Suicide & Deliberate Self-Harm

A high-yield psychiatry topic that sits at the crossroads of mood disorders, substance use, and medicolegal duty. NEET PG tests risk stratification, named scales/mnemonics, the single best predictor of completed suicide, and the emergency physician's obligations. Master the numbers and the differentials below.

Key definitions & terminology

Term	Meaning
Suicidal ideation	Thoughts of ending one's life (passive: "wish I were dead"; active: with plan/intent)
Suicide attempt	Self-injurious act with at least some intent to die
Completed suicide	Death resulting from a self-inflicted act with intent to die
Deliberate self-harm (DSH)	Intentional self-injury irrespective of motive; includes acts without suicidal intent
Non-suicidal self-injury (NSSI)	Self-injury (cutting, burning) to regulate emotion, without intent to die
Parasuicide	Apparent attempt that is not intended to be fatal (older European term)
Suicidal gesture	Self-harm aimed at communicating distress rather than dying

High-yield: Distinguish NSSI from a suicide attempt — NSSI is repetitive, low-lethality, used for affect regulation (classically in borderline personality disorder), and lacks intent to die. A suicide attempt requires some intent to die.

DSM-5 introduced Suicidal Behaviour Disorder and Non-Suicidal Self-Injury as conditions for further study.

Epidemiology — the testable numbers

• Suicide is among the leading causes of death in the 15–29 year age group worldwide.
• Attempts vs completions: Women attempt suicide ~3–4× more often; men complete suicide ~3–4× more often (men use more lethal/violent methods — firearms, hanging).
• Most common method of completed suicide globally: hanging; in India: hanging and poisoning (organophosphate/pesticide ingestion) are leading methods, especially in rural areas.
• Highest-risk psychiatric diagnosis: Major depressive disorder; lifetime suicide risk in mood disorders ~15%.
• Highest per-illness risk: historically quoted highest in major depression and in completed suicide overall, but anorexia nervosa carries the highest standardised mortality from suicide among psychiatric disorders; alcohol/substance use and schizophrenia also markedly raise risk.
• Roughly half of completed suicides have a mood disorder; a large fraction (~½) visit a physician within the month before death — hence the screening imperative.

High-yield: The single strongest predictor of completed suicide is a previous suicide attempt. The strongest psychological correlate is hopelessness (Beck) — even more predictive than depressed mood itself.

Risk factors

Static (non-modifiable) and dynamic (modifiable)

Domain	High-risk features
Demographic	Male sex (completion); extremes of age — adolescents and elderly (>65); widowed/divorced/single > married; unemployed
Psychiatric	Major depression, bipolar (mixed/depressive), schizophrenia (esp. command hallucinations, early illness, post-discharge), alcohol & substance use, borderline & antisocial personality, anorexia nervosa, panic disorder
Clinical	Previous attempt (strongest), hopelessness, anhedonia, severe anxiety/insomnia, recent psychiatric hospital discharge, active plan with lethal & available means
Psychosocial	Social isolation, recent loss/bereavement, financial/legal crisis, access to firearms/pesticides, chronic painful physical illness, family history of suicide, childhood abuse

High-yield: Risk is highest in the early phase of recovery from depression — as psychomotor retardation lifts (often with antidepressant onset), the patient regains energy to act on persisting suicidal thoughts. Watch the first 7–14 days after starting an antidepressant and the early post-discharge period.

Protective factors

Strong social support, religious/cultural prohibitions against suicide, pregnancy and presence of young children at home, future-oriented plans, good therapeutic alliance, problem-solving skills, restricted access to lethal means.

Etiology & neurobiology

• Serotonergic hypofunction: reduced CSF 5-HIAA (5-hydroxyindoleacetic acid, the serotonin metabolite) correlates with impulsive/violent suicide and aggression — a classic exam fact.
• HPA-axis dysregulation (non-suppression on dexamethasone suppression test in some depressives).
• Genetic loading: family history independent of psychiatric diagnosis.
• Psychological model (Shneidman): psychache — unbearable psychological pain. Beck: hopelessness cognitive triad.

High-yield: Low CSF 5-HIAA → impulsive aggression and violent suicide attempts. Frequently asked single-best-answer.

Clinical assessment — how to interview

Approach the suicidal patient with a graded, empathic, non-judgemental sequence. Asking about suicide does NOT plant the idea — it is therapeutic and mandatory.

Stepwise interview flow:

1. Ideation → "Have you felt that life is not worth living?" / "Have you thought of harming yourself?"
2. Plan → "Do you have a plan? How would you do it?"
3. Intent → "Do you intend to act on these thoughts?"
4. Means/Access → "Do you have access to pills/firearm/pesticide?"
5. Lethality & rescue → likelihood of being found; prior rehearsal.
6. Protective factors → reasons for living, dependents, support.

Risk synthesis: Ideation → Plan → Intent → Access to lethal means → Imminent danger → Admission.

The presence of a specific, lethal, available plan with stated intent = high imminent risk → does NOT leave alone, arrange admission.

Named scales & mnemonics (exam favourites)

SAD PERSONS scale

A 10-item screen; 1 point each, used in emergency settings.

Letter	Risk factor
S	Sex (male)
A	Age (<19 or >45)
D	Depression
P	Previous attempt
E	Ethanol/substance abuse
R	Rational thinking loss (psychosis)
S	Social support lacking
O	Organised plan
N	No spouse (single/divorced/widowed)
S	Sickness (chronic illness)

Interpretation: 0–2 → may discharge with follow-up; 3–4 → close follow-up, consider admission; 5–6 → strongly consider admission; 7–10 → admit/involuntary admission.

Other instruments

• Beck Scale for Suicidal Ideation (BSS/SSI) and Beck Hopelessness Scale — Aaron T. Beck; hopelessness predicts eventual suicide.
• Columbia-Suicide Severity Rating Scale (C-SSRS) — widely used, validated across ideation and behaviour.
• Pierce Suicidal Intent Scale.

High-yield: Pair the eponyms — Beck → Hopelessness/Suicidal Ideation Scale; Shneidman → psychache & "suicidology"; Durkheim → sociological types (egoistic, altruistic, anomic, fatalistic).

Durkheim's sociological classification

Type	Driver
Egoistic	Low social integration (isolation)
Altruistic	Excessive integration (sacrifice for group — e.g., suicide bombers, sati)
Anomic	Sudden disruption of social norms (economic collapse, sudden loss)
Fatalistic	Excessive regulation/oppression (prisoners)

Investigations

Suicide risk is a clinical diagnosis — there is no confirmatory lab test. Investigations are aimed at the underlying disorder and the consequences of an attempt:

• Treat-the-cause workup: screen for depression, bipolar, psychosis, substance intoxication/withdrawal.
• After an attempt: toxicology screen, paracetamol and salicylate levels (paracetamol overdose is common and treatable), ECG (TCA overdose → wide QRS), ABG, electrolytes, renal/liver function, blood alcohol.
• Organophosphate poisoning: measure RBC acetylcholinesterase/pseudocholinesterase; clinical SLUDGE/DUMBELS.

High-yield: Antidote pairs to remember — paracetamol → N-acetylcysteine; benzodiazepine → flumazenil (caution: seizures); opioid → naloxone; organophosphate → atropine + pralidoxime (2-PAM); TCA → sodium bicarbonate.

Management

Immediate / emergency

Stepwise: Ensure safety → treat medical sequelae of attempt → risk stratification → decide disposition (admit vs discharge) → treat underlying psychiatric illness.

1. Ensure physical safety and treat the acute medical/toxicological consequences first (ABCs, antidote).
2. Constant observation / one-to-one nursing, remove lethal means, no sharp objects.
3. Risk stratify (plan, intent, means, prior attempt, hopelessness).
4. Disposition: High imminent risk → psychiatric admission, voluntary if possible, involuntary (Mental Healthcare Act 2017 — supported admission) if the patient lacks capacity or refuses and is at serious risk.
5. No-suicide "contracts" are NOT evidence-based and do not replace clinical judgement — a known exam distractor.

Treat the underlying disorder

• Depression: antidepressants (SSRIs first-line); ECT is the treatment of choice for acutely, severely suicidal or psychotic depression because of its rapid onset.
• Bipolar / recurrent depression: Lithium is the only agent with proven anti-suicidal (mortality-reducing) effect — high-yield.
• Schizophrenia: Clozapine uniquely reduces suicidality (InterSePT trial) and is approved for this indication.
• Borderline personality / NSSI: Dialectical Behaviour Therapy (DBT) is first-line; reduces self-harm.
• General psychotherapies: CBT for suicide prevention, problem-solving therapy, safety planning.

High-yield: Two drugs with genuine anti-suicide evidence — Lithium (mood disorders) and Clozapine (schizophrenia). ECT is fastest-acting for the acutely suicidal depressed patient.

Black-box warning

SSRIs/antidepressants carry a warning for increased suicidal ideation in patients <25 years, especially early in treatment — monitor closely; this does not contraindicate use but mandates follow-up.

Medicolegal & ethical obligations (India)

• Section 309 IPC (attempt to commit suicide) — historically penalised attempts. The Mental Healthcare Act (MHCA) 2017, Section 115 establishes a presumption of severe stress in a person who attempts suicide, decriminalising the act and barring prosecution/punishment under IPC 309 (now BNS), and obliges the government to provide care and rehabilitation.
• Duty of the treating physician: assess and ensure safety, document risk assessment, never leave a high-risk patient unsupervised, arrange psychiatric referral; breach can constitute negligence.
• Confidentiality vs duty to protect: may be breached to prevent imminent harm to the patient or identifiable others.
• Capacity & consent: supported admission under MHCA 2017 for those at serious self-harm risk lacking capacity.

High-yield: Under MHCA 2017, attempting suicide is presumed to be due to severe stress and is decriminalised — the State must provide treatment, not punishment.

Complications & sequelae

• Medical: organ damage from the attempt (hepatotoxicity after paracetamol, aspiration, anoxic brain injury after hanging, ARDS after pesticide, arrhythmia after TCA).
• Psychiatric: repeated attempts (re-attempt risk highest in the first 3–12 months, peaking in the first months), completed suicide.
• Family/social: "survivor" bereavement, complicated grief, contagion/cluster suicides (Werther effect — copycat after media reports; counterpart Papageno effect — protective effect of responsible reporting on coping).

Key differentials

Condition	Distinguishing feature
NSSI	Repetitive, low lethality, affect regulation, no intent to die
Suicide attempt	Self-harm with intent to die
Suicidal gesture/manipulative behaviour	Communicative intent; low lethality, high rescue likelihood
Malingering / factitious	Secondary gain or assuming sick role; inconsistent presentation
Accidental injury / overdose	No intent; history clarifies
Delirium / organic confusion	Self-injury due to disorientation, not intent

High-yield: Borderline personality disorder classically shows recurrent NSSI plus genuine suicide attempts — both can coexist; never dismiss self-harm in BPD as "just attention-seeking."

Mnemonics

• SAD PERSONS — the 10-item ED risk screen (above).
• IS PATH WARM? (American Association of Suicidology warning signs): Ideation, Substance abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood change.

Recently asked / exam angle

• Single best predictor of completed suicide → previous suicide attempt. (Repeatedly tested; hopelessness is the strongest psychological correlate.)
• CSF 5-HIAA decreased → impulsive/violent suicide.
• Lithium reduces suicide in mood disorders; Clozapine reduces suicide in schizophrenia (InterSePT).
• ECT — treatment of choice for severely/acutely suicidal depression.
• Identify components of SAD PERSONS and the cut-off for admission (≥7).
• MHCA 2017 / decriminalisation of attempted suicide (presumption of severe stress).
• Most common method of suicide in India → hanging/pesticide poisoning.
• Highest standardised mortality ratio among psychiatric disorders → anorexia nervosa.
• Risk rises early in antidepressant treatment and during recovery from depression (energy returns before mood/ideation resolves).
• Werther vs Papageno effect (media contagion vs protective reporting).
• Match-the-eponym: Beck–hopelessness, Durkheim–sociological types, Shneidman–psychache.

Rapid revision

1. Previous attempt = strongest predictor of completed suicide; hopelessness = strongest psychological correlate.
2. Women attempt more; men complete more (lethal methods).
3. Low CSF 5-HIAA → impulsive/violent suicide (serotonin hypofunction).
4. SAD PERSONS ≥7 → admit; remember all 10 letters.
5. Lithium (mood disorders) and Clozapine (schizophrenia) are the only drugs proven to cut suicide.
6. ECT = treatment of choice for acutely, severely suicidal/psychotic depression — fastest acting.
7. Suicide risk peaks early in antidepressant therapy and during recovery from depression; SSRIs carry a black-box warning in <25 yrs.
8. NSSI ≠ suicide attempt — NSSI lacks intent to die; classic in borderline PD; treat with DBT.
9. Asking about suicide does not induce it — screening is mandatory and protective.
10. MHCA 2017 presumes severe stress and decriminalises attempted suicide in India.
11. Antidotes: paracetamol→NAC, OP→atropine+pralidoxime, BZD→flumazenil, opioid→naloxone, TCA→NaHCO₃.
12. Protective factors: pregnancy, young children at home, strong support, religious prohibition, restricted access to means.