Suicide is the act of intentionally causing one’s own death. It is a major public health concern associated with significant social, psychological, and economic consequences.

Suicidal behaviour exists on a spectrum ranging from suicidal thoughts, suicidal plans, suicide attempts, to completed suicide. It is often associated with underlying mental health disorders, substance misuse, psychosocial stressors, and severe life difficulties.

Suicide prevention requires early identification of risk factors, treatment of underlying conditions, restriction of access to lethal means, and strengthening social support systems.

Epidemiology

• Suicide occurs worldwide and affects individuals across all age groups

• It is a major cause of preventable mortality

• Rates vary according to age, sex, social conditions, cultural factors, and access to mental health services

• Individuals with previous suicide attempts have a significantly increased risk of future attempts

Risk Factors

Mental Health Disorders

• Depression

• Bipolar disorder

• Schizophrenia

• Anxiety disorders

• Personality disorders

• Autism spectrum disorders

• Substance use disorders including alcohol dependence

Medical Conditions

• Chronic painful illnesses

• Severe disability

• Chronic fatigue syndrome

• Other chronic medical conditions associated with reduced quality of life

Psychosocial Factors

• Financial difficulties

• Academic difficulties

• Relationship breakdown

• Death of a close person

• Social isolation

• Harassment or bullying

• Major life stressors

Previous Suicidal Behaviour

• Previous suicide attempts are among the strongest predictors of future suicidal behaviour

Pathophysiology

Suicidal behaviour results from complex interactions between biological, psychological, social, and environmental factors.

Contributing mechanisms include:

• Altered emotional regulation

• Impaired problem-solving ability

• Increased impulsivity

• Hopelessness and cognitive distortions

• Neurobiological changes associated with psychiatric disorders

• Reduced coping capacity during periods of severe stress

Clinical Presentation

Patients at risk of suicide may present with psychological distress, behavioural changes, or symptoms related to underlying psychiatric or medical conditions.

Assessment should include evaluation of:

• Suicidal thoughts

• Intent

• Previous attempts

• Access to means

• Psychiatric illness

• Substance use

• Protective factors and social support

Symptoms

Possible symptoms include:

• Persistent sadness or hopelessness

• Feelings of worthlessness

• Loss of interest in usual activities

• Severe anxiety or distress

• Social withdrawal

• Feelings of being a burden

• Expressions of wanting to die

• Increased substance use

• Sudden changes in behaviour or mood

Clinical Signs

Clinical findings may include:

• Agitation or severe restlessness

• Withdrawal from family and social activities

• Poor self-care

• Mood instability

• Signs of intoxication or substance withdrawal

• Evidence of untreated psychiatric illness

• Behaviour suggesting preparation for self-harm

Differential Diagnosis

Conditions that may present with suicidal thoughts or behaviours include:

• Major depressive disorder

• Bipolar disorder

• Schizophrenia

• Schizoaffective disorder

• Anxiety disorders

• Substance-induced disorders

• Personality disorders

• Delirium

• Dementia

• Severe adjustment disorder

Diagnostic Criteria

Suicide itself is not a psychiatric diagnosis but a behaviour requiring clinical assessment.

Assessment should determine:

• Presence of suicidal thoughts

• Presence of suicidal intent

• Presence of a suicide plan

• Previous suicide attempts

• Severity of psychiatric symptoms

• Presence of substance misuse

• Presence of underlying medical or psychiatric conditions

• Level of immediate risk

Investigations

Investigations should be guided by clinical presentation and suspected underlying causes.

Possible investigations include:

• Full blood picture

• Serum electrolytes

• Renal function tests

• Liver function tests

• Blood glucose

• Thyroid function tests where indicated

• Toxicology screening where substance use is suspected

• Assessment for underlying medical illness

Psychiatric assessment is essential.

Management

Management requires immediate assessment of safety, treatment of underlying causes, and prevention of further suicidal behaviour.

Initial management includes:

• Assess immediate suicide risk

• Ensure patient safety

• Provide a supportive and non-judgmental environment

• Remove access to potentially harmful means where possible

• Treat underlying psychiatric or medical conditions

• Involve family or trusted caregivers when appropriate

Non-pharmacological Treatment

Effective suicide prevention interventions include:

• Psychological support and crisis intervention

• Cognitive Behavioural Therapy

• Psychotherapy targeting underlying mental disorders

• Family support and psychoeducation

• Social support strengthening

• Stress management and coping skills training

• Safety planning

• Regular follow-up and monitoring

• Treatment of substance misuse

Pharmacological Treatment

Pharmacological treatment should target the underlying condition contributing to suicidal risk.

Examples include:

• Antidepressants for major depressive disorder

• Mood stabilizers for bipolar disorder

• Antipsychotics for psychotic disorders

Patients starting antidepressants should be monitored closely for increased agitation or suicidal behaviour, especially young patients.

Management According to Underlying Cause

Depression

• Treat depressive disorder according to depression management guidelines

• Assess suicide risk regularly

• Provide urgent psychiatric referral if risk is high

Bipolar Disorder

• Treat mood episodes with appropriate mood stabilizers

• Avoid antidepressant monotherapy in bipolar depression

Psychotic Disorders

• Manage psychosis with appropriate antipsychotic therapy

• Assess risk related to hallucinations, delusions, or severe behavioural disturbance

Substance Misuse

• Manage intoxication or withdrawal

• Provide substance use treatment and relapse prevention support

Referral

Urgent psychiatric referral is indicated for:

• Active suicidal thoughts with intent

• Presence of a suicide plan

• Previous serious suicide attempt

• Severe depression

• Psychotic symptoms

• Severe agitation or behavioural disturbance

• Substance-related suicidal behaviour

• Inability to maintain patient safety

Complications

Possible complications include:

• Suicide attempt

• Completed suicide

• Psychological trauma to family and caregivers

• Social and occupational impairment

• Recurrence of suicidal behaviour

Prognosis

Prognosis depends on:

• Early identification of risk

• Treatment of underlying disorders

• Availability of social support

• Adherence to treatment

• Follow-up care

Many individuals recover when appropriate mental health care and social support are provided.

Prevention

Effective suicide prevention strategies include:

• Limiting access to methods of suicide such as hanging, firearms, drugs, and poisons

• Treating mental disorders and substance misuse

• Early identification of individuals at risk

• Improving access to mental health services

• Careful media reporting about suicide

• Improving economic conditions

• Strengthening community and family support systems