INTRODUCTION:

Suicide is an important psychiatric emergency which needs immediate intervention. It is one of

the most common causes of death. Approximately 95% of all persons who commit or attempt
suicide have diagnosed as mental disorder.

EPIDEMIOLOGY OF SUICIDE:

An estimated 1 million people worldwide die by suicide every year. It is estimated that global
annual suicide fatalities could rise to over 1.5 million by 2020. Globally, suicide ranks among the
three leading causes of death among those aged 15–44 years. Attempted suicides are up to 20
times more frequent than completed ones. WHO figures show a suicide takes place somewhere
in the world every 40 seconds.

The National Crime Records Buru (NRCB) recently published a report which is great matter of
concern for our country. It is reported that in the year 2016, in every hour fifteen persons (both
male and female) and one person in every four minute committed suicide. In India the total
number of suicidal case for that year was 1,31,008; among them 68% are male.

DEFINITION:

Suicide – defined as an act with a fatal outcome that is deliberately initiated and performed by
the person in the knowledge or expectation of its fatal outcome. It’s a complex phenomenon,
Insurmountable disparity between expectations and outcomes, real or imagined – tremendous
pressure on mind, blinding its logic, forcing it a conclusion of escape.

Derived from Latin word (sui = oneself , cidium = a killing), it means death caused by self-
directed injurious behavior with any intent to die as a result of behavior.

Suicide attempt: A nonfatal self-directed potentially injurious behavior with any intent to die as
a result of the behavior or any self directed actions taken by the individual that will lead to death
if not interrupted .A suicide attempt may or may not result in injury.

Aborted suicide attempt: Acts or preparation toward making a suicide attempt, but before
potential for harm has begun. This can include anything beyond a verbalization or thought, such
as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by
suicide (e.g., writing a suicide note, giving things away).

Suicidal ideation: Passive thoughts about wanting to be dead or active thoughts about killing
oneself, not accompanied by preparatory behavior.

Self-harm: An act with nonfatal outcome, in which an individual deliberately initiates a non
habitual behavior that, without intervention from others, will cause self-harm, or deliberately
ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and
which is aimed at realizing changes which the subject desired via the actual or expected physical
consequences.

Suicidal behavior: Includes suicide, suicide attempts, aborted suicide attempt and preparatory
acts.

Suicidal gestures: It is a suicide attempt directed towards the goal of receiving attention rather
than actual destruction of the self

Suicide threat: It may be veiled but usually occurs before overt suicidal activity takes place.

Completed suicide: It is the death from self inflicted injury, poisoning or suffocation where
there is evidence that the decent intended to kill himself or herself.

TYPES OF SUICIDE

In 1951, Emi Durkhiem classified social categories of suicide.

Egoistic suicide: Response of the individual who feels separate and apart from the mainstream
from the society. Integration is lacking and the individual does not feel a part of any cohesive
group.

Altruistic suicide: It is the opposite of egoistic suicide. The individual is excessively integrated
into the group. The individual will sacrifice his/her life for the group.

Anomic suicide: It occurs in response to changes that occur in an individual’s life that disrupt
feelings of relatedness to the group eg: Loss of job, divorce

Samsonic suicide or suicide of revenge: To spite others or experiencing as being unfriendly.

For example, if husband is unfaithful to his wife she may attempt to commit suicide to take
revenge.

RISK FACTORS OF SUICIDE

Marital status: Suicide rate for single persons is twice that of married persons. Divorced,
separated, or widowed persons have rates four to five times greater than those of the married.
Gender: Women attempt suicide more, but men succeed more often. Successful suicide rates
about 70% for men and 30% for women.
Age: The rates rise sharply during adolescence, peak between 40 and 50 years, level off until age
65years.
Religion: Depressed men and women who consider themselves affiliated with a religion are less
likely to attempt suicide than their non- religious counterparts.
Socio economic status: Individuals in the very highest and lower social classes have higher
suicide rates than those in the middle classes.
Ethnicity: With regard to ethnicity, statistics show that whites are at highest risk for suicide
Psychiatric disorder: Major depression and bipolar disorder, substance abuse, schizophrenia,
personality disorder, anxiety disorder, eating disorders, conduct disorders in adolescent.
Familial history: History of suicide, family history of suicide

RISK FACTORS FOR SUICIDE IN SPECIAL POPULATION:

 Hospitalized depressed patients
 High level of anxiety
 First week of admission, First month after discharge
 Elderly patients
 Death of loved one’s
 Patient’s with alcoholism
 Lose of dear ones
 Substance use
 Late in course of illness
 Depressed adolescent
 Loss of significant relationship
 Co-morbid substance use
 Prior suicide attempt
 Family history of major depression
 Previous anti depressant treatment
 History of legal problems
 Incurable disease
 Financial and occupational difficulties

PROTECTIVE FACTORS AGAINST SUICIDE

 Ability to cope with stress
 Learned skills in problem solving, conflict resolution and non violent handling of dispute
 Effective and appropriate clinical care for mental, physical and substance abuse disorder
 Support for help seeking for medical and mental health care relationship
 Restricted access to lethal methods
 Cultural and religious belief that discourage suicide and preservation instinct
 Family and community support
 Ongoing sense of hope in adversity
THEORIES OF SUICIDE
Psychological theory
Anger turned inward: Freud believed that suicide was a response to the intense self-hatred that
individual possessed. Freud believed that suicide occurred as a result of an earlier regressed
desire to kill someone else. He interpreted suicide to be
an aggressive act toward the self that often directed towards others.

Hopelessness: Carroll-Ghosh and associate, Beck, Brown also found a high correlation between
hopelessness and suicide.

Hopelessness With desperation an individual feels helplessness to change, but he or she also
feels that life is impossible without change. Guilt and self recrimination are other aspects of
desperation.

History of aggression and violence: Some studies have indicated that violent behavior often
goes hand-in-hand with suicidal behavior.

Shame and humiliation: Some individual have viewed suicide as face saving me status or
income.

Developmental stressors: The stressor of conflict, separation and rejection are associated with
suicidal behavior in adolescents and early childhood. The principle stressor associated with
suicidal behavior in the 40-60 years old group is economic problem. Medical illness plays a
significant role after age 60.

Sociological theory:
A difference in group cohesiveness is an important socio-cultural variable of suicide. French
sociologist Durkheim (1951) has conducted a very valuable and illuminating study in this regard.
He believed that the more cohesive the society, more the individual felt an integral part of the
society, the less likely he or she committed suicide. Durkhiem classified social categories of
suicide-
 Egoistic suicide
 Altruistic suicide
 Anomic suicide

Biological theory
Genetics:
Several studies indicate, a genetic factor in suicide. In a study, among 51 monozygotic twin pairs
there were nine cases of suicide. In the same way, in another study, 26 suicides were committed
in just 4 families.
Neurochemical factors
Serotonin deficiency was found in a sub group of depressed patients with attempted suicide. A
few other studies have also indicated ventricular enlargement and abnormal EEG in some
suicidal patients.
Analysis of blood sample of a group of normal volunteers for Platelet Moredamine Oxidase
indicated that those persons with the lowest level of this enzyme in their Platelets had eight times
the prevalence of suicide in their families compared with persons with high levels of enzyme.
Thus, there is a strong evidence for an alteration of Platelet M.A.O. activity in depressive
disorders.

MANAGEMENT OF SUICIDAL CLIENT

Assessment

Assessment of the patients with suicide tendencies is done through detailed psychiatric
evaluation and mental status examination .While conducting assessment of clients with
suicidal tendencies, adequate information should be collected on the present psychiatric
diagnosis, past experiences of client, family history, stressors, presence of support systems
and any life stage issues. Nurses should identify suicide gestures, ideas or acts in the patient.

Demographic assessment:
Age, Gender, Ethnicity, Marital status, Socio economic status, Occupation, Method, Religion,
Family history

Presenting symptom
Assessment must be gathered regarding any psychiatric or physical condition for which the client
is being treated.

Suicidal ideas/acts
How serious is the intent? Does the person have a plan? How lethal are the means? These are the
questions to be answered by the nurse conducting the assessment. Nurse should be alert when the
client:
 Talks about death, suicide, and wanting to be dead, and appears to be in deep thought;
 Asks suspicious questions such as, "How often do the night personnel make rounds?"
"How many of these pills would it take to kill a person?" "How high is this window from
the ground?" "How long does it take to bleed to death?" and so forth;
 Fears being unable to sleep and fears the night;
 Is depressed and cries frequently;
 Keeps away from others due to self-imposed isolation, especially in secluded areas or
behind locked doors;
  Is tense and worried and has a hopeless, helpless attitude;
 Imagines he or she has some serious physical illness such as cancer or tuberculosis feels
very guilty about something real or imaginary or feels worthless talks or thinks about
punishment, torture, and being persecuted;
 Is listening to hallucinating voices; (The voices may tell the person to try to take his or
her life.);
 Suddenly seems very happy, without any apparent reason, after being very depressed for
some time (The person may be happy now that she or he has figured out a method of
committing suicide.);
 Collects and hoards strings, pieces of glass, a knife, or anything else sharp that might be
used for self-harm.
 Is very aggressive or very impulsive, acting suddenly and unexpectedly
 Give away costly things to others.
 Make will.

Interpersonal support system:

Lack of a meaningful network of satisfactory relationship may implicate an individual as a high
risk for suicide in emotional crisis.

Analysis of the suicidal crisis:

 The precipitating stressor: Adverse life events in combination with other risk factors
such as depression, emotional disturbance include the loss of a loved person, problem in
major relationship, change in role, serious physical illness.
 Relevant history: Numerous failure or rejection increase his or vulnerability for a
dysfunctional function in current situation.
 Life stage issue: The ability to tolerate loss and disappointment is often compromised if
they occurred in various developmental stages.

Psychiatric/ Medical/ Family history:

The individual should be assessed with regard to previous psychiatric treatment, chronic or
terminal illness, family history of depression and suicide.

Coping strategies:
How does the individual handled the previous crisis situation.

Nursing diagnosis:
 Risk for suicide related to feelings of hopelessness and desperation
 Hopelessness related to absence of support systems and perception of worthlessness.

Outcome identification:
The client:
 Has experienced no physical harm to self.
 Sets realistic goals for self
 Expresses some optimism and hope for the future

Intervention for the client with suicidal tendency

The nurse should have adequate knowledge of necessary precautionary measures for prevention
of suicide and should immediately effectively intervene in such situations.
A. Precautionary measures
B. Management of attempted suicide in the inpatient setting
C. Emergency measures to be instituted in case of suicide

A. Precautionary measures

a. Providing a safe environment:

 Remove all potentially harmful objects from the environment such as materials on
cleaning carts, their own medications, sharp scissors, pen, knives, sharp objects, belts,
hairpins, nail cutter, lighter, matches, rope from the client’s environment.
 Clothing and bed linens are removed from the room because these items have been used
to attempt suicide by hanging.
 Ensure all windows are meshed with the rods on the external side of the mesh, so that the
patient cannot access the rods.
 Keep the medications in the ward under lock and key away from the patients reach.
 Perform periodic/ surprise checks in the patient room for presence of potentially harmful
objects.
 Inform supervisors, concerned authorities about any structural defects in the ward which
can aid in any potentially harmful acts.

b. Supervision and monitoring

Suicide precautions and level of observation vary according to the client's intention of
suicide and established protocol of the facility or agency providing care.
 Close observation of the patients with suicide tendencies round the clock is mandatory.
 Do serial mental status examinations.
 Find out if the patient has a well formulated suicide plan.
 Be alert about decreased communication, conversations about death, low frustration
tolerance and dissatisfaction with dependency.
 Elicit suicidal, homicidal ideas or gestures from the patient or any changes in mood and
report to the concerned doctor, colleagues and next shift nurses and document
 For clients with high potential lethality, one-to-one supervision by a staff person is
initiated.
 Take all suicidal threat, gesture and attempt seriously and notify a psychiatrist.
 Clients are under constant staff observation with no exceptions. This may be frustrating
or upsetting to clients, so staff members may need to explain the purpose of such
supervision usually more than once.
 Enhance observation by informing all hospital personnel in the ward about such
patients.
 Do not leave the patients alone at any time. Ensure that someone accompanies the
patient for meeting his basic hygienic needs.

c. Enhancing therapeutic nurse patient relationship

 Build adequate rapport with the patient.
 Ensure that the patient develops trust in the nursing personnel.
 The patient should be encouraged to discuss freely his feelings.
 Spend time with the patients to facilitate ventilation of his/her feelings.
 Provide guidance and counseling if required
 Be aware of the nonverbal communication
 Encourage and support the clients' expression of anger /emotions.
 Teach problem solving skills, social skills and self care activities. Do proper
documentation of facts and patient observations in the nurses' record.

d. Initiating a No-Suicide Contract

The nurse can implement a no-suicide contract with the patient to prevent the occurrence of
suicide. In such contracts, clients agree to keep themselves safe and to notify staff at the
first impulse to harm themselves (at home, clients agree to notify their caregivers; the
contract must identify backup people in case caregivers are unavailable). A list of support
people who agree to be readily available should be generated. These contracts are not a
guarantee of safety. Contracts also can specify when clients will be re-evaluated.

e. Seclusion and restrain

If the client is very agitated, the hospitalized client may require confinement to a comfort
room to allow staff to observe the client's behaviour more readily. The door to the
seclusion room is locked whenever the client is left alone, and frequent, periodic checks are
made according to established protocol. The use of restraints may be necessary to
immobilize agitated, self-destructive clients. When restraints art necessary, periodic checks
(Eg, every 15 minutes) are made to assess and document the client's location, behaviour,
interventions to meet the client's needs, and the reason for the continued use of restraints.

f. Interactive Therapies
 Interactive therapies, such as cognitive behavioural therapy, family therapy, group therapy,
dialectical therapy etc are provided to help the client explore the reasons behind suicidal
ideation, improve problem solving skills and prevent relapse of symptoms.

g. Medication Management
 The use of psychotropic medication to manage behaviour is referred to as chemical
restraint.
 Various psychotropit drugs are used as the "drugs of choice" in the treatment of suicidal
or self-injurious behaviour.
 ECT is useful for treatment of suicidal client
 Administer SOS medications as and when required and inform the psychiatrist.
 Keep resuscitation trolley in the ward containing medications for medical and
psychiatric emergencies.

h. Creating a support system

The nurse must assess the support systems and the type of help each person or group can give a
client. Mental health clinics, psychiatric emergency evaluation services, student health
services, church groups, and self-help groups are part of the community support system. The
nurse offers a list of specific names and agencies that clients can call for support.

i. Family Education
 Explain suicide precautions to the family members.
 Help the family members to recognize changes in mood or behaviour that could
indicate a plan for self-injury (E g, irritability, anger, agitation, withdrawal, or self
deprecating comments) and notify the client's health care provider.
 Inform that every suicidal ideation, gesture, impulse or attempt should be taken
seriously.
 Advise family members to be always supportive and non judgemental with client.
 Explain to the family members about the disease condition of the patient if any,
encourage them to clarify all their doubts regarding care of the patient.
 Advise family members to have continuous supervision of the patient.
 Advise the client and the family on the need for drug compliance and follow -ups.

B. Management of attempted suicide in the inpatient setting

Attempted suicide is a psychiatric and medical emergency.
 Do not panic or raise an alarm on being informed about a suicide attempt.
 Act with the most speed and in a coordinated manner, not only to help the patient who
has attempted suicide patient but to protect the wellbeing of other clients.

a. Attempted overdose
  In psychiatric wards, the most likely means of attempted self-poisoning involves
building up a stock of prescribed medication or bringing tablets to be taken at a later date
(e.g., while on leave of absence).
 Try to ascertain the type and quantity of medication taken (look for empty bottles,
medication strips, etc.) and establish the likely timeframe
 Check airway, attempt to clear airway if necessary.
 Turn the clients head and neck to one side to prevent regurgitation and swallowing of the
vomitus.
 Examine the clients pulse and vital parameters, if the pulse is weak, start IV fluids.
 If patient is unconscious, significantly drowsy, or at medical risk, arrange immediate
transfer to emergency medical services
 Inform medical team about the patient's diagnosis, current mental and physical state and
current medications.
 Do not try to induce vomiting.
 If available, consider giving activated charcoal (single dose of 50g with water) to
reduce absorption (esp. if NSAIDs/acetaminophen). Immediately notify the doctor and
shift the patient to the emergency department depending on the vital parameters.

If patient is asymptomatic, and significant overdose unlikely:

 Monitor closely (general observation, level of consciousness, evidence of

nausea/vomiting, other possible signs of poisoning).
 Perform routine blood investigations (CBC, electrolytes, LFTs, HCO3, INR) and request
specific serum levels after the ingestion of the drug. (4 hr post ingestion for
acetaminophen).
 Urgent serum levels (e.g., lithium, anticonvulsants) need to be checked.
 Be aware that baseline LFTs may be abnormal in patients on antipsychotic or
antidepressant medication.

b. Self-injurious behavior
Most episodes of self-injurious behaviour involve superficial self-inflicted injury (e.g.,
scratching, cutting, burning, scalding etc.) to the body or limbs .Any significant injuries
(e.g., stabbing, deep lacerations) should be referred to emergency medical services, with
the patient returning to the psychiatric ward as soon as medically fit.

Medical advice should also be sought if:

  Lacerations are to the face/other vulnerable areas (e.g., genitals) or where you cannot
confirm absence of damage to deeper structures (e.g., nerves, blood vessels, tendons).
 The patient has swallowed/inserted sharp objects into their body.
 The patient has ingested potentially harmful chemicals.

c. Attempted hanging:

On being summoned to the scene

 Support the patient's weight (if possible enlist help).

 Loosen/cut off ligature.
 Lower patient to flat surface, ensuring external stabilization of the neck and begin usual
basic resuscitation (Call a code, ABCs, IV access, etc.).
 Emergency airway management is a priority:
 Where available, administer 100% 02.
 If indicated arrange for emergency nasal or oral endotracheal intubation.
 Assess consciousness level, full neurological examination, and degree of injury to soft
tissues of the neck.
 Arrange transfer to emergency medical services as soon as possible.

d.Attempted asphyxiation
 Remove source (ligature, plaitic bag, etc.).
 Give 100% 0 2 .
 If prolonged period of anoxia or impaired conscious level, arrange immediate
transfer to emergency medical services.
 Once the patient is fit for interview, formally assess mental state and conduct assessment
of further suicide risk.
 Establish level of observation necessary to ensure patient's safety, clearly
communicate your decision to staff, and make a record in the patient's notes and
elsewhere based on the facility's policy.

e. Orthopedic injuries (fall from a height)

 Immediately shift the patient to emergency department with adequate care during
shifting.
 Stabilize the spine and place collar around the neck.
 Maintain adequate oxygenation and ensure airway maintenance.
 Assess for blood loss and provide IV fluids

Whatever be the modality,

 Clients have to be reassured arid taken away from the scene of the attempt as soon as
possible.
 Do not panic and reassure the other staff.
 Inform the senior staffs and doctors.
 Support the patients' attenders /relatives.
 If attenders /relatives are not present at the site, inform them immediately.

3. Emergency measures to be instituted in case of suicide

 Check for evidence of life by checking the pulse/respiration.

 If there is no evidence of life leave the body in the same position/room in which the
body was found.
 Immediately inform the doctor and the senior staff.
 Transfer all clients who are in the vicinity of the incident from the room.
 Inform the police as soon as possible.
 Even in case of completed suicide by jumping from a height, ensure that the body is not
removed until the photographer has taken photo and the police have seen the body.
 Place an attendant on duty outside the room where the body is kept.
 Contact the local guardian immediately and inform them about the client's condition.
 Ensure safety of the other clients, monitor them and check for disturbances in their
behaviour.
 Can hold a meeting with other clients and encourage venting.
 Venting is done to help all the staff who had care for the patient to have relief through
catharsis.

Follow Up Action

 Clean the place where the body was found with a strong disinfectant.
 Transfer the belongings of the deceased from room.
 The body will be usually handed over after post-mortem in the presence of the police.
 Follow the statutory regulation regarding the institution of an unnatural death and
carryout the necessary formalities and obtain death certificate.
 The senior nursing staff should discuss the incident in detail with all the staff and
reassure them. The discussion should focus on possible lapses and preventive
measures that need to be undertaken.
 It may be necessary to arrange a specific, "critical incident review" or Psychological
Autopsy where all staff involved in the care of the patient, participate in a confidential
debriefing session. This is not to establish blame, but rather to review policy and to
consider what measures (if any) might be taken to prevent similar events occurring in the
future.
Intervention of families and friends of suicidal victims:

 Encourage the family members to talk about the suicide ,each responding to others view
point and reconstructing of events. Share memories.
 Be aware of any blaming or scapegoating of specific family members
 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 relationship with the lost loved one-
both positive and negative aspect of relationship. Gradually point out the irrationality of
any idealized concept of the deceased persons.
 Recognized how the suicide has caused disorganization in family coping. Discuss the
coping strategies that have been successful in crisis of past and identify new adaptive
coping strategies that can be incorporated.
 Identify resources that provide support: religious belief, spiritual counselors, close friend,
support group.

Evaluation

Evaluation of the suicidal client is an ongoing process accomplished through continuous

reassessment of the client, as well as determination of goal achievement. Once the immediate
crisis has been resolved, extended psychotherapy maybe indicated. The long term goal of
individual or group psychotherapy for the suicidal client would be for him or her to-

 Develop and maintain more positive self concept

 Learn more effective ways to express feelings to others.
 Achieve successful interpersonal relationships.
 Feel accepted by others and achieve a sense of belonging.

LEGAL ASPECT IN SUICIDE

As per IPC Section 309- attempt to suicide can lead to one year imprisonment and fine Section
306- abetment to suicide lead to ten years of imprisonment

SUICIDE PREVENTION STRATEGIES

 Decreases availability of lethal weapons
 Limitations on sale and availability if alcohol & drugs.
 Increased public and professional awareness about depression and suicide.
 Less attention and reinforcement of suicide behavior in media.
 Community based crisis intervention clinics
 Campaign to decrease stigma associated with psychiatric care.

CONCLUSION
Suicide is one of the most common psychiatric emergency, which to a greater extent can be
prevented by the vigilance of caregivers at home and health personnels in the hospital. As part of
the mental health team, it becomes important for every psychiatric nurse to take necessary
precaution to prevent the occurrence of suicide, be efficient in the management of client with
suicidal tendency and promote the health of individuals.
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