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Suicide- Risk Assessment and Prevention
Submitted by: Dr. Geetha Gopinath
______________________________________________________________
Abstract
Suicide, a deliberate ending of one’s own life is a tragedy that affects society in the deepest
social, economic, psychological, and spiritual level is complex but can be prevented. This article deals
with assessment of risk and prevention, discusses the epidemiology, causes, assessment of risk including
the-general and clinical (biological, psychological, pharmacological/medical), the suicide inquiry,
warning signs and inquiry of suicide ideation, goals of assessment, and tools for assessment, prevention
strategies and role of media in prevention. Suicide risk assessment and prevention can go a long way to
prevent a useless and lonely death in the Indian context.
Key words: risk assessment, prevention strategies,
"Death must be so beautiful.
To lie in the soft brown earth, with the grasses waving above one's head, and listen to silence
To have no yesterday, and no to-morrow
To forget time, to forgive life, to be at peace
- Sylvia Plath, The Bell Jar
Introduction
Suicide, a tragedy that affects society in the deepest social, economic, psychological, and spiritual
level raises a question that has theological relevance: Why has God allowed this to happen? In addition, it
also raises sociological and psychological questions: What could society do differently to prevent this? or,
What are the psychological factors that push a person to commit suicide? It is a malady that has affected
all facets of society. Suicides by cultic religious practitioners and fasts unto death, terrorists’ suicide
blasts, are quiet common. Finally, the spate of farmer’s suicides due to debt burden raises psychological
questions, since all persons in debt do not commit suicide. Suicides are complex but can be prevented. It
is difficult but possible to stop a person who is considering suicide, as most suicides and suicide attempts
are reactions to intense feelings of loneliness, worthlessness, helplessness, and depression. The threat or
attempt of suicide is often an expression of feelings- to communicate and ask
for help. Considering the psycho-social-economic dimensions of suicide and the far reaching effects it
has, this article focuses on suicide risk assessment and prevention.
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Epidemiology
In India more than one lakh persons (1,35,445) in the country lost their lives by committing
suicide during the year 2012. 79,773 men and 40,715 women had taken the extreme step. Tamil Nadu
tops the list with 16,927 suicides, followed by Maharashtra with 16,112 suicides, West Bengal 3rd and
Andhra Pradesh following it with 14,328 suicides. It ranks in the top ten causes of death for all age
groups in North America and majority of the European countries. In a World Health Organization study
conducted in 1999 it was determined that industrialization has resulted in an increase in the rate of suicide
and the gradual rise parallels the increase in urbanization and education. The increase is also noticed in
the age group below forty years. Epidemiological knowledge about suicide in the world is limited to
countries that report suicide statistics to WHO. The majority of countries in Africa, the central part of
South America, and a number of Asian countries do not report data on suicides. The data available can
vary in accuracy and quality. Misreporting suicide as unintentional poisonings, or undetermined deaths
reduces the statistics.
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What is Suicide?
The American Association of Suicidology defines it as the deliberate ending of one's own life. Suicidal
behavior includes: Serious suicidal thoughts or threats, Self destructive acts, Attempts to harm, but not
kill oneself, Attempts to commit suicide, Completed suicide. (American Association of Suicidology and
The U. S. Army Center for Health Promotion and Preventive Medicine)
Why do People Commit Suicide?
‘Family problems’ and ‘illness’, accounting for 25.6% and 20.8% respectively, were the major
causes of suicides among the specified causes. ‘Drug abuse/addiction’ (3.3%), ‘love affairs’ (3.2%),
‘bankruptcy or sudden change in economic status’ (2.0%), 'poverty' (1.9%) and ‘dowry dispute’ (1.6%)
were the other causes of suicides. Suicides due to 'drug abuse/ addiction', has shown an increasing trend
while ‘failure in examination’, ‘fall in social reputation’, ‘physical abuse’ and ‘property dispute’, have
shown a decreasing trend during last 3 years. However, suicides due to ‘bankruptcy or sudden change in
economic status’, ‘suspected/illicit relation’, ‘cancellation/non settlement of marriage’,
‘barrenness/impotency’, ‘dowry dispute’, ‘divorce’, ‘family problem’, ‘illegitimate pregnancy’, ‘love
affairs’, ‘poverty', ’professional/career problem’ and ‘unemployment’ have shown a mixed trend during
this period.
Whatever be the cause of suicide psychological pain is a basic ingredient of suicide. Suicidal
death is often an attempt to escape pain. Psychological pain is the hurt or ache that takes hold in the mind;
the pain of excessively felt shame, guilt, fear, anxiety, loneliness, and the pain of growing old or dying
badly. People who complete suicide feel driven to it and feel that suicide is the only option left. The
primary source of severe psychological pain is frustrated psychological needs. The need to succeed, to
achieve, to affiliate, to avoid harm, to be loved and be appreciated; to understand what is going on. When
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an individual completes suicide, he or she is often trying to blot out psychological pain that comes from
defeated or frustrated psychological needs "vital" to that person. Most suicides can be classified into one
of four categories of unfulfilled psychological needs. They reflect different kinds of psychological pain:
Lack of control related to the needs for achievement, order and understanding,
Problems with self-image related to frustrated needs for affiliation,
Problems with key relationships related to grief and loss in life,
Excessive anger, rage, and hostility. (American Association of Suicidology and The U. S. Army
Center for Health Promotion and Preventive Medicine)
Societal attitude to suicide has changed drastically in the past decade and it is now viewed as a
multifaceted bio-psycho-socio-cultural phenomenon, not merely a sinner/criminal behavior. Research
based interest in the field has grown with professional associations and several professional journals
contributing to newer understandings. Research is exploring various aspects of suicide raising questions
that are epidemiological, demographic, biological, constitutional, neurological, psychiatric, psychological,
psychodynamic, and socio-cultural in nature, and the questions explore such areas as mental illness,
prevention, public health, individual rights, family obligations, treatment, and survivor relationships.
(Saint-Laurent, (7/25/2009)
Assessment of Risk
Suicide is often difficult to predict due to its complex nature. Research shows that the
suicide risk factors are additive but can be divided into underlying causes such as biological and
psychological factors, and more proximal stressors such as life events or a major depressive
episode. Clinicians and
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others dealing with individuals who may be at risk for suicide should be taught to recognize,
assess, and address such factors and to appropriately screen at-risk patients for suicidality. The
assessment can be classified as General and Clinical Risk factors.
General Risk Factors
Risk factors include major depression, male sex, alcohol/substance abuse, previous
suicide attempts and threats, unmarried or widowed individuals, youth and elderly,
unemployment, living alone, and chronic illness or pain, loss of romantic relationships, inability
to cope with academic challenges, poor problem solving skills, low self esteem and struggles
with sexual identity are some important determinants. The risk of suicide is also related to age
and is discussed below:
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Age between 13-30: males, whites than blacks, persons suffering from depression
affective disorders, and substance abuse, positive family history of early onset affective disorder
and history of previous suicide attempts.
Age 30 and above: Family history, affective disorders, Schizophrenia, and alcoholism,
feelings of hopelessness, despair, pessimism, and helplessness, males are more prone to suicide
even though females are more prone to be depressed. Single, separated, divorced, or widowed
status, associated medical illness, lack of support, sudden change in socio-economic status, and
inadequate or no treatment for associated psychiatric illness. (Unni, 2003)
Factors common to all ages : Trauma of physical, emotional or sexual abuse, low
educational levels, social stress, problems with family functioning, personal losses, poor coping
skills, impaired judgment, lack of impulse control, self destructive behaviors, poor coping skills,
exposure to suicide of other persons, destructive and violent events, and problems of sexual
orientation.( World Health Organization (2006).
Clinical Factors of Suicide Risk
A Clinical evaluation of suicide risk should incorporate the biological, psychological,
pharmacological, aspects of suicidality. It also has to consider the warning signs of suicide
ideation or suicide attempts.
Biological:
Low cerebrospinal fluid 5-hydroxyindolacetic acid levels
Hypothalamic-pituitary-adrenal axis disregulation
Low blood cholesterol levels
Medical or neurological illnesses (such as multiple sclerosis, stroke, Huntington disease, and
epilepsy)
Cigarette smoking
Psychological:
Acceptability of suicide
A childhood history of physical or sexual abuse
Discouraged help-seeking behavior
Aggressive/impulsive traits
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Pessimism
Hopelessness
Low self-esteem
Poor access to psychiatric treatment
More proximal stressors that indicate an increased suicide risk include:
Relationship problems
Financial troubles
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A family or personal history of suicide
Major depression
Substance use (American Association of Suicidology and The U. S. Army Center for Health
Promotion and Preventive Medicine)
The clinical evaluation of the medical and psychiatric history of a patient and of their current
state is the crucial and essential element of the suicide assessment process. This evaluation
enables the clinician to identify risk factors and protective factors, to determine the patient's
immediate safety and the best setting for treatment, and to develop a differential diagnosis and
treatment strategies.
Pharmacological factors that could potentiate Suicide
The US Food and Drug Administration (FDA) has issued a public warning in October 2004 about
an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with
SSRI antidepressant medications. A review of trails between 1988 and 2006 published in April 18, 2007,
issue of the Journal of the American Medical Association showed that no completed suicides occurred
among nearly 2,200 children treated with SSRI medications. However, about 4 percent of those taking
SSRI medications experienced suicidal thinking or behavior, including actual suicide attempts—twice the
rate of those taking placebo, or sugar pills. These medications which are SSRIs include :
·
·
·
·
·
·
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluvoxamine (Luvox)
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As with all medical decisions, doctors and families should weigh the risks and benefits of
treatment for each individual patient.(nimh 2014)
The more the number of diagnosis is present, the higher the risk of suicide:
A psychological autopsy of 229 suicides revealed




44% had 2 or more Axis I diagnosis
31% had Axis I and Axis II diagnosis
50 % had Axis I and at least one Axis III diagnosis
Only 12% had an Axis I diagnosis with no co-morbidity (Jacobs, Douglas MD
(December 19, 2003),
Warning Signs of Suicidal Ideation
According to research studies persons attempting suicide give warnings that can help
identify their intentions:
1.
2.
3.
4.
5.
Previous Attempts - this may mean that the person is at a high risk to try again.
Threats - these are often followed by suicide attempts. Take all threats seriously.
Depression and hopelessness
Changes in Personality or Behavior - sleeplessness; weight loss, social withdrawal.
Preparations for Death – quickly putting affairs in order, giving away personal
possessions, acquiring a means to commit suicide such as a gun, rope or knife. World
Health Organization (2006).
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Goals in the assessment process:
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`
-determine the seriousness of the danger that the person will attempt.
-determine how much time there is to prevent a death or serious injury.
-find a way to break the suicidal thought process of the person and defer the decision
to take their life. (American Association of Suicidology and The U. S. Army Center for
Health Promotion and Preventive Medicine)
Process of Risk Assessment
Effective counseling intervention and prevention requires that a comprehensive
assessment of suicidal behavior. Suicide assessment provides information for prevention and
counseling, guides clinical judgment, kind of intervention, prevention and also postvention.
Assessment includes:
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1. Review of risk factors
2. History of suicidal behavior
3. Unchangeable biological, psychosocial, mental, situational or medical conditions
4. Extent of current symptoms and degree of hopelessness
5. Precipitant stressors
6. Level of impulsivity and personal control
7. Other mitigating information
8. Prevalence of Protective factors (World Health Organization (2006).
On completion of assessment it is necessary to rate the overall suicide risk in terms of severity.
The scale varies from 1-5.
1. Nonexistent risk
2. Mild
3. Moderate
4. Severe
1.
2. Extreme
Assessment data can be useful in comparing an individual’s pre- and post- counseling level
for functioning for intervention and prevention. Assessment includes a clinical interview,
information from
formal evaluation procedures, gathering of valuable collateral data from third parties, availability
and quality of family and peer support. Important cognitive factors include the reasons for living
or continuing with life.
Tools for Assessment
It is possible to screen and assess the person’s potential for attempting or committing suicide.
These include Gated Screening developed by the US Army, Implicit Association Test, and The
Specific Suicide Inquiry- which includes the inquiry of suicide ideation.
Gated Screening
Gated screening is developed by the US Army is done at a broad level and is the primary
level of screening. It involves screening for well being at a broad level and steps up in
specificity. It is done to afford treatment to the individual at the first sign of distress and save
them from multiplied problems stemming from lack of early intervention.
Gated screening is done by using ‘The Goldberg Well-being Scale’ to assess his or her personal
well-being. It gives permission to the individual to self-refer if they identify areas of distress in
their lives. (American Association of Suicidology and The U. S. Army Center for Health
Promotion and Preventive Medicine)
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These types of scales are not available in India and there is scope for development of such
scales.
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Implicit Association Test
Matthew Nock of Harvard University, with colleagues from Harvard University and
Massachusetts General Hospital, modified the Implicit Association Test (IAT) that measures
automatic associations people hold about various topics to measure associations between life and
death/ suicide to see if it would be effective in predicting suicide risk. Participants are shown
pairs of words; the speed of their response indicates if they unconsciously associate those words.
In the IAT version used in this study, participants classified words related to “life” (e.g.,
breathing) and “death” (e.g., dead) and “me” (e.g., mine) and “not me” (e.g., them). Faster
responses to “death”/”me” stimuli than “life”/”me” stimuli would suggest a stronger association
between death and self. Results indicate that participants at the emergency room after a suicide
attempt had a stronger implicit association between death/ suicide and self than did participants
presenting with other psychiatric emergencies. Participants with strong associations between
death/ suicide and self were significantly more likely to make a suicide attempt within the next
six months than were those who had stronger associations between life and self. The results of
this study indicate that an implicit association between death/ suicide and self may be a
behavioral marker for suicide attempts. (Nock, 2010)
The Specific Suicide Inquiry
A specific suicide inquiry should ask the following questions:
Whether there is suicidal ideation and what plans does the person have about carrying it out.
Added consideration should be given to actual and aborted attempts, first episode, hopelessness,
ambivalence, psychological pain history, intent- subjective expectation and desire for a selfdestructive act to end in death, lethality- associated with the method or action, degree of
ambivalence-wish to live, wish to die, Intensity and frequency, rehearsal/availability of method,
presence/absence of suicide note and finally the deterrents or protective factors (like family,
religion, positive therapeutic relationship, positive support system) (American Association of
Suicidology and The U. S. Army Center for Health Promotion and Preventive Medicine)
Inquiring About Suicidal Ideation
The specific suicide inquiry involves focusing on characteristics of the individual’s
current state that can enhance the degree of risk. These characteristics are: perturbation,
cognitive constriction, intentionality, and lethality of the plan.
a.
Perturbation is "the degree of upset, disturbance, tension, anguish, turmoil, discomfort, dread,
hopelessness, or other excessive psychological pain." When it is no longer tolerable a person
becomes motivated to do something about it. Assessment involves asking questions such as the
following:
"How bad is the hurt?"“Is it bearable?""Is the feeling of unhappiness so strong that sometimes
you wish you were dead?"
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b.
Cognitive constriction "can be defined generally as dichotomous thinking, tunnel vision, or a
narrowing of the range of options to two and ultimately one." The counselor needs to determine:
(1) if suicide is an option for the person being assessed, and (2) if suicide is now seen as the only
option. Perturbation often contributes to cognitive constriction. That is, anguish or anxiety causes
a narrowing of cognitive processes called "tunnel thinking". Edwin Shneidman, a pioneer in the
field of suicide prevention, said that "only" is the four-letter word in suicide. Cognitive
constriction may be assessed by asking the "sometimes" question:
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"Sometimes when people feel this way, they think about hurting themselves or killing
themselves. Have you ever thought about hurting yourself or killing yourself?" "Is this your only
option?"
c.
Intentionality refers to the conscious aim, goal, or purpose in seeing suicide as a viable option
and eventually the only option in alleviating perturbation." Intentionality includes both of the
following: (1) the insight or thought that cessation of consciousness is the solution for unbearable
psychological pain, and (2) "the decision for action". Most people who complete suicide
deliberately plan to do so. In the case of younger people, however, a suicide plan is a less
important sign of risk, given their history of, or tendency toward impulsive behavior.
d. Lethality is the dangerousness of a planned or likely action, [e.g., if one puts a loaded gun to my
head and pulls the trigger, death is the likely result (high lethality)]; if one ingests six aspirin
with intent to kill oneself, one would have low lethality. To assess lethality, one should assess
the how, when, what, and where of a person’s plan for suicide. (American Association of
Suicidology and The U. S. Army Center for Health Promotion and Preventive Medicine)
The Suicide Plan
The risk increases with the suicide plan, which includes: Method, Time, Place, Available
means, Arranging sequence of events. (Jacobs, Douglas MD (December 19, 2003)
Protective Factors that reduce risk of suicide
Protective Factors reduce the risk of suicide and are considered as insulators against suicide.
They include:
1. Support from family, friends, and other significant relationships;
2. Religious, cultural and ethnic beliefs;
3. Community involvement;
4. Satisfying social life;
5. Social integration- through employment, constructive use of leisure time;
6. Access to mental health care and services.
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Protective factors (Personal and Environmental) do not negate the risk of suicide but they
counterbalance the extreme stress of life events. World Health Organization (2006).
Suicide Prevention
Intervention for prevention involves three levels: Primary, Secondary, and Tertiary.
a. Primary: Anticipating potential times of crisis and structuring pre-emptive support systems.Handled by all who are immediately in contact with the suicidal person
b. Secondary: Recognizing the obvious signs and symptoms of distress/crisis and potential
emotional/mental disorder while providing caring support and needed interventions- Handled by
professionals to screen person encountering distress
c. Tertiary: Recognizing and treating psychiatric disorders that result in acute suicidal behaviorsHandled by professionals. SPAN USA, (2001)
The U.S. Department of Health and Human Services, under the direction of the Surgeon
General, published the National Strategy for Suicide Prevention in 2012. This focuses on
identifying patterns of suicide and suicidal behavior throughout a group or population (as
opposed to exploring the history and
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health conditions that could lead to suicide in a single individual). The document also
outlines 11 specific objectives, listed below:
1. Promote awareness that suicide is a public health problem that is preventable
2. Develop broad-based support for suicide prevention
3. Develop and implement strategies to reduce the stigma associated with being a consumer
of mental health, substance abuse and suicide prevention services
4. Develop and implement community-based suicide prevention programs
5. Promote efforts to reduce access to lethal means and methods of self-harm
6. Implement training for recognition of at-risk behavior and delivery of effective treatment
7. Develop and promote effective clinical and professional practices
8. Increase access to and community linkages with mental health and substance abuse
services
9. Improve reporting and portrayals of suicidal behavior, mental illness and substance abuse
in the entertainment and news media
10. Promote and support research on suicide and suicide prevention
11. Improve and expand surveillance systems (www.surgeongeneral.gov/.../national-strategysuicide-prevention,2012)
A Suicide crisis hotline could be very helpful. Similarly in the Indian context teaching
children that they do not have to fear failure or poor results in major exams would be essential as
we hear many reports of school children committing suicide immediately after the Board exam
results are out. Various specific suicide prevention strategies have been used:
-Selection and training of volunteer citizen groups offering confidential referral services.
-Promoting mental resilience through optimism and connectedness.
-Education about suicide, including risk factors warning signs and the availability of help.
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-Increasing the proficiency of health and welfare services at responding to people in need.
This includes better training for health professionals and employing crisis counseling
organizations
-Reducing domestic violence and substance abuse are long-term strategies to reduce many
mental health problems.
-Reducing access to convenient means of suicide (e.g. toxic substances, handguns).
-Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g.
aspirin.
-Interventions targeted at high risk groups.
-Research
The media also have a role in preventing suicides, they can:
·
·
·
link suicide with negative outcomes such as pain for the suicide and his survivors
convey that the majority of people choose something other than suicide in order to solve their
problems,
avoid mentioning suicide epidemics, and avoiding presenting authorities or sympathetic, ordinary
people
as
spokespersons
for
the
reasonableness
of
suicide.
(http://en.wikipedia.org/wiki/Suicide_prevention)
Conclusion
Death is real and we all have to die one day. However, dying due to a lack of desire to live, for
whatever reason is not the purpose of life. This can and should be prevented. All life is
worthwhile and beautiful. We can make it so. For this we need each other.
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As Sylvia Plath said, "How we need another soul to cling to." - Sylvia Plath. Plath, Sylvia, (2009). In one
way or another we are all alone. Prejudices in social systems, gender bias, racial/religious barriers, the list
can go on, each of which separately and together prevent our coming together and alienates us from each
other. As Syivia Plath’s words echo in our ears the hope remains that one day we will be able to cling to
each other and no one will ever have to die a ‘lonely death.’ This paper should help us go one more step
in that direction.
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