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Management of Suicidal Attempts – Are Health Care Providers Paying Due Attention?

Submitted by on July 23, 2014 – 5:32 PM

help2Meaning of life is very much subjective based on personal feeling and thoughts; some people enjoy it at their full extent to achieve what they desire. On the other some people consider life as meaningless; they lose interest or motivation in activities of daily. Above mention behavior of human being where a person has no more interest in daily life leads to suicidal ideas and attempts. But a question arises here what is suicidal attempt. According to Picardi, Lega, and Tarolla (2013) “A suicide attempt defines any act, including medication overdose, with nonfatal outcome that attempts to cause or actually causes self-harm or would have done so without intervention from others” (p.47)[10].


The reasons for selecting this topic for publication are to probe the factors of suicidal attempt; to integrate theoretical knowledge for empowerment of mental health practice and prevalence of suicidal attempts in overall population of Pakistan is high. According to Aga Khan University Hospital Health Management Information System Karachi the cases reported in hospitals across Pakistan from 2008 to 2013 age range 16 to 50 years are 228[1]. These are the registered cases only in AKUH, while there are various cases which are not reported in Pakistan because of sociocultural context of Pakistan; which labels suicidal attempts as sinful and shameful act. According to Khan, Mahmud, Karim and Prince (2008), in Karachi prevalence of suicidal attempts in male and female is 4.9:1[6].


During my clinical rotation, I encountered a case of suicidal attempt in a tertiary care hospital in Karachi. A 25 years old male patient was admitted in the Medical Surgical Ward for the immediate management of wound in occipital region. Patient had history of suicidal attempt. He had jumped from the second floor to end his life. The patient was on anti-psychotic medications for the treatment of schizophrenia.


Society provides coping resources and ways to human beings. Like sports, religious practices, cultural festivals and public awareness regarding mental health. Sometimes it affects negatively; for example suffering from terrorist attacks, loss of family members, social injustice and hopelessness are precipitating factors of suicidal attempts.  An important social factor is familial factors, according to Xing, Tao, Wan, Xing, Hao, and Huang (2010) patients who attempted suicide were those who faced  stressful life, for example the parental separation in the term of death or divorce, physical child abuse and improper rearing of children. One of the negative coping behaviors is smoking [12].


According to Boden, Fergusson and Horwood (2008), the etiological factor of the cigarette smoking and suicidal attempts are matching each other, for example a severely depressed patient starts smoking and at the end stage of the depression he attempts for suicide [2]. The other social risk factors of suicidal ideation and attempts are unemployment, family conflict, childhood abused, homelessness and low self-esteem. (Van, Orden, Witte, Cukrowicz, & Joiner, 2010)[11].


There are bio-psychological factors which lead to suicidal attempts. One important factor is protein kinase which creates psychosis in the human being. According to Dwivedi and Pandey (2011) Guanine nucleotide-binding proteins (G proteins) passes the signals in the intracellular environment which triggers gene like brain-derived neurotropic factor (BDNF). This is responsible for the alteration in the mental activities and human brain is unable to respond to the external stimuli, increases the depression, suicidal ideation and attempts.


Another two genes which are activated by PKA i.e. CREB and Rap1 are responsible for the cognitive distortion. Moreover there are the biochemical changes which lead to schizophrenia. Bipolar disease and borderline personality also have higher risk of the suicidal attempts [4]. Related to clinical case scenario with the bio psychological model the level dopamine altered in patient.


According to Levine, Bakst and Rabinowitz (2010) dopamine causes suicidal ideation and 25 to 30% patients of schizophrenia attempt suicide. Dopamine also plays a role in the impulsiveness. Likewise in the Major Depression Disorder the level of the serotonin becomes low and it causes stress and studies have been done on border line personality disorder patients [7]. According to Goodman, Roiff, Oakes and Paris (2012) the border line personality patient with heightened level of impulsivity and aggression committed suicide more violently [5].


According to McIntyre, Muzina, Kemp, Blank, Woldeyohannes, Lofchy, and Konarski,  (2008), there are various variables in bipolar disease which enhance suicidal attempts in the patients, for example disease course, early onset of bipolar disorder, history of recurrent severe depressive episodes. Bipolar disease could be genetic, run in family, severely depressive episodes and impulsiveness and aggression are the major factors of suicidal attempts. Another important factor which is very important is medication compliance of the patient. If a patient is not adhered to the medication he is much more prone to suicidal attempt as compare to those patients who are compliant to the prescribed medications [9].


According to Mangnall and Yurkovich (2008) suicidal attempts are not considered as the deliberate self-harm if it is in response to psychosis or any other disease. Attributes are main key factors of this model i.e. repetitive episode of self-harming, addicted behavior, borderline or any other disorder and other comorbidities. Above described attributes enhance tension, anxiety, hostility and feelings of depression. While proper treatment and care of above mentioned attributes reduce the risk of suicide attempt [8].


In such scenarios role of society is very important because it is coping resource which can change the negative attributes into the positive attributes which result positive consequences in the behavior of the patient. In the clinical scenario discussed in first paragraph, patient was jobless and low self-esteemed. By integrating role of society such problems can be managed through social therapies like Cognition Based Therapy (CBT) and occupational therapy.


The role of health care providers in the psychiatric emergency is very complex in term of medication compliance of patient, suicidal strict observation and one to one patient care in the acute phase of the suicidal ideation. Secondly it is very important to understand that suicidal attempt is a symptom of the underline disease. The above mentioned recommendations are generally applied to all patients who have suicidal ideation or attempted the suicide. In addition to above recommended disease appropriate care is very important.


It has been my clinical experience that in above mentioned scenario staff called the psychiatric consult for the patient and long term management of schizophrenia. Another important technique is known as critical interpretative synthesis. According to Chan, Chien and Tso (2009) the critical interpretative synthesis is a six step method i.e. formulating and reviewing questions, searching literature, sampling, determining quality, and interpret synthesis[3]. The mentioned method is very effective to evaluate disease process and enables to provide disease appropriate care in psychiatric settings.


Another important role of health care provider is advocacy of patient in Governmental and Nongovernmental Organizations for awareness of general public regarding importance of life and policy making for the patients. The need of time for our country is research and scholarly detail on the psychiatric emergency like suicidal attempts and its management which enhances the practice of health team.


It is a matter of fact that the most vulnerable who need immediate attention of health care providers are the patients with past history of suicidal attempts or with suicidal ideation. The sign and symptoms of suicidal attempt are just like cry for help. Being member of health team it is our prime duty to manage the causative or precipitating factors. Being professionals of health team we are responsible and accountable.


We are legally and ethical accountable for the negligence, malpractice and other actions which compromise our care to the psychiatric emergencies like suicidal attempts. Considering these emergencies as cry for help, health care providers should help them out at individual level, institutional level and community level so that the prevalence of suicidal attempts can be lowered down





[1]Aga Khan University Karachi Pakistan Health Information Management System (2013). Suicidal attempts reported in akuh durring 2008 to 2013 . statistical data

[2]Boden, J. M., Fergusson, D. M., & Horwood, L. J. (2008). Cigarette smoking and suicidal behaviour: results from a 25-year longitudinal study. Psychological medicine, 38(3), 433.  doi: 10.1017/S0033291707001547 Retrieved from

[3]Chan,  S.W. C., Chien, W. T., & Tso, S. (2009). Evaluating nurses’ knowledge, attitude and     competency after an education programme on suicide prevention. Nurse Education    Today, 29(7), 763-769.. doi:10.1016/j.nedt.2009.03.013 Retrieved from  

[4]Dwivedi, Y., & Pandey, G. N. (2011). Elucidating biological risk factors in suicide: Role of     protein kinase A. Progress in Neuro-Psychopharmacology and Biological Psychiatry,35(4), 831-841.doi:10.1016/j.pnpbp.2010.08.025 Retrieved from  

[5]Goodman, M., Roiff, T., Oakes, A. H., & Paris, J. (2012). Suicidal risk and management in borderline personality disorder. Current psychiatry reports, 14(1), 79-85. doi: 10.1007/s11920-011-0249-4 Retrieved from:


[6]Khan, M. M., Mahmud, S., Karim, M. S., Zaman, M., & Prince, M. (2008). Case–control study   of suicide in Karachi, Pakistan. The British Journal of Psychiatry, 193(5), 402405.doi:10.1192/bjp.193.5.A18  Retrieved from

[7]Levine, S. Z., Bakst, S., & Rabinowitz, J. (2010). Suicide attempts at the time of first   admission and during early course schizophrenia: a population based study. Psychiatry      research,177(1), 55-59. doi:10.1016/j.psychres.2010.02.01 Retrieved from  

[8]Mangnall, J., & Yurkovich, E. (2008). A Literature Review of Deliberate Self‐Harm. Perspectives in psychiatric care, 44(3), 175-184. doi:10.1111/j.17446163.2008.00172.x                                                                                                     Retrieved from
[9]McIntyre, R. S., Muzina, D. J., Kemp, D. E., Blank, D., Woldeyohannes, H. O., Lofchy, J., …& Konarski, J. Z. (2008). Bipolar disorder and suicide: research synthesis and clinicaltranslation. Current psychiatry reports, 10(1), 66-72.  Retrieved from

[10] Picardi, A., Lega, I., & Tarolla, E. (2013). Suicide risk in skin disorders. Clinics in dermatology,   31(1), p.47. Retrieved from

[11]Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S., Selby, E. A., & Joiner Jr,T.E. (2010). The interpersonal theory of suicide. Psychological review, 117(2), 575.  doi:10.1037/a0018697 Retrieved from    

[12]Xing, X. Y., Tao, F. B., Wan, Y. H., Xing, C., Qi, X. Y., Hao, J. H., … & Huang, L. (2010).  Family factors associated with suicide attempts among Chinese adolescent students:         a national cross-sectional survey. Journal of Adolescent Health, 46(6), 592-599.           doi:10.1016/j.jadohealth.2009.12.006 Retrieved from  



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