Suicide Suicidal behaviour consists of thoughts of suicide, suicidal intent, suicide threats, and deliberate self-harm.

Suicidal intent is not a static concept and changes over time (Shah, 2008). Stengel (1977) suggested that suicidal people neither wanted to live nor die, but desire both at the same time usually one more than the other. It is a balance between self-destructive wishes and self-preservative wishes at that point in time, and can fluctuate rapidly (Ganesvaran & Rajarajeshwaran, 1988). The issue of intent becomes even more complex in elderly patients who, although not overtly expressing a desire to kill themselves, have hidden intent. Inpatient suicides in psychiatric settings are associated with fluctuating-suicidal ideation rather than non-fluctuating ideation (Shah & Ganesvaran, 1997). This is consistent with reports of patients committing suicide when they are getting better (Morgan & Priest, 1991; 1984). It is possible that patients may erroneously reassure staff by falsifying improvement and that they may improve in the asylum setting but cannot cope with reexposure to stressful events in the community or their improvement may simply result in more energy to commit suicide (Morgan & Priest, 1984). An additional important explanation is the concept of terminal malignant alienation (Morgan & Priest, 1988) which is when a patient feels alienated because of the way they are treated. The combination of such alienation and fluctuating suicidal ideation may lead the treating health-care professional to fail to recognise when a patient has a serious risk of suicide (Morgan & Priest, 1991). These issues are equally important in elderly people (Shah, 2008). A passive form of suicide has been observed among elderly patients and has been described as hidden suicide, sub-intentional suicide and indirect self-destructive behaviour (Hasegawa et al, 1992). This is characterised by refusal to eat, or to accept medication, other treatments, or domiciliary services (Nelson & Farberow, 1980). Patients who have hidden or passive suicidal intent are likely to be found in the community or geriatric medicine settings rather than a psychiatric ward. GPs, geriatricians, and community-based psycho-geriatricians should therefore carefully assess the risk of suicide in any patients displaying the described symptoms. Unfortunately, the concept of hidden suicide has been poorly studied. Aetiology & Contributory Factors Comorbidity of disorders greatly increases risk of suicide - more than half of all people who die by suicide meet criteria for current depressive disorder (Cavanagh, Carson, Sharpe & Lawrie, 2003). About 4% of depressed people die by suicide, but the risk is greatest in males and in those who have needed psychiatric hospitalisation, especially for suicide (Coryell & Young, 2005). Clinical predictors of suicide in people with major depressive disorder also include a history of attempted suicide, high levels of hopelessness, and high ratings of suicidal tendencies (Coryell & Young, 2005). Suicide in major depressive disorder is most likely to occur during the first episode, and this seems to be related to alcohol misuse and impulsive-aggressive personality traits (McGirr, Renaud, Bureau, et al, 2008).

10-15% of patients with bipolar disorder die by suicide, commonly early in the illness course (Goodwin & Jamison, 2007). Attention deficit hyperactivity disorder (ADHD) seems to increase the risk of suicide in males via increasing severity of comorbidities, in particular conduct disorder and depression (James, Lai & Dahl, 2004) The risk of suicide seems to be particularly increased in borderline and antisocial personality disorders (Duberstein & Conwell, 1997; Lieb et al, 2004). Although the concept of personality disorders might be irrelevant when suicidal acts often seem to be impulsive (Mishara, 2007). In most studies of risk factors for suicide, a history of self-harm or suicide attempts is the strongest factor, present in at least 40% of cases (Cavanagh et al, 2003). In prospective studies of individuals who are hospitalised after non-fatal selfpoisoning or self-injury, 1-6% dies by suicide in the first year (Owens, Horrocks & House, 2002). The risk is higher in older people, men (Hawton, Zahl & Weatherall, 2003), people who repeatedly self-harm (Zahl & Hawton, 2004), those with high suicidal intent (Harris, Hawton & Zahl, 2005) and those not living with relatives (Cooper et al, 2005). Physical and in particular, sexual abuse during childhood is strongly associated with suicide. The effects of childhood maltreatment and its relations to suicide are compounded by inter-generational transmission of abuse. Familial transmission of suicidal behaviour is most likely if the person attempting suicide has been sexually abused as a child (Brent et al, 2003). Risk of suicidal behaviour can be influenced by exposure to similar behaviour by other people. People bereaved by suicide have an increased risk of themselves dying by suicide (Qin, Agerbo & Mortensen, 2002).

To summarise, risk factors for suicidal behaviour include previous self-harm, family history of suicide, early onset and increasing severity of the disorder, depressive symptoms (including hopelessness) and mixed affective states, rapid cycling and comorbid psychiatric disorder and misuse of alcohol or drugs (Hawton, Sutton & Haw, 2006). Alcohol misuse, particularly dependence, is strongly associated with suicide risk (Conner & Duberstein, 2004). The severity of the disorder, aggression, impulsivity, and hopelessness seem to predispose to suicide. Key precipitating factors are depression and stressful life events, particularly disruption of personal relationships (Conner & Duberstein, 2004). Assessment and Management The management of people at risk of suicide is challenging because of the many causes and poor evidence based. Nevertheless, each person with depression should be screened for suicide risk by specifically asking about suicidal thoughts and plans. Is suicidal ideation is present or if suicidal intentions are suspected, risk factors for suicide should be assessed (Hawton & van Heeringen, 2009) Intention to die (explicitly expressed or inferred from behaviour), cogent plans, and high levels of hopelessness might indicate imminent risk. This risk is likely to be heightened by alcohol misuse, and easy access to method to carry out the suicidal act.

In cases of high or imminent suicide risk, immediate action is needed, including vigilance and supervision of patients, perhaps through hospitalisation, removal of potential methods of suicide, and initiation of vigorous treatment of associated psychiatric disorder. Assessment of fluctuating suicide ideation is also important in inpatient settings, and this should be done before the patient is granted leave from the ward. Clinical principles include taking the patients history carefully, examining their mental state, and ascertaining a detailed collateral history should be adhered to meticulously. While assessing the risk of suicide, careful attention should be paid to longitudinal history of any fluctuation in suicidal ideation as well as intention to commit suicide (Shah, 2008). Managing the high-risk patient: patients who are identified as having depression the most probable diagnosis in the elderly patient with suicidal intention (Shah, 1977) should be treated with anti-depressants. In cases of mood disorder, antidepressants are also included in treatment options, along with mood stabilisers, and psychotherapy. Diagnosis and treatment of depression plays a pivotal part in prevention of suicide. However the relation between antidepressants and risk of suicidal behaviour is heavily debated (Gibbons, Hur, Bhaumik & Mann, 2005; Gunnell, Saperia & Ashby, 2005), particularly in young people (Wheeler et al, 2008). The benefits of adding CBT are debated but might include reduction of the risk of suicide during medication treatment (Goodyer et al, 2007). Although electroconvulsive therapy is commonly the last resort in the treatment of depression, it might have the immediate benefit on expressed suicidal intent in patients with depression (Kellner, Fink, Knapp, et al, 2005) A meta-analysis of randomised trials suggested that the risk of death and suicide in people with mood disorder was reduced by 60% in those taking LITHIUM (Cipriani, Pretty, Hawton & Geddes, 2005). Clozapine may also have anti-suicidal effect. In randomised trial in patients with schizophrenia or schizoaffective disorder at risk of suicide, patients treated with clozapine had fewer suicide attempts and rescue interventions to prevent suicide than did those receiving olanzapine (Meltzer, Alphs, Green, et al, 2003). Because most suicides associated with psychiatric hospitalisation happen shortly after admission (mostly through hanging), or after discharge, safer services, intensive clinical care, and on-going care beyond the point of clinical recovery are important to reduce the risk of suicide in patients with psychiatric disorders (Meehan, Kapur, Hunt, et al, 2006). The high risk of suicide after self-harm or attempted suicide means that individuals with such behaviours, especially those with characteristics indicating high risk, such as repeated self-harm (Skegg, 2005; Zahl & Hawton, 2004), should be targeted in prevention programmes.

School programmes aimed at improving psychological well-being have the potency to contribute to suicide prevention in young people (Gould, Greenberg, Velting & Schaffer, 2003). Programmes in school curricula might increase knowledge of psychological symptoms and help-seeking behaviour (Portzky & van Heeringen, 2006) but also hopelessness and maladaptive coping (Gould et al, 2003). Parents and friends might be appropriate target for gate-keeper training. Another approach is the use of school-based screening strategies, such as the Columbia Suicide Screen, to identify individuals at risk who should receive a second-stage clinical assessment. This approach seems to be reasonably reliable, valid and safe (Gould, Marrocco, Kleinmann, et al, 2005), although a high rate of false-positive cases might be a drawback (Hawton & van Heeringen, 2009). Evaluation One of the main drawbacks of most treatment studies to date involving deliberate selfharm (DSH) patients has been their relatively small size and hence limited power (Hawton et al, 1998). Given the large number of DSH patients presented in hospitals (Wilkinson et al, 2002) and the need to target this population as part of national suicide prevention strategies e.g. the Dept. of Health in the UK in 2002, there is a need for robust information from large trials of pragmatic treatment suitable for application in NHS settings.

Conclusion Because suicide is a complex problem, no single approach is likely to contribute to a significant substantial decline in suicide rates. Clinical studies of suicide prevention are hindered by methodological and ethical problems, especially since many people at risk do not have contact with clinical care. Knowledge about who is at risk of suicide has nevertheless increases substantially, and a number of interventions show promising effects/ Future research must focus on the development and assessment of empirically based suicideprevention and treatment protocols. The challenges of preventing suicide in developing countries need particular attention, because most research comes from developed countries, but most deaths by suicide happen in developing countries (Hawton & van Heeringen, 2009).