ASSESSMENT OF SUICIDALITY RISK FACTORS AND ITS MANAGEMENT

AT POISON CONTROL CENTER CAIRO UNIVERSITY

By
Nareman Aly Mohammed
(B.Sc Nursing)

Submitted for Partial Fulfillment of the Requirements for

Master Degree in Psychiatric/ Mental Health Nursing

Thesis Supervisors

Prof. Dr. Sayeda Ahmed A. Latief

Prof. Dr. Ahmed A. Latief

Professor of Psychiatric/

Professor of Psychiatry

Mental Health Nursing

Head of old age psychiatry unit

Faculty of Nursing

Faculty of Medicine

Prof. Dr. Abdel Rahman El Naggar

Professor of Clinical Pharmacology
Head of Poison Control Center (NECTR)
Faculty of Medicine
Cairo University

FACULTY OF NURSING
CAIRO UNIVERSITY
2012


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Assessment of Suicidality Risk Factors and Its Management at Poison

Control Center Cairo University

Abstract
By
Nareman Aly Mohammed

Suicidality is undoubtedly a pressing clinical issue. It represents a significant public

health problem worldwide. Suicide represents a complex and multi factorial human
behavior, mental illness, genetics, biological, psychosocial and cultural factors that
contribute to the etiology of suicidal behavior. Effective treatment of suicidal
behavior can potentially save an individual's life; therefore, this study was conducted
to assess the suicidality risk factors and its management. A descriptive correlational
design was utilized in this study. A sample is convenient; all patients who were
admitted to Poison Control Center, Cairo University over three months were
recruited. Socio-demographic/medical data sheet, Perceived Social Support Scale,
Beck Depressive Inventory Scale, Beck Suicidal Ideation Scale, Life Stressors
questionnaire and Management questionnaire were used to achieve the purpose of this
study. Results revealed that most of attempters were female adolescents, showed a
higher tendency to be single, unemployed, moderate education , resided urban areas,
using drug self poisoning ,showed none previous attempts ,high suicidal ideation and
moderate depression. The most prominent problems were family problems.
Attempters found low family support and high friend support and without receiving
any type of management except medical management. To conclude suicide attempters
need social and emotional support from their significant others. Further studies about
suicidal ideation assessment among group at risk for early detection are
recommended.

Key words: Suicide, Depression, Suicidal ideation, Social support, Life events

Chairperson of the Thesis

Signed

ACKNOWLEDGEMENT
First and foremost thanks are due to ALLAH, the most beneficial
and merciful.
I wish to express my deepest appreciation and respect to Prof. Dr.
Sayeda Ahmed Abdel Latief, Professor of Psychiatric Mental Health
Nursing, Faculty of Nursing, Cairo University, for her valuable
guidance, kind advice, and useful help throughout this work.

I am very grateful to Prof. Dr. Ahmed Abdel Latief, Professor of

Psychiatry, Faculty of Medicine, Cairo University, for his continuous
support and for his detailed constructive comments and valuable
suggestions.

I also express my sincere thanks and deepest gratitude to Prof. Dr.

Abdel Rahman El Naggar, Professor of Pharmacology and Head of
Poison Control Center(NECTR), Cairo University, Faculty of Medicine,
Cairo University, for his generous encouragement and continuous
supervision during this work.

Finally, my ever lasting thanks should go to all participants and

their families who accepted to cooperate and help me in this research.

Nareman Aly Mohammed

To soul of my mother
To my grandmother
To my husband

vii

TABLE OF CONTENTS
CHAPTER

Items

Introduction
Aim of the Study
Significance of the study
Research Questions

1
3
3
5

II

Review of Literature

Historical perspective
Overview about Suicide
Incidence and prevalence of suicide
Theoretical perspectives of suicide
Etiology
Drug self poisoning
The warning signs of suicide
Epidemiology and risk factors of suicide
Protective factors
Depression and suicide
Suicide and social support
Management and Prevention of Suicide

6
7
11
14
19
22
24
26
41
42
46
48

Subject& Methods

86

III

Research Design
Sample
Setting
Tools for Data Collection
Procedure
Ethical Consideration
Pilot Study

Page

Statistical Analysis

86
86
86
87
90
90
91
91

Limitations of the Study

92

IV

Presentation and Data Analysis

94

Discussion

111

VI

Summary, Conclusion & Recommendations

172

Reference

179

Appendices

214

Thesis Proposal
Arabic Summary

viii

LIST OF TABLES
Table

Title

Page

Table (1)

Distribution of the studied sample according to diagnosis and age

95

Table (2)

Distribution of the studied sample according to marital status and occupation

Table (4)

9
6
Distribution of the studied sample according to previous hospitalization and 97
previous suicide attempt
Distribution of the studied sample according to drug group
98

Table (5)

Distribution of the studied sample according to residence and diagnosis

99

Table (6)

Distribution of the studied sample according to stressful life events

99

Table (6-a)

Distribution of the studied sample according to family and job problems

111

Table (6-b)

Distribution of the studied sample according to study and financial problems

111

Table (6-c)

Distribution of the studied sample according to emotional and health 112

problems
Distribution of the studied sample according to personal problems
113

Table (3)

Table (6-d)
Table (7)
Table (8)
Table (9)
Table (10)
Table (11)
Table (12)
Table (13)
Table (14)

Distribution of the studied sample according to suicidal ideation and 111

depression
Distribution of the studied sample according to family and friend support
111
Distribution of the studied sample according to age groups and suicidal 115
ideation
Distribution of the studied sample according to age groups and depression
116
Distribution of the studied sample according to age groups and family social
support
Distribution of the studied sample according to age groups and friend social
support
Distribution of the studied sample according to age groups and family
problems
Distribution of the studied sample according to age groups and job problems

117
118
119
111

study 111

Table (15)

Distribution of the studied sample according to age groups and

problems

Table (16)

Distribution of the studied sample according to age groups and financial 112
problems
Distribution of the studied sample according to age groups and emotional 113
problems
Distribution of the studied sample according to age groups and personal 111
problems

Table (17)
Table (18)

ix

LIST OF TABLES (Cont`d.)

Title
Table
Table (19)

Page
115

Table (22)

Distribution of the studied sample according to age groups and health

problems
Distribution of the studied sample according to age groups and stressful life
events
Distribution of the studied sample according to stressful life events and
gender
The correlation between suicidal ideation and socio demographic data

118

Table (23)

The correlation between depression and socio demographic data

119

Table (24)

The correlation between family support and socio demographic data

121

Table (25)

The correlation between friend support and socio demographic data

121

Table (26)

The correlation between suicidal ideation, depression, family support and 122
friend support
The relationship between stressful life events and suicidal ideation and 123
depression
The relation between stressful life events and family support and friend 124

Table (20)
Table (21)

Table (27)
Table (28)

116
117

support
Table (29)

The relation between stressful life events and number of previous suicide 125
attempt

Table (30)

Distribution of the studied sample according to the medical management

Table (31)

Distribution of the studied sample according to the psychosocial management, 127

126

rehabilitation, services in hospital and follow up

Tables of Qualitative data
Table (32-a)

Distribution of the studied sample according to family problems

129

Table (32-b)

Distribution of the studied sample according to family conflicts

132

Table (32-c)

Distribution of the studied sample according to marital conflicts

133

Table (33)

Distribution of the studied sample according to job problems

135

Table (34)

Distribution of the studied sample according to study problems

136

Table (35)

Distribution of the studied sample according to financial and emotional 138

problems
Distribution of the studied sample according to health and personal problems 140

Table (36)

LIST OF FIGURES
Figure

Title

Page

Distribution of the studied sample according to

gender.

95

Distribution of the studied sample according to educational

level.

96

Distribution of the studied sample according to

residence.

97

xi

LIST OF ABBREVIATIONS
NECTR

National Egyptian Center of Environmental and Toxicological Research

WHO

World Health Organization

DSH

Deliberate Self Harm

MDD

Major Depressive Disorder

APA

American Psychological Association

RANO

Registered Nurse's Association of Ontario

ECT

Electro Convulsive Therapy

BDI-II

Beck Depressive Inventory

OPI

Organo Phosphorus Insecticides

NSAIDs

Non Steroidal Anti-inflammatory Drugs

OPP

Organo-Phosphorus Poison

CHAPTER I
Introduction

Suicide is a complex problem for which there is no single cause or single

reason. It results from complex interaction of biological, genetic, psychological,
social, cultural, and environmental factors. It is difficult to explain why some people
decide to commit suicide while others, in a similar or even worse situation, do not
(Rihmer, 2007). An important difference between those who attempt suicide and
those who do not may be assigned to the effective use of coping skills or problemsolving skills (Williams, Barnhofer, Crane, & Beck, 2005).

Suicidal behavior is a major health concern in many countries, developed and

developing alike. At least, a million people are estimated to die annually from suicide
worldwide, many more people, especially the young and middle-aged attempt suicide
(Wasserman, Cheng, & Jiang, 2005), 10-20 million attempt suicide, and 50-120
million are profoundly affected by the suicide or attempted suicide of a close relative
or associate (Beautrais, 2006).

Despite this, suicide has received relatively less attention. Lack of resources
and competing priorities in many countries have contributed to this under-emphasis.
Cultural influences, religious sanctions, stigmatization of the mentally ill, political
imperatives, and socio-economic factors have also played a significant role. As a
result, the magnitude of the problem is unknown in some countries and although

there are some highlights in terms of preventive initiatives overall efforts are
uncoordinated, under-resourced, and generally unevaluated (WHO, 2007).

Suicidal behavior is a personal and family tragedy causing great deal of

suffering to the person concerned and to those close to him /her. Such behaviors
cover the whole range from suicidal thoughts to attempted suicide and completed
suicide. Thoughts bout suicide and suicidal attempts can be seen as preliminary
stages of completed suicide; which means that there is a development from thoughts
or ideas about suicide to completed suicide (WHO, 2002).

According to Cohen, Underwood, and Gottlieb (2000), there is a good

evidence that social support plays an important role in mental health or substance use
problems. Therefore, people who are clinically depressed report lower levels of
social support than people who are not currently depressed. Specifically, people
coping with depression tend to report fewer supportive friends, less contact with their
friends, less satisfaction with their friends and relatives, lower marital satisfaction,
and confide less with their partners. It is likely that lack of social support and
feelings of loneliness can make people more vulnerable to the onset of mental illness
like depression.

Suicide is a permanent solution to a temporary problem (American

Association of Suicidology, 2003). It is considered more preventable than any other
cause of death. All suicide persons are ambivalent about life and therefore are never
100% suicidal and approximately 80% of all potential suicide victims give some clue
before exhibiting self destructive behavior (Townsend, 2000; Shives & Isaac, 2002).

Prevention requires knowledge of the dynamics of suicide and the ability to

recognize the potential for suicidal actions in every client (Pompili, Ruberto, &
Tatarelli, 2004). Nurses should be aware of their duty and responsibility towards
their clients, even from themselves whenever possible. Hopefully, through all their
efforts, the tide of senselessness loss of life can be turned, and choices will be made
looking toward life instead of a way from it, through decreasing the risk of suicidal
behavior, supporting effective coping strategies, and promoting well being (Schultz
& Videbeck, 2002).

If suicide does occur, the treating/caring psychiatric nurse has a role and a
number of responsibilities and responses. He or she has a responsibility of informing
the family, working with the staff, communicating with the proper authorities, and
accurately documenting the event in the record. When dealing with a client who has
suicidal ideation or attempts, the nurses attitude must indicate unconditional positive
regard not for the act but for the person and his or her desperation. The ideas or
attempts are serious signals of a desperate emotional state. The nurse must convey
the belief that the person can be helped and can grow and change (Videbeck, 2011).

Aim of the Study

The aim of this study is to assess the suicidality risk factors and its
management.

Significance of the Study

Data generated from this study would help in planning and managing care of
suicidal client as well as training adequately the personnel responsible for the
provision of such care. Moreover, delineating problems of such patients will help
nurses and the families of the patients to institute appropriate measures for reducing
these problems.

Data on suicide is not available for roughly half of the countries (53%) of the
world and slightly more than quarter (27%) of the population. Seventy three percent
of suicides in the world occur in developing countries, though data is unavailable for
73% of these countries. Considering that under- reporting of suicide is major issue in
developing countries, suicide attempts are difficult to count, because many may not
be treated in a hospital or may not be recorded as self-inflicted injury, (Centers for
Disease Control and Prevention, 2007). The enormity of the problem and the urgent
need for suicide prevention is evident. The different risks and protective factors and
the scarcity of human and economic resources necessitate the development of
integrated suicide prevention strategies in developing countries, which function at the
individual, family, community and societal level (Kumar, 2004).

Suicide is a complex dilemma that threatens the major investment of any

nation, which has many contributing factors to be studied aiming at preventing it
primarily. In recent years, the phenomenon of parasuicide has become major focus of
interest to researchers and public health officers alike. In several countries,
parasuicide today compromises one of the most frequent reasons for emergency
hospital admissions in young age group (15-34 years). Again, the knowledge of the
true magnitude of this phenomenon of parasuicide is extremely deficit, even
compared with committed suicide. National records on parasuicide are kept no were
in the world. Health care institutions that treat parasuicide people may or may not
register such cases. So, the actual number of people engaging in some form of
deliberate self harm is unknown, but is probably much greater because, in many
cases, there is no contact with medical services (McAllister, 2003).

Research Questions

1- What are the risk factors that lead to attempt suicide?

2- What are the various types of management for suicidal individual?

CHAPTER II
Review of Literature
Historical Perspective
Suicide is a painful and confusing phenomenon not only for family and friends of
the individual who shows suicidal behavior but also for many professionals. Suicide
occurred with beginning of human history. The word suicide, however, was not used until
centuries after the first recording of such deaths since an ancient time, the right to live or
die was a universal question that has been debated for centuries. It was considered an
intensely complex moral, ethical, religious, and legal issue. In the past, European view on
suicide's beliefs included viewing suicide as wrong, evil, against the law, a sin, and an
embarrassment to the family (Barker, 2011).

According to Okasha (1999), in the Pharaonic times there was no suicide as the
ancient Egyptian felt that not only the "Ka"(Soul), but also the whole body and its organs ,
heart, kidney, etc., came under the responsibility of gods. Thus, by destroying the body, the
soul would lose the house into which, according to the Egyptian belief, it must return every
night in order to be renewed and to be reborn the following morning at sunrise, so as to live
eternally. In ancient Egyptian history according to Okasha, et al., (1986) references to
suicide were very rare. They viewed suicide as a passage from one existence to another.
This view of suicide remained popular through the sixteenth century, and through the
seventeenth and eighteenth centuries, theologians and philosophers were actively debating
the morality of suicide. Since the late eighteenth century suicide has been viewed as a
mental disorder, psychological response, and as such, suicide has come under the mandate

of the health care system. Although pioneers such as Durkheim and Freud began to study
the phenomena from suicidal ideation to parasuicide to suicide, yet, little is known of the
causes and patterns of recruitment from suicidal ideation to parasuicide, and from
parasuicide to suicide, and on the factors which precipitate or protect against these
transformations. So, it is worthwhile to further study the phenomenon of suicide from
theoretical and epidemiological perspectives.

Overview about Suicide

Suicide is derived from the Latin word "self murder". If successful, it is a fatal act
that represents the person's wishes to die. There is a range however, between thinking about
suicide and acting it out. some persons have ideas of suicide that they will never act upon;
some plans for days, weeks or even years before acting; and others take their lives
seemingly on impulse, without premeditation, (Kaplan &Sadock, 2002). Moreover,
Meltzer, Conley, Green, Kane and Knesevich (2003) defined suicide as it is not a diagnosis
or disorder; it is a behavior and is the action of intentionally taking one's own life. The
etiology of suicide is complex and may clinically be classified as continuum that ranges
from suicidal ideation and suicide plans towards (non-violent or violent) attempt and
completed suicide.

Additionally Kettles and Woods (2009) stated that, suicidal behavior is complex
and involves many aspects of an individual's personality, state of health and life
circumstances. Certainly, someone considering a form of suicidal behavior is in a

depressed mood, but this state of mind does not necessarily represent a psychiatric
diagnosis, as it may be a reaction to psychosocial issues and adverse life circumstances.

Lethality of suicide refers to the probability that a person will successfully complete
suicide. Lethality is determined by seriousness of the person's intent, the degree to which
he/she has developed available plan, and availability of the means to execute the plan
(Boyd, 2002). Not all the subjects who survive a suicidal act intended to live, not all
suicidal deaths were planned, consequently, "fatal suicidal behavior "is proposed for those
suicidal acts that result in death, while "non fatal suicidal behavior" refers to suicidal
behavior that doesn't result in the person's death (DeLeo, Bouno, & Dwyer, 2002).

"Nonfatal suicidal behavior" may overcome the long lasting debate among definitions
of "attempted suicide","parasuicide", "deliberate self harm", which are terms used in USA,
and the WHO European Office. For an individual who has engaged in self harm, the risk of
dying by suicide is significantly higher than for the general population (Sakinofsky, 2002),
especially during the first 12 months following self harm. Suicide intent at the time of self
harm was associated with risk of subsequent suicide, especially among female patients
(Haw, Hawton, & Houston, 2003).In this respect, Cooper, Kapur and Webb (2005) found
that risk was highest in the first 6 months in male subjects, compared to females.

Traditional markers of suicidal risk, i.e. suicidal ideation, suicidal threats, mild
suicidal attempts and serious suicidal attempts may therefore not be as helpful a previously
thought. Suicidal behavior as described by Stuart and Laraia (2005) is usually divided into

the categories of suicide ideation, suicide threats, suicide attempts, and completed suicide.
Suicide ideation is the thought of self inflicted death, either self reported or reported to
others. Suicidal ideation may vary in seriousness. It can be passive, when there are only
thoughts of suicide with no intent to act; or active, when there are plans or thoughts of
causing one's own death. All suicide behavior is serious, whatever the intent is, and thus
suicidal ideation deserves the nurse's highest priority care.

Stuart and Laraia (2005) added that, a suicidal threat (suicide gestures) is a warning,
direct or indirect, verbal or non-verbal, that a person is planning to take one's own life. It
may be veiled but usually occurs before overt suicidal activity takes place. Townsend
(2000) stated that, the threat is an indication of the ambivalence that is usually present in
suicidal behavior. It presents the hope that someone will recognize the danger and rescue
the person from self destructive impulses. It also may be an effort to discover whatever any
one cares enough to prevent the person from harming himself or herself. This is considered
to be manipulative behavior, and may be observed.

The term deliberate self harm (DSH) is an intentional, self inflicted, non fatal act
commonly affected by physical means, including attempted hanging, impulsive self
poisoning and superficial cutting in response to intolerable tension (Skegg, 2005). In their
studies, Hawton and James (2005) suggested that the term deliberate self harm is preferred
to "attempted suicide" or "parasuicide" because the range of motives or reasons for this
behavior includes several non- suicidal intentions. They found that although adolescents
who harm themselves may claim they want to die, the motivation in many is more to do

10

with an expression of distress and desire for escape from troubling situations. Even when
death is the outcome of self harming behavior, this may not have been intended.

A suicide attempt is any selfinflicted actions taken by a person that will lead to death
if not stopped. Although all suicide threats and attempts must be taken seriously, vigilant
attention is indicated when the person is planning or trying a highly lethal method. Such
methods include gunshot, hanging, or jumping. Less lethal means include carbon monoxide
and drug over dose, which allow time for discovery once the suicidal action has begun
(Sudak, 2005).

Completed suicide or simple suicide, is death from self inflicted injury, poisoning, or
suffocation where there is evidence that the decedent intended to kill himself or herself. It
may take place after warning signs have been missed or ignored and at the same time some
people do not give any easily recognizable warning signs (Stuart & Laraia, 2005).

Para suicidal behaviors are unsuccessful attempts and gestures associated with a low
likelihood of success. The last level is completed suicide, the successful attempt to end
one's life. Motivation for successful suicide may be conscious or unconscious (Townsend,
2000). Also, WHO defined it as an act with non fatal outcome in which an individual
deliberately initiates a non habitual behavior, that without intervention from others will
cause self harm, or deliberately ingests a substance in excess of the prescribed or generally
recognized therapeutic dosage and is aimed at realizing changes that the person desires via
the actual or expected physical consequences.