Module details Name Affiliation

Subject Name Social Work

Paper Name Mental Health

Module Suicide Interventions

Paper Coordinator Dr. Asha Banu Soletti School of Social Work, TISS

Module Writer Dr.Janardhana and Ms.Manjula Additional Professor,

Department of Social Work,
NIMHANS

Keywords Suicide Interventions, Factors, Myths,

Interventions

Summary To provide an understanding of factors

influencing suicides and interventions

Content reviewer Prof .Kalpana Sarathy Professor, Tata Institute of

Social Sciences, Guwahati off-
campus

Language editor Mr Venkatnarayanan Ganapathy Freelancer, Pune

Introduction:

The word Suicide derives from the Latin word Sui (of oneself) Cide or Cidium (a killing).
Suicide is now understood as a multidimensional disorder which results from a complex
interaction of biological, genetic, psychological, sociological and environmental factors. It is
an intended result of a process of cognition based on negative perception of an individual’s
predicament by the individual, the quality of the perception being morbidly distorted by
psychiatric disorder or personality, and the adamant refusal to bow to the predicament. It is
characterised as the final common pathway of diverse circumstances, of an interdependent
network rather than an isolated cause, a web of circumstances tightening around a single time
and space. WHO declared the fight against suicide as a priority for the first time in the year
2000.

Basic terminologies:
 • Suicide—self-inflicted death with evidence (either explicit or implicit) that the person
intended to die.
• Suicide attempt—self-injurious behavior with a nonfatal outcome accompanied by
evidence (either explicit or implicit) that the person intended to die.
• Aborted suicide attempt—potentially self-injurious behavior with evidence (either
explicit or implicit) that the person intended to die but stopped the attempt before
physical damage occurred.
• Suicidal ideation—thoughts of serving as the agent of one’s own death. Suicidal
ideation may vary in seriousness depending on the specificity of suicide plans and the
degree of suicidal intent.
• Suicidal intent—subjective expectation and desire for a self-destructive act to end in
death.
• Lethality of suicidal behavior—objective danger to life associated with a suicide
method or action. Lethality is distinct from and may not always coincide with an
individual’s expectation of what is medically dangerous.
• Deliberate self-harm—wilful self-inflicting of painful, destructive, or injurious acts
without intent to die.

Myths and Facts about suicide

The following table explains myths and misconceptions associated with suicide

Myths Facts

People who talk about Many people who die by suicide have given definite warnings
suicide don’t complete to family and friends of their intentions. Always take any
suicide. comment about suicide seriously.

Suicide happens without Most suicidal people give many clues and warning signs
warning. regarding their suicidal intention.
Suicidal people are fully Most suicidal people are undecided about living or dying –
intent on dying which is called suicidal ambivalence. A part of them wants to
live; however, death seems like the only way out of their pain
and suffering. They may allow themselves to “gamble with
death,” leaving it up to others to save them.

Males are more likely to be Men COMPLETE suicide more often than women. However,
suicidal. women attempt suicide three times more often than men.

Asking a depressed person Studies have shown that patients with depression have these
about suicide will push ideas and talking about them does not increase the risk of
him/her to complete suicide. them taking their own life.

Improvement following a Most suicides occur within days or weeks of “improvement”

suicide attempt or crisis when the individual has the energy and motivation to actually
means that the risk is over follow through with his/her suicidal thoughts

Once a person attempts The most common psychiatric illness that ends in suicide is
suicide the pain and shame Major Depression, a recurring illness. Every time a patient
will keep them from trying gets depressed, the risk of suicide returns
again.

Sometimes a bad event can Suicide results from serious psychiatric disorders not just a
push a person to complete single event.
suicide

Factors associated with increased risk for suicide

Sl Factors Description
No
1 Suicidal Suicidal ideas (current or previous)
thoughts/behaviors Suicidal plans (current or previous)
Suicide attempts (including aborted or interrupted
attempts)
Lethality of suicidal plans or attempts
Suicidal intent
2 Psychiatric diagnoses Major depressive disorder
Bipolar disorder (primarily in depressive or mixed
episodes)
Schizophrenia
Anorexia nervosa
Alcohol use disorder
Other substance use disorders
Cluster B personality disorders (particularly borderline
personality disorder)
Comorbidity of axis I and/or axis II disorders
3 Physical illnesses Diseases of the nervous system
Multiple sclerosis
Huntington’s disease
Brain and spinal cord injury
Seizure disorders
Malignant neoplasms
HIV/AIDS
Peptic ulcer disease
Chronic obstructive pulmonary disease, especially in men
Chronic hemodialysis-treated renal failure
Pain syndromes
Functional impairment
4 Psychosocial features Recent lack of social support (including living alone)
Unemployment
Drop in socioeconomic status
Poor relationship with family
Domestic partner violence
Recent stressful life event
5 Childhood traumas Sexual abuse
Physical abuse
6 Genetic and familial Family history of suicide (particularly in first-degree
effects relatives)
Family history of mental illness, including substance use
disorders
7 Psychological features Hopelessness
Psychic pain
Severe or unremitting anxiety
Panic attacks
Shame or humiliation
Psychological turmoil
Decreased self-esteem
Extreme narcissistic vulnerability
Behavioral features
Impulsiveness
Aggression, including violence against others
Agitation
8 Cognitive features Loss of executive function
Thought constriction (tunnel vision)
Polarized thinking
Closed-mindedness
9 Demographic features Male gender
Widowed, divorced, or single marital status, particularly
for men
Elderly age group (age group with greatest proportionate
risk for suicide)
Adolescent and young adult age groups (age groups with
highest numbers of suicides)
White race
Gay, lesbian, or bisexual orientation
10 Additional features Access to firearms
Substance intoxication (in the absence of a formal
substance use disorder diagnosis)
Unstable or poor therapeutic relationships

Consider assessing the patient’s potential to harm others in addition to him- or herself
• Are there others who you think may be responsible for what you’re experiencing (e.g.,
persecutory ideas, passivity experiences)?
Are you having any thoughts of harming them?
• Are there other people you would want to die with you?
• Are there others who you think would be unable to go on without you?

Documentation of suicide assessment is essential and is usually included in the treatment

planning section of the psychiatric evaluation. Generally, these notes are written just after the
assessment is completed. A suicide assessment should be conducted and documented at a
patient’s initial visit, as well as whenever suicidal ideation or behaviour occurs. “On inpatient
units, important points of documentation of assessment occur at admission, changes in the
level of precautions or observation, transitions between treatment units, the issuance of
passes, marked changes in the clinical condition of the patient, and evaluation for discharge.”

Specific treatment modalities include Primary, secondary and tertiary prevention

Primary prevention: National Surveillance Policy, Promoting local employment, preventing

migration, improving educational status, Social mapping for high risk populations,
Counselling services for high risk families at community level, Involving media to increase
awareness can contribute for prevention of suicide.

Secondary prevention strategies includes Specialized suicide prevention centers,

Aggressive treatment of mental disorders-prescription habits guided by family situations,
Banning over the counter sale of drugs/easy availability of O.P compounds, Helplines to be
expanded to rural areas, more adequate training of volunteers, Strengthening of emergency
services.

Tertiary prevention strategies includes Managing stigma of survivors and bereavement of

families and encouraging Suicide survivors to form self help supportive groups, involving
media to fight against stigma. There is a need for more research to address the issues and test
the efficacy of interventions and prevention programmes.

Pharmacotherapy and psychosocial interventions, including psychotherapies are part of

treatment plan for a patient with suicidal thoughts and behaviours. The treating team should
address the modifiable risk factors previously identified and continue to assess the patient
during the course of treatment. Pharmacotherapy is often focused on acute symptom relief,
whereas psychotherapies tend to have broader and longer-term goals related to the patient’s
psychosocial functioning.

Pharmacotherapy
Antidepressants: Antidepressants are a mainstay in the treatment of suicidal patients with
acute, recurrent, or chronic depressive illness. Prescriptions for suicidal patients should be
conservative quantities of antidepressants with low lethality in overdose. Patients should be
under close monitoring during the early weeks of antidepressant treatment. Patients should be
informed that symptom relief may not occur for a period of days or weeks and be advised that
recovery is sometimes uneven and setbacks are possible even when medication is being
administered.

Treatment of anxiety: Severe insomnia, agitation, panic attacks, and psychic anxiety are
associated with an increased risk of suicide. Benzodiazepines can address these symptoms
and may be indicated for short-term symptom reduction.
Mood stabilizers: Recent studies have shown major reductions in the risk of both suicide and
suicide attempts associated with long-term maintenance treatment of bipolar disorder with
lithium salts. There is moderate evidence for a similar anti-suicide effect of lithium on
patients with major depressive disorder. The risk–benefit analysis regarding prescription of
mood stabilizers must include the anti-suicide effect of lithium but also its potential toxicity
in overdose.

Antipsychotic agents. “Antipsychotic medications are an essential treatment for patients

with psychotic symptoms and disorders. For highly agitated patients, antipsychotics may
reduce suicide risk.

Electroconvulsive therapy: ECT has established efficacy in patients with severe depressive
illness with or without psychotic features. ECT is associated with a rapid and robust
antidepressant response as well as a rapid reduction of suicidal thoughts. ECT is the treatment
of choice for patients with catatonic features, regardless of diagnosis. ECT may also be
indicated for suicidal patients for whom medication is not appropriate because of pregnancy
or prior treatment failure. Maintenance medication or ECT is necessary for long-term
reduction of suicide risk.

Psychotherapies

Psychodynamic and psychoanalytic psychotherapies

In patients with suicidal behaviours, 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.

Cognitive behaviour therapy- for suicidal people was developed by Aaron Beck and
Gregory Brown. Unlike other CBT treatments, this approach is not time limited. The third
and last stage is "Relapse Prevention with a Twist," which involves inducing a suicidal crisis
for the client while they are in session. The theory behind this technique draws from the fact
that people who are suicidal have trouble using newly acquired skills when in crisis. By
evoking the crisis in session, the client is able to apply and test coping skills with the
therapist's help and support. Clients do not graduate from treatment until they demonstrate
that they are ready to do this on their own.

Cognitive behaviour therapy has evidence to suggest its effectiveness in treating depression
and related symptoms such as hopelessness and it might be expected to also be of benefit in
the treatment of suicidal behaviours. Primary goals of this intervention are to reduce suicidal
risk factors, enhance coping and to prevent suicidal behaviour. A central focus of CBT-SP is
the identification of proximal risk factors and stressors, including emotional, cognitive,
behavioral and family processes active just prior to and following suicide attempt or recent
suicidal crisis. The initial phase of acute treatment consists of five main components- Chain
Analysis, Safety Planning, Psycho education, Developing Reasons for Living and Hope and
Case Conceptualization. During the middle phase of acute treatment after the immediate
suicidal crisis has resolved, the primary area of intervention is behavioural and/or cognitive
skills training using individual or family sessions The final component of the acute
intervention phase includes a relapse prevention task.

Dialectical behaviour therapy developed by Marsha M. Linehan, PhD, is designed to treat

emotion regulation difficulties and suicidal behaviour. One element, the skill-building
component of DBT, addresses the issues of distress tolerance and the development of healthy
affect regulation strategies, both of which are essential for suicidal clients. Originally
developed to treat the seriously and chronically suicidal patient, DBT has evolved into a
treatment for suicidal patients who also meet criteria for borderline personality disorder
(BPD), and it has since been adapted for BPD patients with presenting problems other than
suicidal behaviors and for other disorders of emotion regulation. Treatment is based on a
unique blend of behavioural psychology principles used to promote change, and Eastern
mindfulness principles used to promote acceptance. Treatment strategies in DBT are divided
into four sets: (1) Dialectical strategies, (2) core strategies (problem solving and validation),
(3) communication strategies (irreverence and reciprocal communication), and (4) case
management strategies (consultation to the patient, environmental Intervention, and
supervision/consultation with therapists). In all treatment strategies, a DBT therapist must
constantly strive for a balance of acceptance and change. There are also a number of specific
behavioural treatment protocols covering suicidal behavior, crisis management, therapy-
interfering behaviour and compliance issues, relationship problem solving, and ancillary
treatment issues, including psychotropic medication management.
Mentalizing treatment, developed by Jon Allen, PhD, and Peter Fonagy, PhD, emphasizes
emotional regulation and expressiveness. The techniques implemented assist clients in
forming good affect regulation and tolerance through the process of developing the
mentalizing capability to observe and understand their minds and the minds of others,
accurately seeing the mind behind the behaviour

Voice therapy, which was developed by Robert Firestone, is a cognitive-affective-

behavioural therapeutic methodology that brings interjected hostile thoughts, with the
accompanying negative affect, to consciousness, rendering them accessible for treatment.
This technique facilitates the client's identification of the negative thoughts that are driving
the suicidal actions, which in turn helps them gain a measure of control over all aspects of
their self-destructive or suicidal behaviours. They develop a greater understanding of
themselves and how these self-destructive voices adversely affect their lives. Their sense of
self is also strengthened, giving them a more realistic perspective on themselves and their
circumstances, so that they can more effectively cope with adverse life events. This process
helps clients expand their personal boundaries, develop a sense of meaning in life, and reduce
the risk of self destructive behaviour, including suicide

Following are the most helpful aspects of psychotherapy:

• Validating relationships: Clients described the existence of an affirming and
validating relationship as a catalyst for reconnecting with others and themselves.
• Working with emotions: Dealing with the intense emotions underlying suicidal
behaviour. Clients who did not receive acknowledgement of such powerful and
overwhelming feelings as despair and helplessness, reported being unable to move
beyond them.
• Developing autonomy and identity: Understanding suicidal behaviours, developing
self awareness and constructing personal identity. Clients identified the therapeutic
process as discarding negative patterns while establishing new, more positive ones.

Other psychosocial interventions includes, working with families, enhancing support

system, building psycho social competence skills, gate keeper trainings etc would help in
treating individuals and preventing further suicide attempts.
No-suicide Contracts: Although widely used, the no-harm, or suicide prevention, contract
must not take the place of a thorough suicide risk assessment. Contracts have not been
demonstrated to reduce suicide, and reliance on contracts may reduce staff vigilance about a
patient without reducing the patient’s suicide risk. The guideline emphasizes patient
discharge or hospitalization should not be based on the patient’s willingness or reluctance to
enter into a suicide prevention contract. No-harm contracts may be useful in opening up
conversation on the availability of clinicians and staff for support, however, especially in
inpatient settings. The no-harm contract specifically is not recommended for use with new
patients, in emergency room settings, or with psychotic or impulsive patients.

Suicide prevention programmes

Public prevention strategies: Crisis intervention centers were started to prevent suicide and
help people. There are many centers, like Medico-Pastoral Association, sneha,viswas-
Bangalore, Sanjivini, Sumaitri- Delhi, Helpline- Bombay, Sneha- Madras, Sahaya,-
Hyderabad, Helpline- Bangalore.

Judicial initiatives concerning suicide: Under the Indian law, suicide and attempted suicide
are punishable offences under Section 309 of IPC. As it prevents people from seeking
treatment and would lead to medico legal entanglements, decriminalization of suicide was
considered. Decriminalization of suicide Rajya Sabha on August 8, 2016 decriminalized the
Offence of Attempt to Suicide by passing Mental Healthcare Bill. Mental health perspective
was highlighted in the case of suicide.

Important Tips:
Questions that may be helpful in inquiring about specific aspects of suicidal thoughts,
plans, and behaviors are as follows
1. Begin with questions that address the patient’s feelings about living
• Have you ever felt that life was not worth living?
• Did you ever wish you could go to sleep and just not wake up?
2. Follow up with specific questions that ask about thoughts of death, self-harm, or suicide
• Is death something you’ve thought about recently?
 • Have things ever reached the point that you’ve thought of harming yourself?
3. For individuals who have thoughts of self-harm or suicide
• When did you first notice such thoughts?
• What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including
real or imagined losses; specific symptoms such as mood changes, anhedonia,
hopelessness, anxiety, agitation, psychosis)?
• How often have those thoughts occurred (including frequency, obsessional quality, and
controllability)?
• How close have you come to acting on those thoughts?
• How likely do you think it is that you will act on them in the future?
• Have you ever started to harm (or kill) yourself but stopped before doing something
(e.g., holding knife or gun to your body but stopping before acting, going to edge of
bridge but not jumping)?
• Have you made a specific plan to harm or kill yourself? (If so, what does the plan
include?)
• Have you spoken to anyone about your plans?
4. For individuals who have attempted suicide or engaged in self-damaging action(s),
• Can you describe what happened (e.g., circumstances, precipitants, view of future, use
of alcohol or other substances, method, intent, seriousness of injury)?
• What thoughts were you having beforehand that led up to the attempt?
• What did you think would happen (e.g., going to sleep versus injury versus dying,
getting a reaction out of a particular person)?
• Were other people present at the time?
• Did you seek help afterward yourself, or did someone get help for you?
• Had you planned to be discovered, or were you found accidentally?
• How did you feel afterward (e.g., relief versus regret at being alive)?
• Did you receive treatment afterward (e.g., medical versus psychiatric, emergency
department versus inpatient versus outpatient)?
• Has your view of things changed, or is anything different for you since the attempt?
• Are there other times in the past when you’ve tried to harm (or kill) yourself?
For individuals with repeated suicidal thoughts or attempts
• About how often have you tried to harm (or kill) yourself?
• When was the most recent time?
 • Can you describe your thoughts at the time that you were thinking most seriously
about suicide?
• When was your most serious attempt at harming or killing yourself?
• What led up to it, and what happened afterward?
For individuals with psychosis, ask specifically about hallucinations and delusions
• Can you describe the voices (e.g., single versus multiple, male versus female,
internal versus external, recognizable versus non recognizable)?
• What do the voices say (e.g., positive remarks versus negative remarks versus
threats)? (If the remarks are commands, determine if they are for harmless versus
harmful acts; ask for examples)?
• How do you cope with (or respond to) the voices?
• Have you ever done what the voices ask you to do? (What led you to obey the
voices? If you tried to resist them, what made it difficult?)
• Have there been times when the voices told you to hurt or kill yourself? (How often?
What happened?)
• Are you worried about having a serious illness or that your body is rotting?
• Are you concerned about your financial situation even when others tell you there’s
nothing to worry about?
• Are there things that you’ve been feeling guilty about or blaming yourself for?