SUICIDE & DELIBERATE SELF HARM

1. Term :

✓ Suicide :
- Self-inflicted death OR
- Act with fatal outcome (completed) which is deliberately carried out with the knowledge or expectation its fatality
✓ Parasuicide /Suicidal Attempt:
- Self harm with no attention of suicide/ end life OR
- Deliberately performed act which mimics the act of suicide without the fatal outcome (Attempted)

2. Epidemiology :

A. Global :

✓ 16 per 100,000 population (1.53 million)

✓ 800000 people die every year
✓ The second leading cause of death among 15-29 year olds globally
✓ 78% → low- and middle-income countries (2015)

B. Malaysia :

✓ 12 per 100,000 population

✓ M>F (2.9:1)
✓ Low educational level
✓ Factor : Indian race (I>C>M), single/Divorced, female
✓ Method : Hanging/strangulation/suffication (Most Common) , pesticides, jumping from high place

3. Risk Factors :

I) Epidemiologic factors

MD ZAKI MEDICAL NOTES

 ✓ Age: increases after age 14, second most common cause of death for ages 15-24, highest rates of completion in persons >65 yr (Dual
Peak Age)
✓ Sex: male
✓ Race/ethnic background: white or Native Canadians
✓ Marital status: widowed/divorced
✓ Living situation: alone; no children <18 yr old in the household
✓ Other: stressful life events, access to firearms, Chronic physical illness

II) Psychiatric disorders

✓ Mood disorders (15% lifetime risk in depression; higher in bipolar)

✓ Anxiety disorders (especially panic disorder)
✓ Schizophrenia (10-15% risk)
✓ Substance abuse (especially alcohol – 15% lifetime risk)
✓ Eating disorders (5% lifetime risk)
✓ Adjustment disorder
✓ Conduct disorder
✓ Personality disorders (borderline, antisocial)

III) Past history

✓ Prior suicide attempt

✓ Family history of suicide attempt/completion

IV) Psychoanalytic theory

✓ Represents aggression or hostility turned inwards against an ambivalently cathected love object

Others : Altruism (Killing oneself help the others), Reserved personality (Aggression and hostility turned inwards)

4. Prevention :

A. Primary :

MD ZAKI MEDICAL NOTES

 ✓ Restrict access to lethal methods
✓ Promote physical / mental health (Campaign)
✓ Law enforcement (Section 306, Section 309)

B. Secondary :

✓ Early identification
✓ Improve PCM care

5. History Taking :

I) Current suicidal ideation, intent and plan :

✓ History of suicidal attempts (Include details of each attempts – date, method used, circumstances of the attempt)
✓ Family history of suicide

II) History of mental Illness (Depression, schizophrenia, bipolar disorder, anxiety disorders and borderline personality) :

✓ Current depressive/anxiety symptoms and severity – hopelessness, anhedonia, severe anxiety, insomnia, impaired concentration,
psychomotor agitation and panic attacks are associated with suicide
✓ Current treatment regime and response
✓ Psychotic symptoms : Specifically commanding auditory hallucination, delusion of control and religious preoccupation
✓ Alcohol and illicit substance abuse/dependence
✓ Comorbid medical condition – especially disabling or painful medical illnesse

III) Recent life event : Separation, job loss, death

IV) Past/present history of aggression/ violence

V) Current living circumstances – social support, access to lethal methods

VI) Family member or next of kin contact details to obtain corroborative history and assess the safety of home situations

6. Management of Parasuicide :

MD ZAKI MEDICAL NOTES

A. Suicide Risk Assessment :

I) Risk factors : SAD PERSONS

S Sex Total Action Severity

(male > female) Score
A Age
Young (≤19) and older (≥ 45) 0-2 Discharged with Low
D Depression or any other psychiatric illness outpatient
psychiatric
P Previous attempt(s)
evaluation
80% of completed suicide preceded by previous attempt(s)
3-6 Consider Moderate
E Ethanol
hospitalisation or at
Alcohol and/or illicit drug use least very close
follow-up

R Rational thinking loss (psychosis) 7-10 Hospitalization High

S Support system loss
*Each score 1 point
Social isolation is a potential & important trigerring factor
O Organized plan
Severity of suicide attempt
N No significant others
Single/divorced/widowed/separated
S Sickness
Terminal/chronic/disabling medical illness(es)

II) Assess severity :

MD ZAKI MEDICAL NOTES

Lethality of the method used
Patient’s believe in the lethality of the
method used
Planned or organized act
Final preparations
Precaution to avoid discovery
Previous attempt(s)
Actions after act
Attitude towards surviving
III) Protective factors against Suicide :
- Compliant to Psychiatric medication and treatment
- Good social support
- Involvement in religious group
- Being a parent
- Good coping skills
- Adequate treatment of chronic pain
- Adequate treatment of substance abuse
- Adequate follow up of discharged patients
MD ZAKI MEDICAL NOTES
Fatal method (e.g. hanging jumping) indicated a clear intent to die
Did the patient believe that the method chosen was fatal?
Was it planned in advance or an impulsive act?
Was there a suicide note?
Prepared a will or gave out valuables to their loved ones?
Apologized or said good bye (verbally/SMS/social medias)
Was the patient alone?
Locked room?
Secluded place?
Informed anyone about their attention?
Any previous attempt(s) in the past?
Different features of the current attempt?
What was done after the act?
How did the patient end up in the hospital
Is the patient upset to be alive?
Still suicidal
Protective factors against suicide?
B. Hospital Care (If HIGH suicide risk) :
- Make sure medically stable
- Hx and PE :
✓ Suicidal ideation
✓ Family Hx
✓ Hx of mental illness / symptoms / substance abuser
✓ Stressors
✓ Compliance to medication (If have underlying psychiatric illness)
- Toxicology Screening and other Ix
- Tx underlying psychiatry / medical illness
- Strict Suicidal Caution : Close observation (Near nurse counter), Remove sharp and dangerous object, Avoid pre-judgement, Built rapport and
empathy

MD ZAKI MEDICAL NOTES

STRICT SUICIDAL CAUTION AS DONE IN HOSPITAL SELAYANG :
I) Nearest to the MA counter

II) Observation (Behavior , Sleep etc) every 15 MINUTES -> If any suicidal attempt -> Chemical (5mg Halo + 5 mg Diazepam) and Physical restraint
– special kind of restraint (As doctors order) -> On restraint chart every 15 minutes for 4 hour –> MO review -> another 4 hours -> Specialist
review

- Supportive Psychotherapy (Long term)

C. Discharge Criteria :

✓ Self : Stable mood, no suicidal idea, hopefulness and future thinking

✓ Good social support
✓ Moral objection to suicide

MD ZAKI MEDICAL NOTES

7. Diff diagnosis of when someone comes with Suicidal Attempt :

✓ MDD
✓ Bipolar
✓ Schizoaffective
✓ Substance Abuse
✓ Borderline Personality Disorder
✓ Underlying Medical illness/Drug-induced

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“ One who adopts patience will never be deprived of success, even though it may take a long time to reach him”

MD ZAKI MEDICAL NOTES