ASSIGNMENT ON

ASSESSMENT, PREVENTION, AND INTERVENTION

RELATED TO SUICIDE ACTS. 
Introduction

The epidemiological and sociodemographic transition along with improving health care
reforms has brought injuries to the forefront of healthcare delivery systems in India. Among
them, suicide has been a leading cause of mortality, morbidity, and socioeconomic losses. At
global level, suicides are one among the four leading causes of death and one among the six
leading causes of burden of disease in the age group of 15-44 years. During the year 2000,
108,000 individuals completed suicides in India with an incidence rate of 11/100,000 per
year, an increase from 40,000 in 1970. It is estimated that nearly 7-10 times this number have
attempted suicides, as real numbers are not known due to lack of reliable population-based
epidemiological studies. The major causes of completed suicides as per police records were:
illness (35.7%); family problems (13.7%); alcohol-related problems (8.4%); financial
problems (5.6%); and marriage-related problems (3.5%).

Suicides in India are different from those reported in high-income countries, even though
some commonalities are observed in the pattern and causation of suicides. Suicides occur due
to a complex interaction of social, economic, cultural, psychological, and biological factors
on an individual maladaptive platform. The interaction and effect of these factors are often
cumulative, repetitive and progressive over a period of time, driving an individual to states of
helplessness, worthlessness and hopelessness in an environment of deficient or absent support
networks and coping mechanisms. The complex web of causative interactions and pathways
has been unresolving in nature for the affected individual, resulting in a chain of events
moving from a mild to a severe state. The strong presence of psychosocial problems due to
unresolved interpersonal conflicts between family members has been cited as a major
precipitating factor in Indian descriptive studies. These conflicts, primarily with spouse,
parents, and children, had resulted in severe dysfunction of the individual, amidst weak
family support systems. Occupational and economic problems are closely linked to suicide
from the early days of classical work by Durkheim. Presence of unemployment, temporary
jobs, chronic work absenteeism, sudden economic bankruptcy, presence of large loans and
poverty were major risk factors in the present study. Most of the Indian studies and even
national data report a higher prevalence of suicide in lower socioeconomic groups. These
observations are in accordance with several studies reported from developed countries and
from Asian regions. In a country with more than a billion people, nearly one-third living
below the poverty line and two-thirds living in rural areas, economic stressors are
undoubtedly a major issue. Most suicide victims had mean income levels of less than Rs.5000
per month, were employed in unskilled and skilled categories, had larger families, and were
residing in deprived environments. In contrast, the economic liberalization and chaotic
urbanization has widened the gap between 'haves' and 'have nots' resulting in greater
discrimination. These two diverging scenarios coexist in a society marked by culture-
determined issues like dowry deaths (often due to economic demands). Hawton et al.
observed a close association between socioeconomic deprivations and deliberate self-harm,
more marked in socially fragmented areas, Cheng et al, in a case-control study from Taiwan,
observed that unemployment and consequent economic problems were closely linked to
suicides. Once again it should be noted that many factors, such as employment, income,
social status, etc, are intricately interlinked resulting in the merging of boundaries between
factors. Violence within and outside the family has been identified as a risk factor in suicide
causation.

Domestic violence had an increased risk of suicide by nearly six times in the present study.
Domestic violence was defined as: 'Any act of gender-based violence that results in, or is
likely to result in, physical, sexual or psychological harm or suffering to women, including
threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public
or private life' as defined in the declaration on the Elimination of Violence Against Women of
The UN General Assembly in 1993. Physical and emotional abuse were often present
together in the series. Suicidal persons experienced bouts of violence from their partners and
other family members, frequently resulting in physical injuries. The respondents openly
remarked that the deceased could not tolerate violence any more in their given environment.
It was surprising that the majority did not seek help from any health or legal agency for their
problems due to stigma and fear of harming the family reputation in their neighbourhoods.
Detailed investigation failed to elicit clear and reliable responses for sexual abuse, as it was
not revealed to even their closest family members. Alcohol contributes both directly and
indirectly in suicidal mechanism.

Alcohol dependency per se is a mental health problem affecting judgement, thoughts,

emotions and reactions. The easy availability prepares the individual for unbiased mixing of
organophosphorus compounds or drugs. Indirectly it is related to greater violence,
deprivation of basic socioeconomic needs of family, loss of income and large loans within the
family. A previous history of suicidal attempt and a family history of completed suicides were
present in 13 and 8% of the cases, indicating high-risk behaviour of this group. the majority
of the subjects had not received any social, emotional or psychiatric help after the previous
attempt, either on their own or through family members. Closely linked to all these factors
was the presence of major negative life events in the recent past acting as precipitating or
causative factors, which have also been implicated in suicidal causation.

Depression, alcohol and substance abuse, mood and personality disorders and schizophrenia
are highly linked with suicide. Without using any diagnostic instruments, we observed the
risk increased by nearly ten times with the presence of an unclassified mental illness. The
presence of a mental disorder was based on the behaviour of the deceased as observed by the
respondent over a period of time prior to death. The symptoms ranged widely from simple
anxiety features to extreme mood and behavioural problems. Further, nearly 78% were
undiagnosed and untreated by any mental health or other professional, as these individuals
did not contact any caregivers. Detailed investigation revealed that the family had not felt the
need for any treatment and attributed the same to ongoing crisis situations often combined
with social stigma.

Assessment

Suicidal ideation, or suicidal thoughts, means thinking about planning suicide. Thoughts can
range from a quick consideration to a detailed plan. Some people may experience suicidal
thoughts once in their lifetime, while others may experience suicidal thoughts on a routine,
even daily, basis for a short or long period. It is important to access and identify people with
suicidal ideation before they actually perform it.

A thorough suicidal ideation risk assessment should be culturally sensitive where cultural
barriers and biases, expectations about communication, the role of self-disclosure,
perceptions about the problem, causes of suicide, and preferred decision-making approach
were considered. Fully explore buffers and protective factors against suicide. Consider the
range of protective factors that may exist for each person. It should also be explorative, fluid,
collaborative and strengths based and also should follow a welcoming, compassionate, and
non-judgmental reception. Suicidal ideation risk assessment is a process of determining how
seriously someone is thinking about and/or planning for a suicide. It involves the following
five steps:

1. Identify Risk Factors:

Trauma: Current and past physical, sexual, or emotional abuse and/or trauma.
Triggering Events: Factors, stressors, or interpersonal triggers, especially those
leading to humiliation, shame, despair, or loss.
 Ideation: Presence, duration, and severity of thinking about death or ending life.
These could be current or from the past.
Medical Health: Current and past medical health concerns or diagnosis, especially a
new diagnosis or worsening symptoms.
Mental Health: Current and past mental health concerns or diagnosis, especially with
recent discharge from mental health treatment or hospitalization.
Chemical Health: Current and past substance use disorders, especially with recent
discharge from substance use disorder treatment or substance-related hospitalization.
Substance Use: Any significant change in pattern of use, or current/past use.
Past Suicidal Behavior: Past suicidal thoughts, attempts, failed attempts, or a family
history of suicide.
Self-Injurious Behavior: Current or past injury to self.
Trapped: Feeling of inability to escape current situation. Examples could include
domestic violence, financial debt, health condition that feels inescapable, etc.
Purposelessness: Presence, duration and severity of feelings of no reason for living or
no sense of purpose.
Hopelessness: Presence, duration, and severity of hopeless feelings.
Withdrawal: Removal from friends, family, and society, isolation, or living alone.
Anger: Rage, uncontrolled anger, or seeking revenge.
Recklessness: Engaging in risky behavior, seemingly without thinking.
Mood: Any significant change from baseline, especially when demonstrating
increased anxiety, agitation, lack of self-control, or impulsivity.
2. Identify Protective Factors
Effective clinical care
Access to a variety of interventions and support.
Connectedness
Support
Skills
Cultural and religious beliefs
3. Conduct Suicide Inquiry
Ideation: Frequency, Intensity and Duration
Plan: Timing, Location, Lethality, Availability/Means
Behaviour: Past attempts, aborted attempts, rehearsals
 Intent: Extent to which they expect to carry out the plan and believe the plan to be
lethal versus harmful.
Notes
4. Determine Risk Level
5. Determine Intervention: The intervention should be based on the Scope and role,
Available resources and referrals, policies and procedures.

Prevention

Suicides are multifactorial and hence the approaches to prevention must be multipronged, by
macro and micro level initiatives aimed at individual, family, and societal levels. Some of the
risk factors are universal and some unique operating in a socio-culturally defined
environment. The realities of suicidal pathways and causation indicate that suicide prevention
must be based on an integrated, coordinated, intersectoral approach with prioritization of
programmes in the current sociocultural environment. It is very crucial for India to develop
socio-culturally relevant and feasible strategies, which can be incorporated into broader
health, education, and welfare programmes.

 Larger macro level initiatives in terms of bridging socio-economic inequalities,

greater occupational and income-generating opportunities, educational reforms, clear
policies on alcohol production, distribution and sales are immediately required.
 Restricting the easy availability of organophosphorus compounds and drugs will go a
long way in reducing suicide.
 Improving emergency care in rural and semi-rural areas and establishing a good
network of referral services between general and mental health professionals will be
of immense benefit.
 There is an increasing need for the training of medical and allied personnel for
identification and better management of those with mental health problems (especially
depression and alcohol dependence).
 A greater participation of the media by scientific reporting and rational analysis will
be of immense benefit for carrying preventive efforts to the people.
 Follow-up support and care to individuals attempting suicide will be a major
intervention to be undertaken in the Indian region.
  Understanding suicidal risk factors needs well-designed population-based studies.
Since there are no proven, cost-effective, sustainable suicide prevention programmes
in India, demonstration of pilot projects needs immediate attention.
 Amidst a plethora of strategies, prioritization for optimal use of resources needs
special mention along with sensitization of policy-makers and politicians.
 At the individual and family level, improving skills to recognize and deal with crisis
situations, strengthening family interactions, early identification, and management of
individuals with alcohol and other mental health problems, increasing accessibility
and improved utilization of mental health services, reducing domestic violence
through individual and family interventions and psychosocial support for violence
victims are some key steps required for reducing suicide.
 Crisis intervention mechanisms of establishing telephone helplines in urban areas,
augmenting social support systems, promoting life skills education in schools also
need consideration in both urban and rural areas (Gururaj et al., 2004).

Management of suicide includes screening for suicidal ideation or behaviors, performing an

assessment of the individual’s current risk of imminent harm, and creating a treatment plan in
collaboration with the patient and any involved supports. This process needs to be
individualized, collaborative, and completed using a calm, cooperative, and curious interview
style.

The Patient Health Questionaire-9 (PHQ-9) is a quick, subjective reporting scale that can
be incorporated into the medical record. Affirmative responses to item 9 regarding thoughts
of death or self-harm have a hazard ratio of 10 and 8.5 for attempts and deaths in a
community setting, respectively.

The Columbia Suicide Severity Rating Scale (C-SSRS) is a public forum questionnaire that
can help screen for suicide and form a detailed account of an individual’s suicidal ideations or
behaviors. It is easy to administer with minimal training, available in multiple languages, and
easily included in an electronic medical record. There is no current consensus on who should
be screened for suicidal ideation or plans. The World Health Organization (WHO) currently
recommends that all individuals over the age of 10 with any mental health disorder, epilepsy,
interpersonal conflict, recent severe life event, or other risk factor for suicide should be asked
about thoughts or plans to self-harm or attempt suicide (Bolton et al., 2015) (Weber et al.,
2017).

specific complaints or patient characteristics may warrant suicide screening. These include:

 Changes in mood, including any depressive symptoms, emotional distress, anger,

irritability, or aggression

 Anxiety or agitation

 Sleep complaints.

 Evidence of unpredictable or impulsive behavior

 Sudden change in life circumstances

 Increase in alcohol or other drug use

 Increasing healthcare utilization, including hospitalizations, office visits, and

emergency room visits

 Therapy non-adherence, including medications, physical therapy, and psychotherapy

 Presentation because of family/friend – more than 50% of individuals who presented

to primary care providers before suicide were convinced to do so by family or friends

After screening has identified an individual at risk, a formal suicide risk assessment should
occur with the following goals: identify modifiable and fixed risk factors, identify protective
factors, clarify the current level of suicidal intent and planning, and estimate the current risk
as low, moderate, or high to guide treatment and disposition.

Interviews between care providers and suicidal patients need to maintain or enhance the
therapeutic alliance. All assessments should be conducted with curiosity, concern, calmness,
and acceptance of the individual’s current emotional and cognitive state. Patients with
suicidal ideation may feel hopeless, desperate, or cognitively overwhelmed, interfering with
their ability to comprehend and convey these thoughts to others. Clinicians should stay
attuned to their own reactions that may be non-therapeutic, such as hostility, avoidance of
negative feelings, or the blurring of professional roles, possibly to take on a savior role (Rudd
et al., 2006).

Intervention
Individuals with suicidal thoughts, plans, or behaviors may benefit from a variety of
treatments. If the patient is at risk for suicide, a plan that integrates a range of biological and
psychosocial therapies may increase the likelihood of a successful outcome. Choosing among
possible treatments requires knowledge of the potential beneficial and adverse effects of each
option along with information about the patient’s preferences.

1. Pharmacotherapy:
a) Antidepressants
b) Lithium
c) “Mood-stabilizing” anticonvulsant agents
d) Antipsychotic agents
e) Antianxiety agents

2. ECT
3. Psychotherapy:
a) Psychodynamic and psychoanalytic psychotherapies In patients with suicidal
behaviors, experience with psychodynamically and psychoanalytically oriented
psychotherapies is extensive and lends support to the use of such approaches in
clinical practice. Research data on the effects of these therapies in suicidal patients
are more limited but supportive.
b) Cognitive behavior therapy: Given the evidence for the effectiveness of cognitive
behavior therapy in treating depression and related symptoms such as
hopelessness, it might be expected to also be of benefit in the treatment of suicidal
behaviors.
c) Dialectical behavior therapy: DBT is a form of cognitive-behavioral therapy
(CBT) originally designed to treat suicidal and self-harming people who meet
criteria for borderline personality disorder. Bohus and colleagues explain that
DBT maintains the behavioral treatment components of skills training and change
motivation, but there are components that make it distinct from traditional CBT.
Specifically, DBT is a change-focused behavioral treatment; the dialectical
approach of DBT utilizes an acceptance focus when a patient feels misunderstood
and adopts a change focus when a patient needs motivation.
d) Collaborative assessment and management of suicidality: CAMS is a suicide-
specific therapeutic framework that is described as “non-denominational” in that a
 range of theoretical orientations and clinical techniques can be incorporated into
the approach. CAMS adopts a phenomenological approach to understanding a
patient’s suicidality, which leads to suicide-specific treatment planning that
emphasizes the use of an outpatient stabilization plan and the identification and
treatment of patient-defined suicidal “drivers”. Within CAMS-guided care,
collaboration is the key to enhancing the therapeutic alliance and motivating the
patient as a pivotal member of the treatment team. Central to CAMS is the use of
a multipurpose assessment, treatment planning, tracking, and outcome tool called
the “Suicide Status Form” (SSF) that serves as a clinical road map and guides this
suicide-specific intervention.
e) Other psychosocial interventions: Stabilization-oriented interventions,
Motivational interviewing for suicidal ideation, Attempted suicide short
intervention program.

Conclusion

The assessment and management of suicidal patients is challenging and further complicated
by a limited number of efficacious approaches. It is hoped that management will improve as
the science of suicide prevention progresses and the number and quality of studies increases.
Nevertheless, current evidence shows that several clinical practices can improve the
management of suicidal people. Given that risk assessment tools to date are limited in their
predictive ability, it might be best to focus efforts on developing effective low resource
intensity interventions that acknowledge a high false positive rate. An important first step is
to appreciate the heightened risk in specific clinical populations and the temporal association
between suicide and service discharge. It is also crucial to recognise the established risk
factors such as a history of self harm. Finally, when determining a treatment approach,
clinicians should consider suicidal thoughts and behavior as an important therapeutic target.

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