Physician assisted programme may help to prevent the high groups
attempt
Personality
Suicide attempters and suicide completers appears to differ in their personality
characteristic, and attempters have the more disturbed personality profiles.
- Attempters are usually women below 24 years, more often neurotic /
personality disorder
- Su~cide completers tend to be mare men and older age groups.
- Lowered or negative self esteem in both suicide & parasuicide.
- BIIPwith great self-destruction behaviour among most of the attempters
- Higher mortality in neurosis & Personality disordres
- Secondary depression related antisocial personality
- Antisoc~al personality disorder and criminology are predictors of
recurrent attempts.
- Attempters with "Psychopathic States" found that the majority of
attempters had previous attempts.
Hopelessness & He&lessness are closely associated with depression, the more
hopelessness people feel is their situation concerning the conditions in their life that
6
burden them. So evaluators need to assess strengthen feelings, they are affected by
faulty perception . and glve more importance to negative aspects in life and ignore.
Positive element. Evaluators need to take note integrity of reality testing and whether
they are able to see anything good, hopeful or worthwhile in themselves,
hopelessness is an Important clue that should alter clinicians to long term suicide
potential.
Social support, soc~al support is the perceived support, a subjective evaluation that
significant others are caring and available in times of need and instrumental in
providing a sat~sfylng relationship,and stress reducing .
Experience of Loss, loss is the central issues in depression as the most cause of
suicide, loss of parent, divorce, separation, loss of viriginity, courmpt as sex, eiends
& lovers. The loss become more serious when it is interpreted as a rejection.
Unemployment, the incidence of unemployment is sured males dying by suicide, was
3 times, and the sulc~de rate of unemployment was 5 times in males. Psychiatric
disorders due to unemployment, lack of work are more risk for suicidal behaviour
History of prior suicide attempt People who have already attempted suicide atleast
once are far more likely to attempt it again
Schizophrenic depresswe symptoms response to hallucinations or delusion associated
with suicide as h~gh risk among young males, single, previous attempt , recent
discharge from hosp~tal.
Physical illness :-Many persons with chronic:, painful or terminal illness to end their
suffering prematurely by taking their own lives, such as rat~onal decisions to commit
suicide are relatively rare.
- Phvsical ~llness bring on a severe depression
- Suicide accounts only 0.5% of males and 0.2% females
- Prevalence varies from 25% to 70% T.B & Parkinsonism are
respectively 10 to 200 times.
- Cancer I5 times, reumatoid arthritics 5 to 7 times, Peptic ulcer 2-5.
- 30% Psychiatric Patients were physically ill before committing suicide.
- Higher incidence among epileptic.
Some of the physical disease are often contribure suicide attempt
- Disease of central nervous system.
- Epilepsy
- Multiple sclerosis
- Head injuries
- Cerebrovascular disease
- Huntington's Chorea
- Other disease of CNS, eg: Cerebral tumors, Dementia, Paralysis agitans
- Cancer
- Gastrointestinal disease
- Other gastrointestinal disease, eg, Cirrhosis of liver and
gallbladderdisease, hepatic cirrhosis.
- Urogenital disease
- Cardiovascular disease and hypertension
- Respiratory disease
- Musculoskeltal disease
- Endocrine disease
- Other conditions such as anorexianemosa, Klinefelter's syndrome, and
acute intermittant perphyris intermittent porphyris, other conditions to
control distress symptoms, particularly severe pain.
Genetic Factors
- Family hrstory of suicide
- First degree of relatives of Psychiatric Patients
- Hlg concordance rates for schizophrenic & Manic depressive illness
C1,ASSIFICA'TION OF SUICIDE
Classification is no use in the clinic where the task is saving lives but examine
how the Socio-Cultural context influence the risk of suicide
In 1967 Douglas classified according to six Eundamental dimentions of the initiation
of the act (that lead to death) the willing (of self destruction). , the loss (of will) the
motivation ( to be dead ) and knowledge ( ofthe death potential of the act). Some of
the classifications are:
- Altrusric Suicide -result from excessive integration is determined by
society. Egoistic: determined by a lack of meaningful family ties or social
interaction
- Eugostic- determined by a lack of meaningful family use or social
interaction
- Anomic-occurs when the relationship between and individual and society is
broken by social or economic adversity.
- Rational : to escape pain
- Reaction , following loss
- Vengefui to punish someone else
- Man~pulat~ve to thwart others pair1
- Psychot~c to hllfill delusuion
- Acc~dental re cons~dered too late
- Ludic referlng to games and play
- Man~cal due to halluc~nation or delusion escape from imaginary danger
9
- Anx~ety su~c~de through out sad, depressed, w~th constant increasing
anxlety
- Others are dynamic orgeneratic, escapist, aggressive, oblative (obligatory)
Seasonal trend in suicide
Monthly peak occurance of suicide
More - May, April, June
Less - September, August, January
Spring and summer peaks for women
Common characteristics of features of committed suicide
In Millers iivmg system ment~on some common features of sulctde , each
s u ~ c ~ d e IS an ~diosynoratic event In some suwcrde these are no un~versals, absolutes,
and other features are
The common purpose of suicide is to seek Solution
The: common goai of suicide is cessat~on of consciousness
The common stimulus (or informatic on input) ia suicide is intolerable Psychological pain
The common stressors in suicide is iiustrated 1)sychological need
The common emotion in suicide is hopelessness - helplessness
The common internal attitude in suic~de is ambivalence
The common cognitive state in suicide is constriction
The common acuon of suicide is escape
The common interpersonal act in suicide is cornminication of intention (80% of
suicide)
The common consistency in suicide is with life long coping patterns.
OBSERVED BEHAVIOURAL PATTERNS
These symptoms must been present nearly every day for a period of at least two
weeks they may attempted suicide.
1 . Poor appetite or significant weight loss (when not dietient) or increased
appetite or significant weight gain.
2. Insomnia or hypersomnia
3. Psycho- motor agitation or retardation (but not merely subjective feelings of
restlessness or being slow down).
4. Loss of interest or pleasure in usual activities or decreased in sexual drive not
limited to a per~od. When delusional or hallucinating,
5. Loss of energy. .Fatigue
6. Feelings of worthlessness, sei6 repoach or excessive or in appropriate guilt
(either mav be delusional)
7 . Complaints or evidence of diminished ability to think or concentrate such as
slowed t'h~nking or indecisioness not associated with marked loosening of
associations or incoherence.
8. Recurrent thoughts of death, suicidal ideation wishes to dead, or suicide
attempt
They may be unable to recognise the signs or the association between
depressed feehngs and actual behaviour
Most studies describing depression and mania indicate ratio of depression
around 6 . 1
WHY DEPRESSED COMMIT SClCIDE :'
The mildly depressed persons suffers from feelings of poor self images,
inadequate and "the blue"
The person often concerned about having some medical illness and about dying.
These thoughts are frequent , repetitive and difficult to avoid for any significant
period of time
In most depressed feel more or more \vorthless and less and less hopeful. The
problems of mcreased slowness & sluggishness of movement (Some experience
opposite motor ag~tation of speech, sometimes to the point of muteness, inability to
think, to concentrate, to feel emotion and feeling that head is empty delusion such as
incurability, self blame, illness of a punishment for sin and hallucination are also
encountered. Two th~rd of suicide victim had seen by physician or psychiatrists in the
month before suicide
55% had glven a hind about the suicide: to someone at sometimes and one third
made an obvious suicidal threat and 113 received depressant adequate dosage.
Don't ignore if any one show the symptoms.
Early identification
Suicidal Signs
Threat of suicide : The belief that those who threaten suicide are less like to do, it is
supported that threats of suicide represent attention seeking behaviour ,
especially among the young, most adolescence who do make suicide attempts
have proceeded the act with some form of warning to others. Suicidal
communication are very significant in indicators Psychological distress. Some
12
of them are less depressed quite happy but immediately commit attempt
suicide.
Depression : 1s the key sign of suicidal potential, depression becomes a critical
importance as a sign of suicide not by its mere presence, but by its severity and
its persistence
The follow~ng signs of behaviour changes, mood changes, loss of previous
interest, risk taking behaviour, changes in appearance and drug & alcohol use, poor
appetite due significant weight loss., insomnia or hypersomnia. Psychomotor agitation
or retardation, sublectlve feeling or restless or being slowed down, decreased sexual
desire, loss of energy, fatigue, feeling of worthlessness, self-reproach or excessive
inappropriate guilt complaint or dimmished ability to think or concentrate recurrent
thought of death.
Reckless behaviour : Keckless, potentially self-destructive behaviour has been noted
before su~cidal behaviour.
Drug and Alcohol use : substance abuse that consistently signals strong likelihood of
serious problems.
Giving away profession : This signs rarely ;among adolescent suicidal behaviour.
This is probably of two reasons. First, adolescence suicide behaviour is so
frequently invested with a powerful desire to survive. Second, the suicidal
behaviour IS usually am impuls~ve act, derived of any extensive planning.
Social Withdrawal : As an important aspect of depression and signs of potential
suicides, difficulty to maintain peer involvement and social competence, the
ability to utilize energy , and social activity, though functioning in other areas
of may suffer Peer relations are a source of distraction from depression and a
source of criticai support.
Break in key Relationship : how to up and make and keep relationships take place,
accurate knowledge about sulcide is the first prerequisition to intelligent
assessment and appropriate intervention.
Individual Features
Suicidal lndicat~ons
The following are danger signals to suicide.
- Depressron with agitation or with persecuted thinking.
- Sleeplessness and painful preoccupation.
- Prev~ous suicide attempt
- morb~d thoughts with talk of death, accompanied by pointed question
such as flow many ,.. .. . of these tablet-would be dangerous ?
- Family history of suicide
- Ser~ous illness or one that is thought to be serious.
- an ~solated life with unconcerned relatives
- loss of lovei respecti trust
- alcohol~sm & drug addiction
- dreams and / paintings of disaster
- frequent quarrels , contlict at home
- loss of communication, isolation from family members
- Rqection by wifei parenti child/ siblingsi
- not providing adequately for the: family
- not tak~ng family responsibility
- Breaking rules at homes. job place
Attempted suicide (Parasuieide) attempts often result in a degree of relief and
frequently lead the individuals to seeking or getting help
ASSESSMENT : SOME FACTORS AFFEXTING THE RISK
1. Personal and social
male > female . age over 40
marital status . widowed, divorced or depressed;
Immigrant
social isolation
mode of liv~ng : alone, does not belongs to domestic group;
Occupation . unoccupied or unemployed, works in recreational services,
retired;
District socially disorganized urban areas, resort towns.
2. Previous h ~ s t o ~
Family history of affective disorder, suicide, alcoholism,
Previous history of affective d~sorder, alcoholism, suicide attempt;
Soon after onset : at the beginning of treatment, 6/12 following discharge from
active treatment.
3 . Life stresses
Bereavement and separations, moving house, loss of job;
In alcoholics. domestic and social complications of drinking,
In capacttating terminal illness in elderly.
4. Personabty
Reactive depression or depressive neurosis and recurrent depression
Sociopath ( ~mpulsive, violent. delinquent, borderline personality disorder)
Excessive dr~nking and drug dependency.
5. Psychiatric illness
Depression, notably manic - depressive and recurrent depression
Alcoholism and other addictions
Early dementia and confusional states in elderly
Organic brain syndromes ( epilepsy and head injury)
Combinarion of the above
15
Schizophrenia. suicidal death occur in delusional states.
6. Symptoms
Depresswe persistent insomnia; dejected appearance and weight loss, slowed
speech:
Loss of usual interests, listlessness and social withdrawal;
Hopelessness and Pessimism; Ideas of worthlessness
Agitation and restlessness
Suicidal thoughts
Alcoholic Medical and CNS complications
7 . Circumstances of an attempt
Precaution taken against discovery
Preparatory acts; precurring means;
Warning statements, suicidal note;
Violent methods and more lethal drugs1 poison etc.
8. Home environment & interpersonal relationship
Broken homes.
Lack of parental support
Disciplinary problems
Rejection
Bereavement
moving house
9. Affective d~sorder
Depressive illness 15%
mania w~th underlying depressed condition
Identification of high group among depressed patients
- symptoms of hopelessness, persistent insomnia,
self neglect, slowed speech, impaired memory, agitation etc.
- seventy of depression.
suicide risk has a negative correlation with coping styles
10 . Drug dependency & Alcoholism
Life time r~sk in hospital -treated alcoholic is 3-4 %
depressive disorder; antisocial personality
loss of key ~nterpersonal relat~onship
length of dr~nking history; currently drinking
1 1. Genetic factors
Family history of suicide
First degree of relatives of psychiatric patients
12. Physical illness
CNS disorder: C'VS disorder
Cancer
Endocrine disease
Genito urmary disease
Gastrointestinal disease
musculo skeiton disorder
Respiratory disorder, peptic ulcer,
AIDS; epilepsy. muiltiple sclerosis , head injury, cardiovascular,
Huntington chorea, dementia.
Biological factors
low CSF
certain serotonergic neurotram~tters
neuro endocrine functions
5-HIAA. I'SH. TRH
Others
17
ASSESSMENT I'Y SUICIDAL BEHAVIOUR
Prediction - it IS possible to predict suicide. The best way that can be done is to
identify groups at risk. The details of their actual plans for suicide ( if they have) need
to be discovered and assessed in considering lethal potential.
- The method of use in the suicide attempt that identify lethal intention.
The actual suicidal act may occur with minimal preparation or planning
General Prediction
Males are greater risk than females in general those in second half of life are
greater risk than young patients
- Women peak age 50 to 60 and those after decline
- Soc~ai sola at ion
- Both sex the divorced have the highest suicide rate
- Marital breakdown reflect Psychopathology in divorced individuals
- More r~sk on men widowed, women being childless
- Marr~ed least risk:- Physical illness, peptic ulceration may reflect
chron~c tension.
Prev~ous history of suic~de act.
Individual Features
The immediate or short term risk requires sensitive clinical assessment
Some of the main consideration as follows
The single most important clinical pointer is whether the partner is actively
entertaining suicidal intention at the time of examination.
- Patient may deny su~cidal intention, but other features may be
suspicious
- These deniel here need to be evaluated through other information.
- Pattents ,just recovered from dangerous parasuicide say they have no
suicidal intention . Since there is often a powerful cathartic effect
associated with self damage.
18
Many of the features already discussed as established as predictors of
suicide in the long term than the near hture, whereas a clinician of
course need to address the immediate situation with more urgency than
the distinct future.
Some of the main considerations are:
1. Whether the patient is already entertaining suicidal intention at the time
of examination.
- this question should be explored if the patients has presented as
the question should be raised if there is the slightest suspicious in a
clin~cians mind
- Fears that ventilating the subject: may make suicide more likely one to
tally misplaced while fallure to enquire may lead to missing a patient at
high risk
- Some patients will deny suicidal intention - but other features may
make the clinicians suspicious - to be evaluated in the same way as any
other ~tems of information
Eg- patient who has just recovered from a highly dangerous parasuicide -
since there is often a powefil cathatic effect associated with self
image.
2. Intensity of depression affect
- hopelessness, pessimism, about the future to be specified hopelessness
component of depression correlates more highly with suicidal intent
than does mood.
3. Patients whose suicidal ideas involve notions of reunions with a &ad
parent or spouse may be at particular hazards.
4. Family history, place, pi-ediction of repeated parasuicide, the genetic
affectwe disorder & aicoholism.
19
5. Depress~on or suicidal intent, history of recent phase and mood. Eg.
M D P patient mood swings develop very suddently and who may be
seriously suicidal in their depressive phase.
6. Soc~ai and interpersonal factors, isolation, living alone, reflect
Psychological hostile relationship in long standing marital conflict and
appropriate support in crisis time.
The mental health professionals to focus on reducing the individuals
hopelessness by social intervention. anti depressant drug or cognitive therapy. The
technique and assumption of cogn~tive therapy have been described in detailed by
Beck and Beck et ai ( 1979).
The depressed patients cognitive set is characterized by a negative self
concept and pervasively pessimistic view of the world and the future. He tend to be
preoccupied with issues of rejection, loss or deprivation.. The various errors of
thinking describes by Beck (1967') including over generalization, magnification, and
selective attention for negative experiences all contribute the patients conclision that
life is hopeless and that suicide may be an appropriate solution for his problems.
The goal d cognitive therapy is to alter the maladapative interpretation and
the belief that the pat~ents employees to guide his behaviour. In the course of C.T, the
patients negative cognition and misconceptions are monitored and elucidated.
Cognitive therapy aims to give the depressed patients some degree of mastery over
the way he think and teach him to substitute and employ reasonable and useful ways
of evaluations h~mseif and the world negative cognition that convey the patients
hopelessness and consequent suicidal wishes have been found to be amenable to
questioning and modltication.
20
Assessment oj' lethality (Suicidal risk)
1 . Episodic Suicidal Ideation and behaviour :- Suicidal behaviour may remit and
relapse both in response to the patients changing emotional and cognitive
states and his or her environmental. Either the patients, the environment, or
both may requlre intervention to protect the patients.
2. Ambivalence of the Suicidal Patient:- The balance between the patients wish
to live and wrsh to die must be evaluated, including the factors that tip the
balance one way or the other prior warnings given in 8 of 10 eventual suicides.
3. Risk factors (Predictor) :- The pati& ambivalence and the episodic nature
of suicidal behaviour allow for identification and prevention in many cases.
The following predictors may aid the physicians in determining both who is at
risk and to what extent.
[a] Demographic indicators:- Unemployed, divorced, above 45 years.
[b] Historic indicators :- recent loss, anxiety &depression
[c] Present illness :- Report of hopelessness, helplessness, loneliness,
wo~~ies , unexpected changes in behaviour., such as giving away possessions, or
unexpected changes in attitude, such as calm or overt and indirect talk of death must
be followed up with specific questions about fantasies, wishes, plans and means
[dl The extent to which the precipitating crisis is resolved or is being
resolved may influence the patients wish to remain alive and his or her attitude
towards the failures
4. History of suicide attempt.
5. Medical history
6 . Family h~storc
7. Diagnostic indicators include conditions of depression, thought disorder, and
impairment of impulsive control especially secondary to alcohol or dmg
abuse.
8. Present Mental status : Assess the severity of depression, the presence of
Psychosis. espec~ally command communications and any problems of impuls
21
control. In add~tion the clinicians should be aware of the patients response to
the interview. Does the patient feel understood, experience some relief, and
express more hopefulness, or does the Patients remain angry, pessimistic,
desperatal
Resources :- The availability and support of family and friends are critical to
understand
the perception of the patients lethality.
What can we do to keep them ?
- Strengthen support systems include family, school, work place
- Identify hlghest risk group and refer to professional.
- Phys~cian ass~sted programme may help toprevention -- of suicide or suicidal behavior. - -
INTERVEXT ION
- assessment of the suicidal act or ideas
- find support systems
- evaluation o i crisis
- assessment of the previous attempt.
Follow this steps
.- hospitalization
.- lowering arousal and distress medication may use
.- reinforcing appropriate communication
.- showing concerning, encouraging hope
.. contacting and arranging for support.
Crisis Counseling
Individual at low r~sk also offered this intervention directly
-. the difference from intensive care
22
- individual 1s seen as an adult with a problem and is not treated as somebody
who is s~ck
- the therapist limit his role the individual himself assumes responsibility for his
problem
The technique for intervention
1) Facilitating the expression of emotions
2) Helping to improve communicat~ons
3) Facilitating the individuals better understanding of his problems and feelings
4 j Showing concerning and empathy and bolstering self esteem
5) Facilitating problem solving behaviour.
PREVENTION
Suicide has multidimensional features. So prevention must be focus on
multidisciplinary orientation that include Psychobiological, Psycho-social,
Philosophical and Socio-cultural components have value in understanding the
etiology, treatment. nature and course of suicidal behaviour and prevention to
suicidal acts.
Epidemiological investigation must aimed to unique features of particular
individuals.
Public Education Model of Prevention :- A critical aspects of prevention involves
educating general public about recognizing of high risk individuals and most
importantly utilization of intervention and treatment services.
In preventive aspects self care functions that they proposed to include
Sufficient positive self esteem to feel onself to be with protecting
The capacltv to anticipate dangerous situation.
The ability to control impulses
Pleasure in mastering inevitable situations on risk.
Knowledge about the outside world onself for survival.
The ability to be self-assertive or aggressive enough to protect onself.
The ability to chose relationship with others who will enhances ones
protection implication for suicidal prevention focus on the fundamental
structure oftam~ly and social life.
Orginise suicide education programme to students, parents, teachers,
communlt!, workers etc.
Provide Counseling & Psychotherapy facilities
Crisis intervention provide by telephone.
Keep away tiom lethal methods.
Suicide Prevent~on Center (S.P.C)
Some tip for suicide prevention
- reduced avatlability of the means of suicide
- Provision of advice on coping strategies . .
- Changing pattern of Psychopathology
- Changing attitudes towards su~cide
- Changing in the social environment
- Reduced publicity about suicide on medias
- Avoid repet~tive on going or excessive coverage of suicide.
- Avoid s e d n a l coverage dramatic photographic of funerals, site,methods~tc .
- Precipitant factors, lurid headlines, glamorise suicide on news papers
Strategies in suicide prevention
- Communicate adequate care for young members
- Govt, pol~cy should implement
- Growing coverages through govt & other agencies
- Govt. must take plan of actions.
Strategies for treatment
(1) Crisis intervention
(2j Early detection and treatment of Psychiatric disorders.
(3) Public education and awareness
(4) Environmental intervention
(5) Nonphamacological therapy
(6) Phannaco therapy
MANAGEMENT OF SUIClDAL PATIENTS
- The great majority of suicides among Psychiatric patients are preventable.
- Evaluation for suicide potential involves a complete Psychiatric history.
- Examination o t mental states.
.- Enquiring about depressive symptoms, Suicidal thoughts, intent, plans &
attempts
.- Lack of future plans.
.. Giving away personal properly
-. Making a will or having recently experienced a loss imply increased risk
-. Assess the severity of depression and suicidal ideation.
- The patients and family ability to cope with stressful situation.
- Availability of Social support.
- The absence or presence of risk factors for suicide.
Outpatient or day patients management%
.- Social support system develop
-. Provide Psychotherapy
-. Behavioural Cognitive Therapy for depression.
-. Frequent appointment
-. The instructions about emergency services
- Collecting telephone number from patients.
- Removing lethal drugs & firearm prescribing medication only in weekly
supplies
Useful measures for the management of the depressed Suicide in.patient includes
Searching the Patients belongings
Should be managed on a locked ward where the windows and shetter : roof
Patients room should be located near the room of nursing staff
Anti depressant medication should be initiated vigorously
If no response to antidepressant, E.C.T can be considered.
Supportive Psychotherapy.
Psychotherapy of the suicidal patients should always be directive, Counseling
& reasoning.
Patients should be told not to become isolated, solitary.
If possible, not to stop normal social activities of work, but at the same time
not force him or help to be extroverted or extremely effective.
Depression is an illness, a natural reaction that depression implies symptoms
like the ones he or she actually has, that depression has often implies suicidal
ideation
that the states is time limited & responds to treatment.
the Psych~atr~st and clinical psychologist, is familiar with the problems.
26
What to do in emergency situation
- listen to them - listen some more and tell them "I don't want you to die" and
try to form a "no suicide contact'' ask them promise that they won't suicide
- Take person ser~ously
In emergency cases
- To seek proiess~onal help immediately
- Do they hake plan
- Do they have means
- Are they ready to do it
DISPOSITION AND GENERAL MANAGEMENT
Inpatient Care:- - Preferably. to treat as an inpatient
- To form a therapeutic alliance with the patients,
- Routines can be maintained whereby nursing staff kept the patients under
close observat~on
- They should maintain continuous but continuous observation and be
particularly aware of the patients need for assurance and supportant of changes
for better or worse, in the patients state. This in term implies force and
virtually hurting relationship between all members of the ward team.
.- It is also essential that the ward stratem should be clear and understood by all.
.- The furnishing of the ward should be governed by common i . .
(a) Ground floor accommodation is preferable
(b) Altemat~vely, windows should be designed as to open only partially.
27
(6) Ward totlets should be deslgned as a compromise between prlvacy and
the need for access in an emergency
(d) Male patlents should be encouraged to use electnc r w o r s
Out Patient Care
- first assess the absolute risk of suicide as judged by all of the criteria reviewed,
should be assessed as comparatively modest.
- Then patients should enjoy the close support of his family and fiiends.
- Relatives should be informed, that some risk of suicide exits.
- The patients own wishes should as always be elicited and seriously considered
- Specific quest~ons of the management of suicidal impulses, such as patients
confidence is controlling them. seeking help in a crisis etc.
.- Last, OP care would be appropriate, at least as an initial measures, for those
whose disorders might be excepted to respond fairly promptly to therapy.
.- Patients with depressive episode must always be assured of a line of support in
the future.
-. OP appointment should be regular & spaced at increasing intervals toward the
end of therapy ~
- The patient should that he or she may always make contact at any time should
he or she wish.
- The patient spouse is often overlooked, as the most important of all the
caretakers with whom the patient will come into contact.
General principles of Management
The therapy and general management of suicidal patient should be guided by 2
cardinal considerations
28
(1) Whether the patients is rece~ving adequate treatment for the disorder which
would have been diagnosed even in the absence of the suicidal ideas or acts.
Eg. Affective disorder, alchohol dependence or schizophrenia
Severe depression -+ ECT
- Small quantity of tablets should be prescribed at a time.
(2) Clinicians must try to establish a therapeutic relationship with the patients.
Eg. Provide some form of Psychotherapy.
- The patient should be help to focus his thoughts again on the possibility of a
future.
This can be promoted if small step can be taken in the course of every
encounter to affirm the few days or weeks to follow.
- Therapist should never allow himself to be involved in philosophical debates
as to whether life is worth liv~ng.
- Questions posed by patients in philosophical terms should be responded to by
persuit of the underlying feeling tone and its classification.
- Beck Cognitive Behaviour Therapy would be useful
SIJPPORT & FOLL,OW-UP
- It has also been noted that premature termination of contact may also be
associated with suicide even if there has already been substantial amelioration
of mood.
- Termination of therapy should occur by spacing of contacts rather than
abruptly and it should be fully discussed with both the patient and his future
'caretakers'
THE ROLE OF PREVENTION TO PROFESSIONAL
1 . Physicians role
- Physicians have a unique role
- Self-destrat~on rarely occurs absense of clinical illness
- Clinical condlt~on predispose
- So, half or more suicide have consult a physician with in a month.
- Identify the risk factors and groups.
- Identify Psycho-somatic complaint, substance abuse, hysteria, antisocial
personality
- Note neurotic complaints, anxiety, Psychosis and refer to mental health
professionals
- Well aware about environmental factors, stress, mood & affect of suicidal
behaviour
- Encourage to develop coping pattern.
- Suicide risk identify take to protect them.
If hospitalization refused or postponed, a serious effort must be made to reduce the
availability of lethal options, instructing the family.
- assess immediate risk, suicidal ideations, tell patientlrelatives
- encourage family members to communicate more free
- encourage to treat Psychological disturbance (if any)
- direct to Mental Health Professionals.
Psychiatrist role
- detailed assessment
.- drug therapy can be address if necessary.
Psychologist role
- evaluate nsk
- Psychotherapy & family therapy
- Strengethen family support
- Behavioural management
- Cognitive therapy
- Group therapy. copying skills training.
- Conduct self help group
- Educate public Professionals. (training or trainers)
- Regular and periodic follow-up
- Conduct research programme.
Social workers role
- conduct awareness programme for in grass root level
- home visit
- help to develop social skills.
- Arrange seminars and workshop for identified high risk group
Society's role
- misconception about suicide should be cleared away through public education
- harmful false assumptions prevented from culture, is talking about suicide
encourage it that stigmatization & prosecution are the best way to prevent.
.- Religious and social workers dlspel myths.
.. Service or Gnation take responsibility for public awareness
-. To provide opportunity for ventilation of feelings
-. Provide professional concern should press their colleagues and institutions
address eg. Local religious, social organizations, along with hospitals,
counseling centers.
- Form joint committee meeting with the help of profess~onals or institutions
3 1
- To remove still existing social and economic conditions that contribute to
increasing to the incidence of suicide poverty, spouse, abuse, demeaning
attitudes toward ages.
- To provide Psychotherapeutic help for low income group eg. SPC, Samaritans
etc.
- Try away from lethal methods.
- Facilitates follow-up programme, crisis intervention centers.
- Conduct goai oriented research programme.
Media's role
- Reduced publicity about suicide, restrict publicity especially young people
- Reporting only essential factors and undramatic fashion as possible.
Media can avoid the following situation
Avoid repetitive, ongoing or excessive coverage of suicide
Avoid sensational coverage of suicide.
Avoid luric head lines, decrease the prominence of news
Avoid dramatic photographs of funerals, site, method, precipitant etc.
Avoid coverage or depiction that amounts to a "how to do it" manual for those who
might wish to imitates the suicide.
Avoid presenting elaborate accounts of the victims, crisis -- which may justify others
acts
Avoid picturisation that legitimates alternation
Avoid coverage or depiction glorifies or glamorize and suicide.
Avoid coverage or depiction suicide is the best solution
Avoid protecting victims demonstrative suicide or self immolation in a politica1,a
martyrs try to change attitude to suicide.
32
If media managers follow these guide lines suicide prevention can be make easier
Community based su~c~de prevention programme
'The initial action could be initiated by an individual, grass root workers, adhoc
group of concerned citizens or leading NGO interested in group. Recommend step to
follow include, but are not limited to
-. initiates the process of knowledge about suicide behaviour include definition,
magnitude of the problems, epidemiologist, methods, service availability for
those at risk.
- Activities are generalized & support from interested parties (local, regional
and national)
- Members of the coalition should collectively revived the existing knowledge
on suicide behaviour and a detailed analysis of the problems should be and
prepared for distribution to members of the public and other potential
supporters
- Form a publ~c awareness strategy, using public forums, media coverage, and
print campaign
- Members of the coalition jointly organize a culturally acceptable strategy to
lobby, petition in influence govt. policy makers for national policy for
prevention.
Goals in suicide prevention
- Preventing premature death due to suicide across the life lifespan.
- Reducing the inc~dence and prevalence of other suicidal behaviour
- Reducing the mortality associated with suicidal behaviour.
- Providing opportunities and settings to enhance resiliency, resources,
interconnechons
Objectives
- Develop speciiic conceptual kame work for implementing, monitoring and
evaluation
- Adopt a standard taxonomy for suicide behaviour.
- Promote the early identification, assessment, treatment and referral of person
at risk of suicidal behaviour for professional care.
- Increase public and professionals access of information about prevention
- Promote support the establishment of an integrated data collections.
- Promote public awareness with regard to issues of mental well being suicidal
behaviour.
Consequences of life stress and effective crisis management
- Develop or maintain a comprehensive training programmes for identified gate
keepers.
Eg. Police, educators, ciergy, health workers, Mental health Professionals.
- Promote compresensive service for risk group
- Promote supportive rehabilitative service
- Reduced availability, accessibility and attraction of suicidal behaviour.
- Identify and establish institutions or agencies to promote and co-ordinate
research. training crisis intervention centers etc.
- Develop or modify relevant legislation and administrative - regulation for
implementat~on.
Procedure for the formulation of strategies
- As part of strategies to influence govt. policy makers.
- The coalition will need to device short and long term steps to sustain their
strategy
34
Co-ordinatlng body formulate and implement national strategies
The mandate of the coordination responsible for promoting, developing,
implementing. and co-ord~nating activities leading to the achievement of
national strategies objectives.
Co-ordinating committee execute financial and technical resources to ensure
effective and efficient formulation and subsequent achievement of national
strategy object~ves.
BEHAVIOURAL METHOD IN PREVENTION AND TREATMENT
The eifectrve cognitive behaviourai intervention in reducing cognitive
distortion, anxiety, depression and suicidal ideation, and increasing problem solving
skills.
lndividualised theraputic procedures like
- Cognitive therapy
- Behaviour modification
- Jacobson-s Progressive muscular relaxation
- Problem solving skillsicoping skills training.
Each client seen ior 30-40 minutes sessions and completed therapy there was
significant changes in cognitive distortions, hopelessness, anxiety, depression and
suicidal ideation
Treatment strategies should focus upon
- Keep sufficient positive self esteem
- Capaciry to ant~cipate negative situations
- Ability to control impulses
- Pleasure In mastering inevitable situation of risk
- Knowledge about outside world
- Ability to be self assertive or aggressive enough
- Ability to choose relationship with others.
Behavioural intewent1011s:-
1. Activity scheduling
2. Graded task assignment
3. Behavioural rehearsal
4. In vivo exposure
5. Relaxation, berthing exercise
6. Home work ass~gnment.
Myths and Facts
1. Talking about suicide decrease the risk : yes, express inner feelings to others
but intervention essential for the suicidal ideation groups
2. Gestures are serlous
3. Suicide attempt are cry for help - seek professional help
4. Discussing or asking questions about suicide- indicator of suicide
5. All such methods are equal lethal. It is based on methods,nature
6. Suicide runs in the families - high risk for suicide is family history of suicide
7 . Suicide is a cry for help.
intervention Techniques
1. Understanding idiosyncratic meaning of suicide
2. Questioning the evidence of dysfunctional thought
3. Reattribution
4. Decastartrophlzing
5. Fantasized consequences
6. Advantages and disadvantages of maintaining or changing suicidal belief.
Turning adversely to advantages
Labeling of distortion errors in self knowledge and thinking
Guided Assoc~ations
Paradox or exaggeration
Scaling
Replacement of imagery
Externalization of voices
Cognitive rehearsal
Self instructions
Thought stopping
Focusing
Direct d~sputation
Cogn,t;c.e dl~sonance. Examining options and alternatives
