Presenter:Dr.Santhosh GoudDNB Resident

Chairperson:Dr.P.Krishna mohanMD DPM

Suicide(Latin suicidium, from sui caedere, "to kill oneself")

Suicide attempted/DSH/para suicide

Unsuccessful but potentially lethal action

Suicide cluster/Copycat suicide

Individuals or groups committing suicide after publicity about suicide of acquaintances or public figures

Suicide pact

agreement or pledge between two or more persons to take their own lives simultaneously

Suicidal ideation is any self-reported thoughts of engaging in suicide-related behavior

To have suicidal intent is to have suicide or deliberate self-killing as one's purpose.

This is contrasted with suicidal motivation, or the driving force behind ideation or intent, which need not be conscious.

Suicide-suicide is conscious act of self induced annihilation, best understood as a multi-dimensional malaise in a needful individual, who defines an issue for which suicide is perceived as the best solution(Shneidman)

Suicide is the intentional act of self destruction committed by someone knowing what he is doing and knowing the probable consequences of his action. The verdict of suicide should be supported with evidence. It can never be presumed(Legal)

Suicidal act is the injury with varying degrees of lethal intent, and suicide is defined as a suicidal act with fatal outcome(WHO,1968)

Suicide -Death caused by self-directed injurious behavior with any intent to die as a result of the behavior(CDC).

The Government of India classifies a death as suicide if it meets the following three criteria:

It is an unnatural death, the intent to die originated within the person, there is a reason for the person to end his or her life.

The reason may have been specified in a suicide note or unspecified

Males>Females Men 10 years earlier than females(45-55) Whites>Black(India north<south) Protestants>Catholics (orthodoxy is a protecting factor) Divorced>never married>married(children are protecting factor) Higher social status Sexual orientation-elevated suicide risk among gay and lesbian

people Physical Illness-Psychosomatic illness Occupation- Physicians >other professions Retirement and unemployment Season- greatest during the late spring and early summer

months, despite the common belief that suicide rates peak during the cold and dark months of the winter season

According to the World Health Organization, approximately one million people die by suicide worldwide every year,

The global suicide rate is 16 per 100,000 population

The suicide rate varies from 0.5/100,000 in Jamaica to 75.6/100,000 in Lithuania for men and from 0.2/100,000 in Jamaica to 16.8/100,000 in Sri Lanka for women

The number of suicides in the country during the decade (2002–2012) has recorded an increase of 22.7% (1,35,445 in 2012 -1,10,417 in 2002).

India in 2012 had nearly 2.6 lakh suicides, dwarfing China's 1.2 lakh.

The rate of suicides has shown a declining trend since 2002 to 2003 and thereafter an increasing trend is observed during 2005 to 2010. However, it was declined in 2011(from 11.4 in 2010 to 11.2 in 2011) and remained static in 2012.

South Indians accounting for a rate above 15 and North Indians below 3

Puducherry reported the highest suicide rate at 36.8 per 100,000 people, followed by Sikkim, Tamil Nadu and Kerala

The lowest suicide rates were reported in Bihar (0.8 per 100,000), followed by Nagaland, then Manipur.

In India, about 46,000 suicides occurred each in 15-29 and 30-44 age groups in 2012 - or about 34% each of all suicides

Poisoning (33%), hanging (31%) and self-immolation (9%) were the primary methods used to commit suicide in 2012

80% of the suicide victims were literate, higher than the national average literacy rate of 74%

In the year 2012, Chennai reported the highest total number of suicides at 2,183, followed by Bengaluru(1,989), Delhi (1,397) and Mumbai (1,296).

Jabalpur (Madhya Pradesh) followed by Kollam(Kerala) reported the highest rate of suicides 45.1 and 40.5 per 100,000 people respectively, about 4 times higher than national average rate.

West Bengal reported 6,277 female suicides, the highest amongst all states of India, and a ratio of male to female suicides at 4:3

In 2012, family problems and illness were the two major reasons for suicides, together accounting for 46% of all suicides. 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

Sociological approach

Psychological approach

Biological aspects

Psychiatric approach

• Emile Durkheim (1867) Le Suicide. Etude de Sociologie

• Each society has a specific tendency toward suicide

• Refuted contribution of individual factors

• Social integration / Social regulation

Aaron T. Beck – Cognitive Theory

Cognitions = Mental processes that are involved in information gathering, thinking, remembering etc and exists in three forms:

- Dysfunctional automatic thoughts skew perceptions of self, others and future

- Schemas: framework or concept that helps organize the information gathered

Post-mortem studies have shown changes in central neurotransmission of serotonin, nor-adrenaline and post-synaptic signal transduction

Dysfunction of Hypothalamic-pituitary-adrenal axis (stress response) predicts suicide in depressed patients

Increased suicide risk associated with low cholesterol levels

Reduced 5-HIAA levels in CSF of depressed patients who suicide

Family history of suicide increases the risk two-fold especially in women and children independent of family psychiatric history

Concordance rates of suicide higher among monozygotic twins

Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.

Genetic factors account for 45% of suicidal thoughts and behaviors: 7 types of genes have been focused on serotonin transporter(SERT), tryptophan hydroxylase (TPH) 1 and 2, three serotonin receptors (5-HTR1A, 5-HTR2A, and 5-HTR1B), and the monoamine oxidasepromoter(MAOA)

Combines psychological and biological factors

Holmes & Rahe 1967

STRESS DIATHESIS

A force that disrupts the equilibrium or normal functioning of an individual’s mental or physical state. Different types of stressors may precipitate suicidal behavior.

Negative Life events

Acute substance intoxication

Acute psychiatric condition

Innate vulnerability or predisposition (in the form of traits) for developing the suicidal state

Familial / genetic influences

Chronic multiple psychiatric problems

Hopelessness

Being male / loneliness

Holmes & Rahe 1967

Study by S.Gupta and C.L. Pradhan more family conflicts and broken love affairs in suicide attempters vs financial issues and death of close family member in people having only suicidal ideations

(Indian journal of preventive and social medicine vol.38 no.3&4, 2007)

The primary and necessary mental state called 'idiozimia' by Federico Sanchez (from idios=self and zimia=loss) followed by suicidal thoughts, hopelessness, loss of will power, hippocampal damage due to stress hormones, and finally either the activation of a suicidal belief system, or in the case of panic or anxiety attacks the switching over to an anger attack, are the converging reasons for a suicide to occur

90% of suicides can be traced to depression, linked either to manic-depression (bipolar), major depression (unipolar), schizophrenia or personality disorders, particularly borderline personality disorder

Anorexia nervosa has a particularly strong association with suicide: the rate of suicide is forty times greater than the general population

Mental state

affective state of hopelessness,

severe anger and hostility, or with agitation, anxiety, fearfulness, or apprehension

Specific psychotic symptoms, such as grandiose delusions, delusions of thought insertion and mind reading

Command hallucinations??

Predictors of risk

Direct statement

Plan

Past attempts

Indirect behaviors and gestures

Depression

Helps in short-term management of problematic emotions

Stress-relieving function

Consequences – disapproval by others and a sense of inability to solve problems

Regulation of unpleasant self-states (eg. depersonalization) common to people experiencing trauma

Sense of mastery and control for people who feel powerless or out of control

Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001

Re-enactment of past experience of trauma or

abuse

Feelings of being evil and bad common

Self-punishment for being bad

Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001

For people who have past experiences of trauma and abuse and there was no recognition of it or they were actively denied by people around them

Way of testifying to the experience – remembering it

Linehan (1993) – Chronic invalidation: feelings are bad or wrong

Miller (1994) – “Men act out while women act out by acting in”

Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001

A way of communicating distress not heeded by words

To care for the person who has harmed

To keep others at a distance

To make the person cared about feel guilty

Babiker and Arnold, 1997; Gratz, 2003; Williams, 2001

Simeon et al. (1992) found that people who self-injure tend to be extremely

angry, impulsive, anxious, and aggressive, and presented evidence that some of these traits may be linked to deficits in the brain's serotonin system

Favazza (1993) refers to this study and to work by Coccaro on irritability to

posit that perhaps irritable people with relatively normal serotonin function express their irritation outwardly, by screaming or throwing things; people with low serotonin function turn the irritability inward by self-damaging or suicidal acts

Zweig-Frank et al. (1994) also suggest that degree of self-injury is related to

serotonin dysfunction

Steiger et al. (2000), in a study of bulimics, found that serotonin function in

bulimic women was significantly lower in bulimics who also engaged in self-harm

Rare genetic syndrome – Lesch-Nyhan (HG-PRT deficiency)

Large turnover of purines

Characterized by self harm

Link largely still unclear

Suicidal behavior disorder With in last 24 months the individual has made suicide

attempt The act does not meet criteria for non suicidal self injury Not applied to suicidal ideation or to preparatory acts The act was not initiated during a state of delirium or

confusion The act was not undertaken solely for a political or religious

objective

Specifiers -current:not more than 12 months since last attempt

in early remission:12-2 months since last attempt

Degree of lethality-violent/non-violent

Non suicidal self-injury In the last year, the individual has, on 5 or more days,

engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, and excessive rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm

The individual engages in the self injurious behavior with one or more of the following expectations

To obtain relief from a negative feeling or cognitive state

To resolve an interpersonal difficulty To induce a positive feeling state

The intentional injury is associated with at least 2 of the following:(1)psychological precipitant: interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act,(2)urge: prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist,(3)preoccupation: thinking about self-injury occurs frequently, even when it is not acted upon, (4)contingent response: the activity is engaged in with the expectation that it will relieve an interpersonal difficulty, negative feeling, or cognitive state, or that it will induce a positive feeling state, during the act or shortly afterwards

The behavior is socially not sanctioned and is not restricted to picking a scab or nail biting

Its consequences cause clinically significant distress or interference in interpersonal academic or other important areas of functioning

Chapter XX External causes of morbidity and mortality

X60-X84(includes purposely self-inflicted poisoning or injury; suicide)

X60-69 –intentional poisoning…

X70-X82- intentional self harm by…methods

X83-intentional self harm by other specified means

X84-intentional self harm by unspecified means

The behavior does not occur exclusively during states of psychosis, delirium, or intoxication. In individuals with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior cannot be accounted for by another mental or medical disorder (i.e., psychotic disorder, pervasive developmental disorder, mental retardation, Lesch–Nyhansyndrome, stereotyped movement disorder with self-injury, or trichotillomania)

Rating scales

Psychological autopsy-A procedure for investigating a person's death by reconstructing what the person thought, felt, and did before death, based on information gathered from personal documents, police reports, medical and coroner's records, and face-to-face interviews with families, friends, and others who had contact with the person before the death

SSI/MSSI-The Scale for Suicide Ideation (SSI) was developed in 1979 by Aaron Beck

Suicide Intent Scale (SIS)- assess the severity of suicide attempts 15 questions which are scaled from 0-2

Suicide Behaviors Questionnaire- Linehan in 1981

1988 it was transformed from a long questionnaire to a short four questions that can be completed in about 5 minutes

Life Orientation Inventory- The Life Orientation Inventory (LOI) is a self-report measure that comes in both a 30 question and 110 question form

Reasons For Living Inventory- It was developed in 1983 by Linehan et al. and contains 48 items answered on a Likert scale from 1 to 6. The measure is divided into six subscales: survival and coping beliefs, responsibility to family, child concerns, fear of suicide, fear of social disproval, and moral objections

1.Alcohol

2.Anti social behavior

3.Previous IP care

4.OP care

5.Previous attempts resulting in hospital admission

6.Not living with relatives

Score 0:only 5%risk of repeating within a year

Score 5 :50% risk of repeating within a year

48

Level of concernabout potential suicidal behavior:

Sum of itemscoded as present

Suicide risk factor groups:

Lowest concern 0 1. Any history of a suicide attempt

Some concern 1-2 2. Long-standing tendency to lose temper or become aggressive with little provocation

Increased concern 3-4 3. Living alone, chronic severe pain, or recent (within 3 months) significant loss

High Concern 5-7 4. Recent psychiatric admission/discharge or first diagnosis of MDD, bipolar disorder or schizophrenia

5. Recent increase in alcohol abuse or worsening of depressive symptoms

6. Current (within last week) preoccupation with, or plans for, suicide

7. Current psychomotor agitation, marked anxiety or prominent feelings of hopelessness

Predisposing factors

Disturbed family background

Drug and alcohol abuse

Conduct disorder/anti social behavior

Physical illness

Losing the parent before age 13

Precipitating factors

Break in relationship

Exposure to someone who died violently

High frequency of moves

Hopelessness

Intoxication

Clinical syndromes

Sex, age, race

Religion

Living alone

Lack of sense of belonging

Bereavement

Unemployment

Health status

Impulsivity

Rigid thinking

Stressful events

Release from hospital

Common in females

Young people(<35yrs)

Low social class, deprived back ground, owercrowding

Impulsivity

Premenstrual syndrome in females

Based on a stress-diathesis model of suicidal behavior

Acts to modify reactions to stressors both acutely and chronically in the context of vulnerability (i.e. positive diathesis).

The treatment includes a 12-week acute phase and a continuation phase, over 6 months of contact.

CBT-SP is primarily individual therapy but also includes family interventions as needed to reduce the suicide risk.

Mainly works on deficits the abilities or motivations to cope with suicidal crises.

These risk factors are identified by conducting a detailed chain analysis of the sequence of events, and their reactions to these events, that led to the suicidal crisis.

A core feature of the treatment is the development of an individualized case conceptualization that identifies problem areas to be targeted and the specific interventions to be employed during periods of acute emotional distress.

Addressing Family/milieu risk factors

Focus on problematic romantic relationships, physical, verbal or sexual abuse, dysfunctional family beliefs, high expectations and low reinforcement, or poor work performance and incorporates specific family /milieu therapy techniques to address these contextual concerns

CBT-SP phases

1)Acute phase 12-16 weekly sessions Mostly individual sessions 6 family sessions (+ Family “check-ins” (5–15 minutes) may also be conducted ) initial phase, a middle phase, and an end of acute treatment phase

2)Continuation phase 12 weeks up to 6 sessions that are tapered in frequency. Additionally, there may be up to three family sessions during the

continuation phase

Total duration 6 months.

occurs during the first three sessions

consist of five main components: Chain Analysis, Safety Planning, Psycho education, Developing Reasons for Living and Hope, Case Conceptualization.

Chain analysis

Safety planning& Psycho education

Developing reasons for living &Case

conceptualization

Chain analysis The basic strategy that sets the framework for the

CBT-SP is a detailed chain analysis of events associated with the index suicide attempt or suicidal crisis.

The chain analysis includes identification of vulnerability factors and activating events associated with the crisis as well as the’ thoughts, feelings and behaviors in reaction to these events.

To conduct a chain analysis of a suicide attempt, the therapist asks the person to describe the events that led to and followed the suicide attempt as well as the details of the actual attempt.

Outcomes of chain analysis

Developing rapport actively

Engages patient in treatment

facilitates the development of a conceptualization of patients’ suicidality and assessment of future risk

it gives patients the opportunity to feel understood and counteract a frequent feeling that the suicidal behavior “just happened

Safety Planning

Safety planning is a technique to help patients remain safe and not to engage in further suicidal behavior, at least until the next therapy session.

The intent of safety planning is to help individuals lower their imminent risk for suicidal behavior by consulting this pre-determined set of potential coping strategies and list of individuals or agencies whom they may contact.

Given that the highest risk period for a re-attempt is shortly after the indexed attempt, as well as during during the time immediately following discharge from inpatient treatment, it is essential to develop a safety plan early in treatment for high suicide risk patients who are being treated as outpatients.

The safety plan includes a stepwise increase in the level of intervention from internal (“within-self”) strategies to external (“outside-self”) strategies.

Internal strategies- a list of activities that the patient could do to cope with suicidal urges without the assistance of other people.

External strategies- a range of behaviors from receiving help from friends or family members to emergency psychiatric evaluation and possible hospitalization.

The safety plan is always written and kept where it can be retrieved during times of crises.

Family members, especially spouse & parents, may be involved in the safety planning. The therapist and patient collaborate on how the family can be helpful in supporting the patient to use the safety plan.

It is important to discuss with the patient and family members the elimination of any potential lethal means in the patient’s environment.

For the initial session, there may not be sufficient time to develop a full elaboration of the safety plan based on a chain analysis. However, it is essential to develop a rudimentary safety plan and chain analysis, both of which are elaborated in later sessions.

Thus, the first session always includes a written safety plan and is further modified in subsequent sessions as more information was gathered through a more detailed chain analysis.

Psycho education

explain to the patient and family members the nature of suicidal behavior, the role of depression and the need for securing potential lethal means

Inputs from family members for chain analysis and making safety plan

Addressing Reasons for Living and Building Hope

Given that hopelessness is often associated with suicide risk, it is important to include treatment strategies that instill a sense of hope.

Discuss the patient’s personal reasons for living.

Delineating reasons to live is an important activity because learning to cope with suicidal urges is rather empty if there are no reasons to want to cope.

The therapist should explain how recalling reasons to stay alive may be impaired during a crisis. The ability to recall reasons for living can be used as a specific coping strategy in distressing times.

The patient is also encouraged to construct a “Hope Kit,” a concrete implementation of the patients’ reasons to stay alive.

The kit serves as a memory aid to be used in times of crisis, can help to increase hopefulness about the future and provide reminders about patients’ sense of purpose.

Hope kits can contain pictures of loved ones, reminders of aspirations and places that give them pleasure (e.g. seashells, picture of mountains).

Case Conceptualization Following the first two sessions, the therapist develops a case

conceptualization based on the chain analysis. As mentioned earlier, the therapist identifies the specific cognitive, behavioral, affective, and contextual problems that were identified during the chain analysis and then selects corresponding strategies to address these problems.

The therapist and patient discuss the specific goals for reducing suicidal risk and then discuss the suggested approach in a collaborative manner. Adjustments to the treatment plan are made for each patient. The prioritization of specific skills training should include those skills that are most likely to prevent a subsequent suicide attempt and that build on the adolescent’s existing strengths. Once the interventions are collaboratively selected by the therapist and patient, the treatment plan is presented to the family for feedback.

During the middle phase of acute treatment (approximately sessions 4–9), after the immediate suicidal crisis has resolved, the primary area of intervention is behavioral and/or cognitive skills training using individual or family sessions. Skills training is included as a series of optional individual and family modules. These modules are presented below.

Individual Skill Modules

Individual skill modules include: (1) Behavioral activation and increasing pleasurable activities; (2) Mood monitoring, (3) Emotion regulation and distress tolerance techniques; (4) Cognitive restructuring; (5) Problem solving; (6) Goal setting; (7) Mobilizing social support; and (8) Assertiveness skills.

Family Skill Modules

The goal of CBT-SP’s family intervention is focused on reducing suicide risk by encouraging family support; improving the family’s problem solving skills; and modifying the family’s communication patterns.

The family modules may be implemented as part of or as adjunctive to the corresponding individual module, or they may be implemented during a distinct, separate session.

The majority of CBT-SP sessions are devoted to introducing and teaching new skills and uses multiple modalities to assist the patient to learn the relevant skill.

These include presenting the rationale, explaining and teaching the skill, using role-play during the session to rehearse the skill, and working collaboratively to develop a homework assignment so that the new skill can be used in the patient’s life.

Each session ends with a summary and a collaborative agreement about a homework assignment.

The therapist helps the patient to summarize the key points that have been raised or the key elements of new learning that appear to be relevant to prevent recurrence of suicidal behavior.

In the first few sessions, the therapist may be very active in summarizing the content of the session but it is important for the patient to do it by him- or herself as the therapy proceeds. In addition, it is very important for the therapist to elicit feedback throughout the session and at the end of the session. Feedback helps the therapist to understand those aspects of the session that were perceived to be most helpful and to address any issues that may have been upsetting for the patient.

The final component of the acute intervention phase includes a relapse prevention task. Once patients have successfully completed the relapse prevention task, the continuation phase is conducted.

Relapse Prevention Task

This module, conducted at approximately sessions 10 to 12, usually marks the end of the acute phase of treatment. The relapse prevention task is an “in-vivo” guided-imagery technique to test the efficacy of the acquisition of skills and coping capabilities in preventing suicidal behavior in the future. If the patient has difficulty completing the relapse prevention task, the therapist and patient identify obstacles to its completion and may review previously taught skills or add new skills.

The relapse prevention task includes five steps: (1) Preparation, (2) Review of the Indexed Attempt or Suicidal Crisis, (3) Review of the Attempt or Suicidal Crisis using Skills, (4) Review of a Future High Risk Scenario, and (5) Debriefing and Follow-up.

They are told that by imagining the suicide attempt and reliving the pain that was experienced, patients will have the opportunity to assess whether the coping skills learned in therapy can be recalled.

During the review of the indexed attempt or suicidal crisis, the patient is asked to imagine the sequence of events that led to the index suicide attempt and the associated thoughts and feeling leading up to and following the suicide attempt.

Next, the clinician again leads patients through the same sequence of events, but this time the therapist encourages the patient to imagine using the skills learned in therapy to cope with the events, feelings and thoughts.

As they imagine the chain, patients are asked to describe the sequence of events and coping skills out loud and using the present tense. Patients are encouraged to rehearse applying the skills learned in therapy to the situation described in the chain analysis to result in a better outcome.

During the next step, patients are encouraged to imagine, and describe in detail, a future scenario that could lead to a suicidal crisis.

A crucial part of the task is for patients to anticipate when and how they can apply the skills learned in therapy in future situations.

Finally, debriefing is conducted after the relapse prevention task has been completed and follow-up plans are formulated. Patients are provided with support and encouragement for conducting this task. In addition, feedback should be obtained from patients. At the end of the intervention and in the following sessions the therapist and patient review the changes the patient has made over the course of treatment and the skills he/she have learned. It is crucial that they also review the safety plan before patients leave the relapse prevention session.

Continuation Phase

During the continuation phase, the therapist may introduce new skills or continue to help the patient or family to learn and implement the skills introduced in the acute phase. The termination sessions include explicit discussion of reactions to the conclusion of treatment, review of successful strategies that were learned in the therapy and the goals that were accomplished as well as a discussion of whether treatment is needed for other problems the patient may be experiencing.

In this final phase, the therapist also encourages the patient to identify specific anticipated difficult or stressful situations and review the use of the new skills as they would apply to these future situations. It is important to prepare the patient for mood fluctuations and setbacks and discuss specific signs of personal risk that have been identified through the chain analysis and the course of treatment with the patient. The importance of continuation or maintenance treatment for both partially and fully recovered patients should be emphasized. Issues surrounding ending treatment also should be discussed with the family and include: (1) Review of warning signs of depressive symptoms and suicidal crises, (2) Goals achieved in therapy, (3) Impact of treatment on the rest of the family, (4) Strategies for handling possible future episodes, and (5) The current need for further treatment.

developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder(BPD) and chronically suicidal individuals

Emotional mind

Logical mind

Wise mind

Core mindfulness-experiencing the event as it is with a relaxed mind(taught by deep breathing skills)

Interpersonal skills

Emotional regulation skills-not controlling: learning how to express ones negative emotions and how to process them

Distress tolerance-how to cope up crisis

Doctors have the highest rate of suicideamong all the professions. In the US every year, between 300 and 400 physicians take their own lives. And, in sharp contrast to the general population, where male suicides outnumber female suicides four to one, the suicide rate among male and female doctors is the same

The rate of suicidal deaths among doctors is 2-4 per cent as against only about 1-2 per cent among general population.

Male physicians have a 70 per cent higher suicide rate than males in other professions; and female physicians have a 400 per cent higher rate than females in other professions

Doctors face severe mental stress and strain. This is usually more than what an average person experiences. this results in mental and physical strains. If these stress and strains are not managed properly and there are various precipitating factors, they can manifest as depression, and under this depressed state the doctors try or commit suicide

Stress in the life of a doctor begins right from this childhood: in fact from his school leaving days, when he faces the tough competitive medical entrance examination followed by high expectations of parents and relatives with high social stigma. There is tough tiring schedule of at least five and a half years of education period. He not only has to pass out, but to secure good marks to get admission in desired post graduate subject. In the present era of specialization and super specialization, the training period ordinarily extends to another 3 to 6 years resulting in:1. Delay in the settlement of life.2. Delay in the marriage and in the further planning.3. Extended financial dependence on parents and the relatives.4. Stress to get good job opportunities and work satisfaction

Medical students and residents also more vulnerable

Burnout, Depression and Suicide among Medical Students

In episodes of depression, the trainees, having both the knowledge and access to dangerous drugs, may get driven to use them and commit suicide in their week moments

A study by Abhinav Goyal et al (Journal of Mental Health and Human Behaviour, 2012) on 265 undergraduate students of a medical college in Delhi reported an association as high as 53.6 per cent with suicidal ideation.

Suicidal ideation was highest in first professional year (64.4%) and lowest in third professional year (40.4%). About 4.9 per cent students seriously contemplated suicide and 2.6 per cent attempted suicide at least once in their life

A suicide survivor or survivor of suicide is one of the family and friends of someone who has died by suicide

Estimates are that for every suicide, "there are seven to ten people intimately affected"

Suicide is a criminal offence under Section 309 of the IPC with a punishment of up to one year in jail and a fine.

The offence is bailable, non-compoundable and triable by any Magistrate

Suicide is never to be presumed. Intention is the essential legal ingredient.

If a person before age for criminal responsibility commits suicide he cannot be held liable

"Mental Health Care Bill 2012“- 'need to care and not punish people with mental illness'

Medically assisted suicide(euthanasia, or the right to die) is currently a controversial ethical issue involving people who are terminally ill, in extreme pain, and/or have minimal quality of life through injury or illness

In P. Rathinam v. Union of India, had taken the view that S. 309 of the IPC was unconstitutional, since it was violative of the provisions of Art. 21 of the Constitution. It was held that the right to die was part of the right to life under Art. 21 of the Constitution and hence if S. 309 of the I.P.C. was held to be unconstitutional any person abetting a commission of suicide by another was merely assisting in the enforcement of the fundamental right under Art. 21, and, therefore, S.306 I.P.C. penalising assisted suicide was equally violative of Art. 21 of the Constitution.

Suicide tourism-is mass-media term for a form of 'tourism' associated with the pro-euthanasia movement, which organizes trips for potential suicide candidates in the few places where euthanasia is permitted.

This is in the hopes of encouraging the decriminalization of the practice in other parts of the world

World Suicide Prevention Day – September 10th – each year since 2003.

In 2014, the theme of World Suicide Prevention Day is 'Suicide Prevention: One World Connected.‘

International Survivors of Suicide Loss Day -November 22, 2014

Nanjing Yangtze River Bridge, Nanjing, China – over 2,000 suicides from 1968 to 2006

Golden Gate Bridge, San Francisco, California, U.S. –over 1,500 suicides

Prince Edward Viaduct, Toronto, Ontario, Canada- 492 suicides committed before the Luminous Veil, a barrier of 9,000 steel rods, was constructed. Nicknamed "a magnet of suicide".

Aokigahara forest, Mount Fuji, Japan – up to 108 suicides a year; one source cites as the second most popular spot.

Suicide point (Green valley), Kodaikanal. India.

Accidental deaths and suicides in India 2012;National Crime Records Bureau Ministry of Home Affairs

Shorter Oxford textbook of psychiatry 6th edition

Textbook of Postgraduate Psychiatry,2nd edition JN Vyas, NirajAhuja

www.dsm5.org

www.psychotherapy.net

www.cssrs.columbia.edu

www.suicide.org/international suicide statistics