Chapter 1 Suicide Learning From The Past To Improve The Fut

Chapter 1: Suicide 5
Chapter 1 Suicide
Definition of Suicide
On the most fundamental existential level, we pay attention to suicide because it is there, has a kind of captivating compulsion to it, and is an unavoidable, sometimes devastating, life issue (Maris et al., 2000) Durkheim (1952) defined suicide, as "all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result." Freud (1923) defined suicide as the victimization of the ego by a sadistic superego. Suicide also can be defined as the destruction of oneself self-killing or self-murder in the legal sense according to (Clinard et al., 1975) Suicide is ultimately a deadly violence directed against self. As a form of death, it has evoked and evokes a multiplicity of reactions from the living, ranging from sadness and fascination to repulsion and blame (Hassan, 1992). While Retterstol (1993) offered a more detailed definition: an act with a fatal outcome, that is deliberately initiated and performed by the deceased him- or herself, in the knowledge or expectation of its fatal outcome, the outcome being considered by the actor as instrumental in bringing about desired changes in consciousness and /or social conditions.
Leenaarss (1993) definition was: "Suicide is a final act of despair of which the result is not known, occurring after a battle between an unconscious death wish and a desire to live better, to love and be loved." In a footnote he stressed that it was his "definition of the day" and that it might vary from one day' to another. According to the APA (2000) suicide was defined as the act of killing oneself, most often as a result of depression or other mental illness. WhileTorpy et al. (2005) defined suicide simply as a self-inflicted death.
Historical Background
Suicide has been glorified or condemned through the ages and the debate continues even today. With the thinking on and understanding of suicides changing, it is now regarded more as a tragedy than a ritual (WHO, 2006) In the Seventeenth Century Suicide was regarded as a heinous crime in sixteenth- and earlyseventeenth century in England, a kind of murder committed by the initiation of the devil (MacDonald, 1989; MacDonald, 1992). Sir Thomas Browne first used the word suicide in 1642. The word originated from SUI (of oneself) and CAEDES (murder). Since then, the word has evoked constant and continuous debate and has been defined in various ways for medical, social, psychological, administrative, legal, spiritual and religious purposes (Gururaj et al., 2001) In 1637 the English clergyman, John Sym, published what Richard Hunter and Ida Macalpine referred to as 'the first English book on suicide,'entitled Lifes Preservative Against Self-Killing (Goldney et al., 2008) John Sym, the author of the first published piece on suicide, warned that Satan preyed particularly on people plagued by melancholy, "speaking to and persuading a man to kill himself." (MacDonald, 1989; MacDonald , 1992). In deed the first scientific attempt to understand the rationale behind suicide started in 1763 with the work of Merian who emphasized that suicide was neither a sin nor a crime, but a disease (WHO, 2006)
In the Eighteenth Century Perhaps the most evident feature of the upper classes' growing tolerance to suicide was the small role played by physicians and medical writers. Although juries normally excused suicide as lunacy, only one physician, William Rowley, argued for this view: "Everyone who commits suicide is without a doubt non compos mentis(not mentally competent)," he wrote in 1788, "and therefore suicide should ever be considered an act of insanity." (MacDonald, 1989; MacDonald,1992; Matsunaga, 2003). In 1790 two volumes entitled A Full Inquiry into the Subject of Suicide were published by the clergyman,Charles Moore who called suicide "the English Malady". Moore noted that suicide did not imply 'permanent
madness,' although he added, 'Yet it may be allowed, that there is a sort of madness in every act of suicide, even when all idea of lunacy is excluded.' , Moore's comment that 'Such distinctions of sanity and insanity are too fine spin to be fair(Goldney et al., 2008). In the Nineteenth Century In 1858 John Bucknill and Daniel Tuke published what was to become the standard textbook of English psychiatry for many years. It contained a classification of four types of suicide, with suicide arising from suicidal monomania; melancholia; delusions and hallucinations (MacDonald, 1977; Goldney et al., 2008). Three quite different techniques of suicide prevention were characteristic of the Victorians in England and effectively pioneered by them. The first was that of extensive, regular, expert social casework among those known to be at risk. The second characteristic Victorian strategy was environmental,
and went naturally with concern with public health and safety. Sanitarians believed that in the population at large suicidal inclinations could be made less likely by providing more opportunities for fresh air, exercise and healthy recreation; these two strategies were essentially urban. The third, however, was routine in both town and country: custodial care in an asylum. (Anderson,1989). To the best of our knowledge there were no significant books devoted solely to suicide published in the United States in the nineteenth century, but there were certainly research reports and commentariesfor example those contained in the Journal of Insanity, the forerunner to the American Journal of Insanity, and the present day American Journal of Psychiatry. (Hunt, 1945; Goldney et al., 2008). Two latenineteenth century books devoted to suicide were by the Italian Enrico Morselli, published in 1879 and translated into English and German in 1881; and by Emile Durkheim in 1897 the publication of Durkheim's classic Suicide: A Study in Sociology (Goldney and Schioldann, 2000) In the Twentieth Century Goldney et al. (2008) found that in the twentieth century the predominant focus of suicide research was on the importance of psychosocial factors, a focus which was undoubtedly a legacy of the influential work of Durkheim. Durkheim believed that social forces would affect the overall suicide rate. In his study, the dependent variable was the suicide rate, while his major independent variables were religious affiliation, marital status,
military/civilian status, and economic conditions (Durkheim, 1952)
It was in 1905, that a famous psychiatrist, Dr R. Gaupp, indicated for the first time that there were some peculiar and unique personality traits among people committing suicide. Over the last 50 years, researchers have advanced this idea further to conclude that it is the state of mind, along with all external influences, which result in suicide (WHO, 2006).
Epidemiology of Suicide& Cultural Variations

Every year one million people commit suicide, accounting for 1-2% of global mortality, it is the leading cause of premature deaths, especially among young adults (Lonnqvist, 2009). According to WHO estimates for the year 2020 and based on current trends, approximately 1.53 million people will die from suicide; and 10-20 times more people will attempt suicide worldwide. This represents an average one death every 20 seconds and one attempt every 1-2 seconds (WHO, 2001). Figure (A)(Pg.20) shows a worldview of suicide with countries of highest and lowest suicide rates (Bertolote et al., 2005) .The rates of reported suicides have been climbing for decades, at least in much of Europe and the Americas, where data go back far enough to reveal trends. This trend is reflected in a sample of four large countries studied by WHO; Brazil, India, Mexico, and the USA, where increases from 5% to 62% were seen in suicide rates over the past two decades (Brown, 2001). The term 'prevalence' of Suicide usually refers to the estimated population of people who are managing Suicide at any given time. The term 'incidence' of Suicide refers to the annual diagnosis rate, or the number of new cases of Suicide diagnosed each year .In 2006 suicide , it was the eleventh leading cause of death in the U.S., and the prevalence was 33,300 deaths among the population (NIMH, 2009). Data on suicides from different countries and over different time periods must be compared carefully. In the 1950s, just 21 countries reported to
WHO; now more than 100 do, but there are still many gaps. In some countries, such as India, suicide is illegal and this is bound to affect the certification of deaths, possibly driving official figures downward (Bertolote et al., 2005). According to the WHO Mortality Database 85% of suicides in the world occur in low and middle income countries, though data are unavailable for 73% of these countries. Overall, there are no data on suicide for more than half of the world's countries, most of which are developing countries in Asia, Africa and South America. Although data from African countries are lacking, there are isolated reports which indicate that suicidal behavior occurs in these countries as wellstudies have been published from Tanzania, Nigeria, Zimbabwe, Uganda, Egypt, and Ethiopia (Khan , 2005). One of the emerging causes of suicidal behavior in African countries is HIV/AIDS, which needs to be recognized and managed effectively (Gali et al., 2004) The non-reporting countries also include more than 50 countries where the majority of the population is Muslim, including those with populations in excess of 100 million such as Pakistan, Indonesia and Bangladesh. Suicide also occurs in all these non-reporting countries but, due to a variety of religious, legal and cultural factors, data collection and reporting is largely neglected (Khan, 2005) Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially, there were indicators, that the burden of undetected attempted suicide is high in different cultures (Bertolote et al., 2005) , especially in countries (such as China) where it is greatly underreported yet still a major public health crisis(Kleinman & Han , 2002).
According to WHO (2009) reports, suicide is of major concern in Eastern Europe, where rates are up to almost 40 suicides per 100,000 people in some countries, such as Belarus, Lithuania, or the Russian Federation. Also, highly affected is Asia, mainly China, India, and Japan, where 30% of all suicides worldwide occur. In all regions, this poses a tragic loss of those in the most productive years of their life; in particular, suicide is the main cause of death among young women in the Western Pacific Region and the second main cause of death among young men in the European Region. WHO (2009) rates of suicide per 100.000 for most recent year available as of 2009; in the first rank came Lithuania (2005) with the highest rates of suicide for males 68.1, and for females 12.9. While Haiti 2003, Honduras 1978,Jordan 1979 and Saint Kitts and Nevis (1995) ranked the last with lowest rates of suicide 0.0 for both males and females. In the year 2000, suicide was estimated to be the 25th leading cause of death in the countries of the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), but was ranked 7th in the European Region, 8th in the Western Pacific Region and 16th in the South-East Asia Region (Krug et al., 2002). Suicide incidence in USA: (NIMH, 2009) ~2,000 adolescents in the US die from suicide, and ~2 million attempt suicide annually. Overall, suicide accounted for 7.3 deaths per 100,000 persons aged 1519 years in 2003 (11% of all deaths in this age group).
In 2003, suicide accounted for 12.0 deaths per 100,000 persons aged 20 24 years (12.5% of all deaths). In 2005, 17% of youth surveyed in grades 912 reported seriously considering suicide at some point in the preceding year: ~8% reported attempting suicide in the previous year, with 2.3% of youth having an attempt that required medical attention. According to the WHO (2009) regional distribution, the following data about suicide statistics in different countries were obtained : Africa: Among the 53 counties in Africa, only the following four countries reported suicide deaths to WHO until 2009; - Mauritius (2005) males 13.2, females 3.8, ranked the 53rd - Zimbabwe (1990) males 10.6, females 5.2, ranked the 56th - Seychelles (1985) males 21.5, Female 3.1, ranked the 73rd - Sao Tome and Principe (1987) males 0.0, females 1.8, ranked the 90th The Americas(PAHO): In 2004, WHO/PAHO (Pan American Health Organization) estimates indicated that 63.000 people had committed suicide that year. - Antigua and Barbuda (1995), Haiti (2003), Honduras (1978) and Saint Kitts and Nevis (1995) ranked the last with rates 0.0 for both males and females. - Uruguay (2001) males24.5, females 6.4, ranked the 25th - Cuba (2005) males 18.6, females 6.2, ranked the 34th - Canada (2004) males 17.3, females 5.4, ranked the 39th
-United States (2005) males 17.7, females 4.5, ranked the 42nd -Brazil (2002) males 6.8, females 1.9, ranked the 74th - Mexico (2005) males 7, females1.4, ranked the 75th - Peru (2000) males 1.1, females 0.6, ranked the 91st In the United States Of America It was thought that Puerto Ricans have higher rates of suicidal ideation and attempts than Whites or other Latin Americans, when Oquendo et al. (2001) examined this in relation to depression, men from Puerto Rico and Mexican Americans have lower relative rates than White men. Furthermore, they stated that the reported suicide rate for Hispanic Americans was almost half that of non-Hispanic Whites. The emphasis on close relationships and the expectation of adversity may contribute to lower suicide rates in the Hispanic group Runyan et al. (2003) found that although the suicide rate has been worsening for black adolescents, the rate of suicide is still lower in blacks than whites. Asia and the Pacific: Pakistan has the lowest estimated prevalence of less than 3 per 100,000, followed by Thailand at 7.3 per 100,000. Australia, Malaysia, New Zealand and Singapore have low to medium rates of between 9.9 and 13.1 per 100,000. Higher rates of above 15 per 100,000 were seen in China, Hong Kong Special Administrative Region (Hong Kong SAR), and India and still higher rates of above 20 per 100,000 are seen in China, Japan, the Republic of Korea, and Sri Lanka (Hendin et al., 2008). The largest numbers of suicides are found in Asia. Given the size of their population, almost 30% of all cases of suicide worldwide are committed in
China and India alone, although the suicide rate of China practically coincides with the global average and that of India is almost half of the global suicide rate. The number of suicides in China alone is 30% greater than the total number of suicides in the whole of Europe, and the number of suicides in India alone (the second highest) is equivalent to those in the four European countries with the highest number of suicides together (Russia, Germany, France and Ukraine) (Bertolote and Fleischmann, 2002) - Sri Lanka (1991) males 44.6, females16.8, ranked the 4th -Japan (2007) males 35.8, females13.7, ranked the ninth - Republic of Korea (2006) males 29.6, females 14.1, ranked the 12th - China (Hong Kong) (2006) males 19.3, females 11.5; ranked the 21st - China (1999) males13, females 14.8; ranked the 26th - Australia (2004) males16.7, females 4.4, ranked the 44th - India (2002) males 12.8, females 8, ranked the 45th In Japan Japan has one of the highest suicide rates in the world with 32,325 people killing themselves in 2004(Naito, 2007). Naito (2007) added Japanese culture may be a way of another explanation for the high suicide rate in Japan; although most Western cultures forbid suicide, some Eastern cultures are more accepting (Bahatia, 2002) stated. More than 40% of Japanese suicide victims are middle-aged (in their 40s and 50s) as found by (Takahashi, 2002) and heavy drinkers among middle-aged Japanese men, who constitute the majority of Japanese suicide victims, are not the only group vulnerable to subsequent death by suicide. Non-drinkers are also at risk (Akechi et al., 2006; Sher, 2006)
In China The male/female ratio of suicide is about 4 in Western countries such as Australia, the USA and the UK. In Asian countries, for example India and Hong Kong (Yip et al., 2000), this ratio is often less than 2 (Mayer & Ziaian, 2002; World Health Organization, 2002). . China is reportedly the only country in the world in which the suicide rate is higher among women than men (Yip & Liu, 2006) Young women in most countries tend to have high rates of attempting suicide, but easy access to pesticide and rat poison in rural areas of China may account for the high fatality rate. In fact, 62% of suicide deaths in China resulted from ingestion of pesticide or rat poison (Phillips et al., 2002).. However, the rapid increase of charcoal-burning suicides among middleaged men in Hong Kong has led to a higher male/female ratio of suicide (Chan et al., 2005; Yip et al., 2005). Europe : Suicide is a serious public health problem in the European Region, where rates vary from about 40 per million people (in Greece) to about 400 per million (in Hungary). The highest suicide rates for both men and women are found in Europe, more particularly in Eastern Europe, in a group of countries that share similar historical and sociocultural characteristics, such as Estonia, Latvia, Lithuania and, to a lesser extent, Finland, Hungary and the Russian Federation. Nevertheless, some similarly high rates are found in countries that are quite distinct in relation to these characteristics, such as Sri Lanka and Cuba (Bertolote and fleischmann, 2002)
The Baltic and European states of the former Soviet Union had suicide rates in men that rose as high as 6070 per 100 000 in the mid 1990s, Tajikistans rate for men was about 5 per 100 000 and Turkmenistans rate has been around 1213 per 100 000 for most of the last 15 years. - Belarus (2003) males 63.3, females 10.3, ranked the 2nd - Russian Federation (2005) males 58.1, females 9.8, ranked the 3rd - Hungary (2005) males 42.3, females 11.2, ranked the 5th - France (2005) males 26.4, females 9.2, ranked the 19th - Sweden (2006) males18.1, females 8.3, ranked the 28th - Germany (2006) males17.9, females 6, ranked the 30th - Italy (2003) males 11.0, females 3.4, ranked the 60th -United Kingdom 2005 males10.4, females 3.2, ranked the 63rd The Eastern Mediterranean Region(EMR): According to the WHO regional distribution, the lowest rates as a whole are found in the Eastern Mediterranean Region, which comprises mostly countries that follow Islamic traditions (Rezaeian 2007; Bertolote and fleischmann, 2002), The countries of the EMR have certain common factors including religion which justify grouping them together as a Region. The Region is the cradle of many religionsIslam, Christianity, Judaism and Zoroastrianismbut Islam is the religion of about 90% of the people (Baasher, 2001). Iran, for example, had 0.3 suicides per 100 000 in men and 0.1 per 100 000 women in 1991, the latest year for which figures are available. Egypt recorded 0.1 suicides per 100 000 in men and none in women in the late 1980s. Kuwait recorded rates below 2.7 per 100 000 for men and 1.6 per 100
00 for women in 1999, and Syria had rates of 0.2 in men and zero in women in the mid-1980s. -Bahrain (1988) males 4.9, females0.5, ranked the 81st - Kuwait (2004) males 2.5, females 1.4, ranked the 86th - Islamic Republic of Iran (1990) males 0.3, females 0.1, ranked the 93rd - Syrian Arab Republic (1985) males 0.2, females 0, ranked the 95th - Egypt (1987) males 0.1, females 0.0, ranked the 96th - Jordan (1979) both males and females 0.0, ranked the 100th In Egypt The crude rate of suicide attempts in Cairo-Egypt was found to be 38.5 per 100 000. Official government reports are misleading and do not represent the true rate; assuming that one in ten suicide attempts ends with actual suicide, a crude estimate of suicide in Egypt would be about 3.5 per 100 000 (Okasha & Lotaief, 1979). Egypts extrapolated annual incidence of suicide according to US Census Bureau (2004) was 8,171 per 76 million approximate population. Much of the research on suicidal behavior in Muslim countries has been simple descriptive studies of samples of completed and attempted suicides. Despite this, and despite the possible under-reporting of suicidal behavior in countries where such behavior is illegal, suicide rates do appear to be lower in Muslims than in those of other religions, even in countries which have populations belonging to several religious groups (Lester, 2006; Rezaeian, 2009) Clearly, a societys perception of suicide and its cultural traditions can influence the suicide rate. Greater societal stigma against suicide is thought
to be protective from suicide, while lesser stigma may increase suicide (Maharajh and Abdool, 2005). These findings suggest not only different risk factors for suicide among different cultures, but also the presence of undetermined cultural (and even biological) protective factors. The identification of these factors should be the core of any suicide preventive strategy (Bhugra, 2004; Lester and Yang,2005).
Figure (A): a Worldview of Suicide (Bertolote et al., 2005)
Risk Factors of Suicide

Suicide has always been an intriguing subject for researches and studies all through centuries; the search continues throughout the 21st century for assessment of the risk factors of suicide. One of the most striking features of suicide in the late 20th century was the epidemic rise in suicide among young men in most industrialized nations (Biddle et al., 2008). What is the exact underlying cause behind this rise is unknown but speculations had been made to point the reason; and no single factor was clearly associated with the rise in suicide, yet changes in several different factors such as levels of employment, substance misuse, and antidepressant prescribing may contribute. Centers for disease control and prevention CDC (2007) listed the risk for suicide; and defined the risk factors as being a combination of individual, relational, community, and societal factors contribute to the risk of suicide. Risk factors are those characteristics associated with suicide; they may or may not be direct causes: Risk factors of suicide: Family history of suicide Family history of child maltreatment Previous suicide attempt History of mental disorders, particularly depression History of alcohol and substance abuse Feelings of hopelessness Impulsive or aggressive tendencies Local epidemics of suicide
Isolation, a feeling of being cut off from other people Barriers to accessing mental health treatment Loss (relational, social, work, or financial) Physical illness Easy access to lethal methods Unwillingness to seek help because of the stigma attached to mental health. Research in literature confirmed that there are three main risk factors indicating continued high risk of suicide: 1. A statement of continued intent; although clinicians may be reluctant to ask such a blunt question, patients are often surprisingly open about their current state of mind. 2. History of previous suicidal behavior; Many people who complete suicide have made a previous attempt, and a history of self harm or suicide attempts is present in at least 40% of cases. 3. Presence of a psychiatric disorder; about 90% of people who have completed suicide have a psychiatric disorder at the time of death (Ginn,2010). Once these three have been dealt with, further risk factors associated with suicide are: Age 25-54 years Male sex Unemployed or retired Poor physical health
Separated, divorced, or widowed Living alone Lower socioeconomic class Criminal record History of violence (Hawton and Taylor , 2009). Impact of Socio-Demographic Data Concerning Suicide is as follow: Sex It is well known that more men than women commit suicide each year (Nock et al., 2008), whereas women are more likely to be involved in suicide attempts (Payne et al., 2008) Bertolote and Fleischmann (2002) found a relatively constant
predominance of suicide rates in males over suicide rates in females: 3.2:1 in 1950, 3.6:1 in 1995 and 3.9:1 in 2020. There is only one exception (China), where suicide rates in females are consistently higher than suicide rates in males, particularly in rural areas (Phillips et al., 2002) Hawton et al. (2009) stated, Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Recent epidemiological studies highlight that within Muslim-dominated Middle Eastern countries suicide rates are high or are increasing among young females(Rezaeian,2010); while In the USA, almost four times as many males as females die by suicide (CDC, 2009), in the U.K. men are around three times more likely than women are to kill themselves. In Sweden, suicide is commoner among men: during 1998 three times as many men as women committed suicide.
Despite these differences, public policies in the West have tended to treat gender as a descriptive, rather than causal, factor in suicidal behaviors. However, differences between socially constructed masculinities and femininities may impact on suicide-related behaviors and help explain gender differences in both behaviors and outcome (Payne et al., 2008) , Indeed, women's higher rates of depression and other types of internalizing behavior may add to their risk for fatal suicidal behavior compared to males. However, this increased risk may be overridden by other important factors such as lethal intentions as well as impulsivity, aggression, alcohol abuse, and disruptive behavior, (including comorbid conditions), all of which may put men at greater overall risk for fatal acts (Wichstrom and Rossow, 2002) Age It is in relation to age, the most striking changes are perceived, currently more young people than elderly people are dying from suicide(Nock et al., 2008), globally speaking. Currently, more suicides (55%) are committed by people aged 5-44 years than by people aged 45 years and older. Accordingly, the age group in which most suicides are currently completed is 35-44 years for both men and women (Bertolote and Fleischmann, 2002) Suicide is becoming more common in younger age groups. Although elderly adults have historically been much more likely than the young to take their own lives, suicide rates in young adults especially men have been rising steeply in recent years in some European countries, the US, Mexico, the Western Pacific, and elsewhere. In the US, for example, the rate among 1524 year olds trebled between the 1950s and the mid-1980s (Brown, 2001)
Dennis et al.(2005) found that older people are at a much lower risk, and when they do self-harm they are more hopeless, have a poorly integrated social network and much more likely to commit suicide later on. Britton et al. (2008) suggested that hopelessness which defined as a system of negative beliefs and expectancies concerning oneself and one's future, is an important risk factor for both suicide ideation and death by suicide in depressed adults over 50. Payne et al. (2008) added that suicide rates are highest in elderly people in most countries, but in the past 50 years, rates have risen in young people. Using data from the WHO global burden of disease project in Eastern Mediterranean region, estimated rates of suicidal deaths were plotted for different sex and age groups. Overall rates of suicide were higher in females than males in age groups 514 and 1529 years. The peak age for suicides among females was 1529 years (8.6 per 100 000) and for males 60+ years (10.8 per 100 000). As a proportion of all deaths due to injury(Rezaeian, 2007). Occupation and Profession Suicide rates are, not surprisingly, higher in unemployed than employed people (Okasha et al., 1986; Zonda et al., 2006; Harwood et al., 2006; Chen et al., 2006; Kolves et al., 2006) .High suicide rates are associated with mental illness, which is also associated with unemployment (Sher et al., 2001; page et al., 2009) Andrs et al. (2009), found that unskilled blue-collar work, non-specific wage work and unemployment, increases suicide risk more prominently for men than for women.
Regarding socioeconomic status the highest percent for attempted suicide in males was for occupation; males 31% and females 16% (page et al., 2009) Among people in employment, some occupational groups are at increased risk of suicide. Medical practitioners have a high risk in most countries, but female doctors are generally most at risk. Nurses also have a high risk. In both these professional groups, access to poisons seems to be an important factor in determining the high rates. Among doctors, anaesthetists are particularly at risk, with anaesthetic drugs being used in many suicide deaths. Several other high-risk occupational groups (eg, dentists, pharmacists, veterinary surgeons, and farmers) also have easy access to means for suicide (Hawton et al., 2009; Ginn , 2010). There were significant differences between physicians specialties( Hawton et al., 2001) stated with anaesthetists, community health doctors, general practitioners and psychiatrists having significantly increased rates compared with doctors in general hospital medicine, the suicide rate among female nurses was also elevated, whereas police officers seemed to have an intermediate suicide risk Education Suicides are associated with both high and low levels of intelligence and educational attainment (Shah and Bhandarkar, 2009) While examining the impact of education on suicide rates (Hem et al., 2005) found that physicians have a higher suicide rate compared with other graduates and the general population, both among males and females which
increased steeply by age, whereas for non-graduates the rate was highest in the 40-60 years age group. According to socioeconomic status almost one third of suicide attempts were attributable to low educational (page et al. 2009) Abel and Kruger (2005) reported that higher educational attainment was associated with lower suicide rate across the United States. On the other hand Shah & Bhandarkar (2009); Shah(2008) in their study proved that the impact of educational attainment on general population and elderly suicide rates; may occur through interaction with other factors, mediation of the effects of other factors, or by its effects being mediated by other factors. Marital Status Marriage usually has a protective effect against suicide ,which might illustrate the fact that those people who may be prone to suicide are more likely to be single or to have been divorced or widowed (Okasha et al., 1986; Charlton, 1995; Pirkis et al., 2000; Johnston et al.,2006; Rezaeian, 2007;Karam et al., 2008) Andrs et al. (2009) stated that marital status has a comparable influence on suicide risk in both sexes; parenthood is protective against suicide, and the effect is larger for women Being unmarried is associated with a higher suicide rate as compared with being married or living with a partner as found by (Sher et al., 2001; Owens et al., 2003; Zonda et al., 2006; Kolves et al.,2006; Yoshimasuet al., 2008;
Masocco et al, 2009), and being married is a protective factor against socioeconomic inequalities in suicide as proved by(Lorant et al., 2005). However, marriage might not be protective in all cultures, especially for young women. For instance, higher rates of suicide have been reported among married women in Pakistan in comparison to both married men and single women (Khan and Reza, 2000), this may be because social, economic and legal discrimination creates psychological stress that leads these women to commit suicide or deliberately harm themselves. Residence Studies from Western countries have demonstrated that urban dwellers are at increased risk of suicide compared with their counterparts in rural areas (Heikkinen et al., 1994; Isomesta et al., 1997; Johansson et al., 1997; Mortensen et al., 2000) Yet Wilkinson and Gunnell (2000); Singh and Siahpush (2002); Middleton et al. (2003); Levin and Leyland (2005); Hirsch (2006), and Pearce et al. (2007) studied rural residence as a risk factor for suicide. They reported that suicide risk increases for males with increasing levels of rurality and that the rural-urban differentials are increasing over time. Rural suicide rates also were higher for women but the rural-urban differential was found to be decreasing over time. Qin (2005) reported that in spite of that suicide rates are generally higher in urban than in rural areas in most countries, there are noteworthy exceptions like China. Yet studies from Western countries have demonstrated that urban dwellers are at increased risk of suicide compared with their counterparts in rural areas. However, these studies have often failed to adjust risk estimates
for possible confounding factors like marital status, income, and psychiatric illness, which are strongly associated with suicide Even though, the great disparity between rural and urban regions may contribute to high suicide rates in rural areas. This might be due to the lower social and economic positions of people living in those rural areas. They are also less well-educated and have fewer contacts with outside people; far fewer psychiatric services and no hot-line services are available (Qin, 2005). Judd et al. (2006) illustrated a variety of factors may contribute to elevated rates of suicide in rural compared with urban areas; combined factors seem to be of particular importance as possible contributors to the elevated rate of suicide among rural males. These include rural socioeconomic decline; facilitators and barriers to service utilization such as service availability and accessibility, rural culture, community attitudes to mental illness and help seeking; and exposure to firearms Still; living in a large city raises suicide risk for women but reduces it for men (Andrs et al., 2009); a fact confirmed by (Qin ,2005) who found that people living in more urbanized areas are at a higher risk of suicide than their counterparts in less urbanized areas. However, this excess risk is largely eliminated when adjusted for personal marital, income, and ethnic differences; it is even reversed when further adjusted for psychiatric status. Moreover, the impact of urbanicity on suicide risk differs significantly by sex and across age. Urban living reduces suicide risk significantly among men, especially young men, but increases the risk among women, especially women aged 24-35 or >65 years.
Recent years have seen a decline in the urban-rural disparities among men. The effects of marital status, ethnics, income, and psychiatric status can largely explain the increased risk in urban areas (Qin, 2005) Weather Changes and Seasonality Psychiatrists, epidemiologists, and sociologists have debated the existence of an association between weather conditions and suicide seasonality since the preliminary statistical investigations in the 19th century. In his masterpiece, "Suicide," Emile Durkheim noted that "when the days grow longer quickly, suicides increase greatly," i.e., suicide has a peak in the spring or summer and a trough in winter, which has been confirmed in studies conducted in the Northern Hemisphere (Partonen et al., 2004, Petridou et al., 2002) Although few studies have addressed this issue in the Southern Hemisphere, their findings were similar. Chew and McCleary (1995) have shown that higher suicides rates occur during months with more daily sunlight hours. In contrast, in Singapore (at the Equator line), a country with little daily sunlight variation throughout the year, there are no seasonal fluctuations of suicide rates (Parker et al., 2001). A number of studies have examined the impact of meteorological factors on suicide and found that lower suicide rates were associated with increased rainfall , decreased temperature , decreased humidity , and increased sunshine (Qi X et al., 2009) These studies suggest that sunshine regulated hormones, such as melatonin, may have a role in triggering suicide ; yet, Carvalho et al.(2006) in a comparison of drug-free depressive patients with healthy volunteers matched
for age and gender did not reveal any difference in major urinary metabolite of melatonin. Ajdacic-Gross et al.(2007) conducted a study to investigate the effect of weather on suicide and concluded that seasonality in suicide depends on a dose-response mechanism, that is, that heat (light, and so on) enhances susceptibility to suicide, and cold (darkness, and so on) smoothens it . Chew & McCleary (1995) compared suicidal behavior among 28 countries and concluded that seasonal variation in suicide is high in temperate zones (between 30 and 60 north and south of the Equator) and low in the tropics The incidence of suicide had its bottom in winter and top in the spring and summer and paralleled closely the number of bright sunlight hours as proved by (Kevan , 1980; Dixon & Shulman, 1983; Lambert et al., 2003; Hawton et al. 2009 ). Physical Illness Physical illness exerts an extra burden on people as said by Sher (2004); Christensen et al.(2007 ); Payne et al . (2008) pushing them to commit suicide. Individuals with epilepsy have a higher risk of suicide, even if coexisting psychiatric disease, demographic differences, and socioeconomic factors are taken into account, in individuals with epilepsy, the highest risk of suicide was found during the first half year after diagnosis was made and was especially high in those with a history of comorbid psychiatric disease. Chronic pain was also found to increase the risk of suicide (Carson et al., 2010)
Quan et al. (2002) found that there was no evidence that ischemic heart disease, cerebrovascular disease, peptic ulcer and diabetes mellitus might be associated with suicide in the elderly. On the other hand cancer, prostatic disorder, chronic pulmonary diseases appear to be associated with suicide among the elderly. More over visual impairment, neurological disorders, and malignant disease were independently associated with increased risk of suicide in elderly people in men more than in women (Waern et al., 2002). In addition, Keisr et al. (2008) found that high rates of suicide have been found in HIV-infected patients above the rate observed in the general population despite of the introduction of highly active antiviral therapy. Kalichman et al. (2000) said, Persons who are in midlife and older and are living with HIV-AIDS; experience significant emotional distress and thoughts of suicide, suggesting a need for targeted interventions to prevent suicide. Lester (2005) found that blood type was the strongest predictor of national suicide rates and it was quite accurate in predicting the relative suicide rates of European nations.
Dementia
Contrary to the popular belief, receiving a diagnosis of a devastating disease like Dementia, does not exacerbate, and may even alleviate, the risk of suicide as reported by Paulsen et al. (2005). Purandare et al. (2009) Found that in contrast to patients with other psychiatric disorders, patients with dementia were found to have a lower suicidal rate than expected. A recent meta-analysis found that only 0.8% of men and 0.3% of women suffering dementia commit suicide (Matusevich et al., 2003).
Schneider et al. (2001) found that the incidence of suicide is less than 1% of all patients with dementia. Matusevich et al. (2003) tried to give explanations for the lower suicide rate in demented patients. He claimed that failure in the executive abilities and the loss of insight in those patients act as protective factors. On the other hand, Polewka et al. (2004) found that 70% of the dementia patients who attempted suicide suffered from depressive, reactive, or situational disorders, affective depression. Loneliness and bad family situation aggravated the suicidal ideation; and that its mainly due to comorbidity with other psychiatric disorders. Depression is an important common risk factor of suicide and dementia. Family History of Psychiatric Disorders and Suicide Qin et al. (2002); Sher (2004); Payne et al. (2008) found that family history of suicide increased suicide risk irrespective of psychiatric illness for people with and without a psychiatric history. Furthermore Brent and Mann (2005) proved that suicidal behavior is highly familial, and on the basis of twin and adoption studies, heritable as well. Both completed and attempted suicide form part of the clinical phenotype that is familially transmitted, as rates of suicide attempt are elevated in the family members of suicide completers, and completion rates are elevated in the family members of attempters. Impulsive aggression in the family members is associated with family loading for suicidal behavior, and may contribute to familial transmission of suicidal behavior. Shared environment effects such as abuse, imitation, or transmission of psychopathology are other possible explanations (Brent and Mann ,2005).
Protective Factors Against Suicide

The protective factors from suicide are those, which buffer individuals against suicidal thoughts and behavior, they decrease the probability of an outcome in the presence of elevated risk (Nock et al., 2008). To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors (CDC, 2007). Houle et al. (2005) added that the identification of protective factors is a critical issue in suicide prevention. Although formal tests of protective factors are rare in the suicide research literature, several studies of factors associated with lower risk of suicidal behavior have yielded interesting results (Nock et al., 2008). In Figure (B)(pg.43) we find that motherhood, social support, help
seeking behavior and religious sanctions against suicide are the main protective factors from suicide (Gunnell et al., 2005) Protective factors against suicide as listed by (CDC, 2007) Effective clinical care for mental, physical, and substance abuse disorders Easy access to a variety of clinical interventions and support for help seeking Family and community support Support from ongoing medical and mental health care relationships Skills in coping strategies, problem solving, conflict resolution, and nonviolent way of handling disputes
Cultural and religious beliefs that discourage suicide and support instincts for self-preservation (CDC, 2007).
Social Support and Integrity

Meadows et al. (2005) stated, Social support seems to protect against suicide attempts among persons at risk. Perceptions of social and family support and connectedness have been studied outside the context of religious affiliation and have been shown to be significantly associated with lower rates of suicidal behavior (Anteghini et al., 2001; Borowsky et al., 2001; Marion and Range, 2002; O'Donnell et al., 2004). Emotional and psychological support in friends and family members helps as a safeguard against suicide (Smith et al., 2004).A negative correlation between societal suicide rates and social integration has been reported by (Shah, 2008) Bradatan (2007) further added that without a structured and satisfactory perspective on life, people are more likely to take their lives and to develop mental sicknesses, so suicide rate, as well as mental illness incidence, can be seen as measures of societal abnormality. Houle et al. (2005) conducted a study is to investigate whether social support may constitute a protective factor for attempted suicide among men and, if so, to identify the most important sources and forms of support. Results indicated that the men who attempted suicide perceive less support; and are less satisfied with the support they received following the stressful event that occurred .These results are in the same direction as those reported
in previous studies (Sokero et al. 2003;Botnick et al. 2002; Eskin, 1995, Lewinsohn et al. 1993;Veiel et al., 1988). Tangible support (lend money, temporary shelter, helping to move, for example) and the assurance of its value (valuing the individual, recognizing his skills, for example) are the forms of support that appear to be of most importance. This study highlights the importance of social support in the prevention of suicidal behavior among men (Houle et al., 2005). Compton et al.(2005); Kaslow et al.(2005) found that social environment factors including deficits in family functioning and social support are associated strongly with suicide attempts among low-income African American men and women. Thus, better family functioning and social supports can be considered protective factors in this population.
Religion
Religious beliefs, religious practice, and spirituality have been associated with a decreased probability of suicide attempts (Garroutte et al., 2003; Clarke et al., 2003; Blum et al.,2003; Dervic et al.,2004). Despite being forbidden by almost all Western & Eastern religions; as clearly said in the Holy Quran, Bible and Talmud ; suicide has managed to flourish over time (Sudak , 2005) yet few studies have investigated the association between religion and suicide either in terms of Durkheims social integration hypothesis or the hypothesis of the regulative benefits of religion. In 1897, Durkheim was the rst one to propose that spiritual commitment may contribute to emotional well-being, as it provides a source of meaning
and order in the world. Of all the questions, the issue of suicide raises at the hands of Durkheim that of religion in its moral dimension has a prominent place. His assertion that religion is a key variable or perhaps the key variable; in analysing rates of suicide; he holds that suicide rates are lower in Catholic countries and provinces than in those dominated by Protestants of various kinds. He asserted that it is extremely difficult to isolate religion from other variable factors (Pickering & Walford, 2000). Lester (1997) found that Thomas G. Masaryk (18501937), almost unknown today to the international academic community, in his work on suicide (Suicide and the Meaning of Civilization, 1881) considers that the main basis of morality in a society is religion. A decrease of religiosity deregulates the social organism, makes people feel unhappy and increases social disorganization. Religion, he says, is a system that makes psychological life coherent because it offers a structured way of thinking. Modern education destroys religious perspective without offering anything similar, because science does not include an ethical component. Thomas Masaryk theory was reviewed and two predictions derived from the theory: namely, that suicide rates should increase with decreasing religiosity and increasing modernization. Both predictions were supported. Suicide rates have increased in the majority of nations over the last hundred years and are associated with church attendance (but not with religious denomination) over the states of America in 1980(Lester, 1997). One striking protective factor seems to be the practice of Islam, a religion that strongly condemns suicide in most circumstances. Islamic countries tend to have some of the lowest suicide rates in the world, and while the
figures may sometimes be low because death certificates avoid mentioning suicide, some researchers believe they are largely genuine (Brown, 2001; Rezaeian, 2007) In Holy Quran, GOD says anyone who commits suicide will be condemned to Hell and Holy Quran states that no one should kill him/herself, because God has been merciful to him/her. This commandment is believed to play a role in the low rates of suicide recorded among Muslim communities(Rezaeian,2007): " O ye who believe! Eat not up your property among yourselves in vanities: But let there be amongst you Traffic and trade by mutual good-will: Nor kill (or destroy) yourselves: for verily Allah hath been to you Most Merciful! 30. If any do that in rancour and injustice- soon shall We cast them into the Fire: And easy it is for Allah. (Holy Quran; The Women 4:29, 30).
(29) (03),
In fact, there are numerous verses in the Holy Quran that prohibits killing any innocent creature: On that account: We ordained for the Children of Israel that if any one slew a person - unless it be for murder or for spreading mischief in the land - it would be as if he slew the whole people: and if any one saved a life, it would be as if he saved the life of the whole people. Then although there came to them Our apostles with clear signs, yet, even after that, many of
them continued to commit excesses in the land. (Holy Quran; The Table 5, 32)
(93),
In the Bible it is said if you are a Christian your life and for that matter your body are no longer your own, & that it is a sin to kill yourself , as clearly in said these verses (NIV 1 Corinthians, 6:19-20)
19
Do you not know that your body is a
temple of the Holy Spirit, who is in you, whom you have received from God? You are not your own; 20you were bought at a price. Therefore honor God with your body.

19
6 02 . .
(NIV 1 Corinthians, 3:16-17)
16
Don't you know that you yourselves are
God's temple and that God's Spirit lives in you? 17If anyone destroys God's temple, God will destroy him; for God's temple is sacred, and you are that temple.
61 3 71 ,
Also in Jewish the first clear mention of suicide is in the post-Talmudic book Semachot, which declares that those who commit suicide are to receive no burial rites: He who destroys himself consciously (lada-at), we do not engage ourselves with his funeral in any way. We do not tear the garments, and we do not bare the shoulder in mourning, and we do not say eulogies for him; but we do stand in the mourner's row and recite the blessing of the mourners because the latter is for the honor of the living. (Semachot, 2) Despite of this the relationship between religion and suicide attempts has received little attention. (Dervic et al., 2004) ;it was found that greater moral objections to suicide and lower aggression level in religiously affiliated subjects may function as protective factors against suicide attempts. Also (Piko & Kovacs, 2009) found that religiosity is a protective factor which has an impact on all of the three dimensions of health status, among others, it goes together with a longer lifetime, better indicators of health status indicators and quality of life, less anxiety, depression and suicide. Gearing & Lizard (2009) conducted a recent research in the USA that focuses on four major religions in the United States. Among the most common religious groups in the United States, Protestants have the highest suicide rate followed by Roman Catholics. Jewish individuals have the lowest rates of suicide. There are lower recorded rates of suicidal behavior found among Muslims when compared to other religions, such as Christianity or Hinduism. However, across religious denominations a higher degree of religiosity is associated with decreased suicide risk.
Furthermore a recent study found that religion suggests two mechanisms behind its protective effect; first, religious communities and social networks more generally, provide social and emotional support, which restrain suicidal tendencies the community-support mechanism. Second, religious communities prohibit suicide, implying that greater involvement in religious life is inversely related to suicide risk the community-norms results are more in favor of a community-norms explanation than a community-support explanation (Tubergen, 2005) While Klein & Albani (2007) stated that religion might be a possible resource for mental health in many cases, while some forms of religious beliefs also might have an impairing, destructive potential. Also religion may reduce (33%) or increase (10%) the risk of suicide attempts (Mohr et al., 2006) In the United States, areas with higher percentages of individuals without religious affiliation report correspondingly higher suicide rates (Dervic et al., 2004). Hilton et al. (2002) found that annual variation in suicide rate tends to correlate with annual variation in church attendance. Furthermore, older adults (50 or more years of age) who are involved with organized religion are less likely to complete suicide (Nisbet et al., 2000; Pritchard and Baldwin, 2000). Parity Being pregnant and having young children in the home are protective against suicide (Marzuk et al., 1997; Qin and Mortensen, 2003; Nock et al., 2008).
Moral objections Moral objections to suicide were also found to be important protective factor from suicide (Oquendo et al., 2005).
Figure (B): Protective Factors against Suicide. (Gunnell, et al., 2005)
Psychology of Suicide and Theories of Suicidal Behavior

Shneidman (2001) said to critique suicidology it is necessary to also critique its three parent disciplines; psychiatry, psychology and sociology, for suicidology relies on these for many of its core concepts and methods. causes are typically limited to purely mental notions of the self. Lonnqvist (2009) stated, Early psychological theories of suicide focused on the concept of the self. Freuds theory assumed that self destructive behavior in depression represents aggression directed towards a part of the self that has incorporated a loss or rejection of a love object.In his later
theory of suicide Freud presented the construction of the dual instincts where Eros is life sustaining and life enhancing drive in constant interaction with Thantos , the aggressive death instinct. While Menninger (1933) believed that suicide could be understood through the interplay of three internal wishes: Wish to kill Wish to be killed Wish to die
Psychological theories of suicide

Furst and Ostow (1965) stated, Fantasy formation in essence is the result of the interplay between psychic mechanisms on the one hand and important wishes and memories on the other either consciously or subconsciously.
The form taken by the fantasy to commit suicide is determined by the following 7 psychological mechanisms (Furst and Ostow, 1965): 1) Identification with a lost object: Identification occurs in individuals whose object relations are characterized by the need to feel the same as-to be one with-the object. By identification, the distance between subject and object is abolished. In sublimated form, identification gives rise to feelings of loyalty. When a love object with whom one has identified dies, or when there is a strong wish to identify with one who is dead, suicide may present itself as a means for reestablishing sameness, for reuniting the fates of subject and object. The fantasy of identification in death with lost objects probably accounts for most of the socalled "anniversary suicides," and, to a certain extent, for the unusual prevalence of suicide in certain families (Furst and Ostow, 1965). 2) Rebirth: The fantasy of being reborn, of "starting all over again" occurs, at one time or another, almost universally. It is particularly prominent and clinically significant at the beginning of recovery from acute episodes of schizophrenia and from melancholia. Commonly, a patient who wishes to die will attempt to make death more acceptable by persuading himself that it is a preliminary to rebirth, that is, that death will bring not only relief but repair and renewal (Furst and Ostow, 1965). 3) Reunion with mother: The regressive wish to be reunited with the giving, protecting mother of earliest infancy finds expression in the fantasies of many deeply disturbed
individuals. The patient longs for an ideal state, characterized by passivity, helplessness, and the relative absence of disturbing stimuli arising from within or from without. In the unconscious death may be endowed with these qualities. At times the fantasy assumes the form of wishing to return to mother's body and to live there. The formal resemblance between the image of inhabiting mother's body and the state of being interred makes the wish to die more compelling (Furst and Ostow, 1965). 4) Escape : To those suffering the misery of depression or psychosis, death may appear to be a release from suffering. Although this idea may occur at any age, it is probably more common among older, depressed individuals who have become preoccupied with the thought that they have lost all that is important to them, and that life is therefore no longer worth living(Furst and Ostow, 1965). 5) Splitting of the self-image: In predisposed individuals intense intrapsychic pressures may induce a defensive splitting of the self image, commonly into a "good" and a "bad" self. The former image is egosyntonic, the latter ego alien. This splitting may give rise to a number of consequences. Depersonalization is a common result of splitting. In melancholia the image of the self is often divided into two portions.The "bad" fragment remains within the ego and becomes the target of the melancholic's relentless, punitive superego with which the "good" fragment identifies. The patient may speak of a demon clawing away at his insides. The resulting inner pain and tension may be so great as to lead to suicide in a desperate attempt to eliminate one of the protagonists.
The associated fantasies indicate that either the harsh punitive superego or the unacceptable "bad self" may be the primary target of the suicidal impulse (Furst and Ostow, 1965). 6) Autoscopy: Here the patient describes encountering an image of himself while awake. The image may be an hallucination, an illusion, or a vivid fantasy. More than 6o years ago it was suggested that in adult life the double appears as a harbinger of death. This hypothesis is supported by (Ostow, 1960) which reported several autoscopic phenomena, including the following. While walking home from an analytic hour, a depressed patient felt weary and stopped to lean against a tree. He felt that he wanted to stay there, and at the same time he could visualize an image of himself continuing to walk home. "I wanted just to stand there, and let another part of me carry on." When questioned, he said, "Yes, I wanted to die." About a week later the same patient reported another autoscopic incident. As he sat alone in his room reading, it seemed to him that ''another one of me goes to the medicine closet and takes an overdose of sleeping pills." In the first autoscopic incident it is the observing self who is to die while the observed image goes on living. In the second, the roles are interchanged. 7) Revenge: Finally, and perhaps best known, are the fantasies in which suicide represents the ultimate act of revenge aimed at a disappointing object, or a real or imagined persecutor. Here, in effect, suicide is homicide which has been turned against the self (Furst and Ostow, 1965).
The Concept of Shattered Self and Suicide

It was Kohut (1971, 1977) who systematically set about to investigate the concept of self and its importance to an individual's functioning. Kohut was of the opinion that self is a permanent mental structure of a person's experience of him/herself, consisting of feelings, memories, and behavior. He further stated that 'self' is the centre of an individual's psychological universe. He pointed out the importance of self as an intrapsychic structure. The concept of self in its relationship to others leads to the growth of selfesteem in an individual. Responses to and from others, that 'fit', evolve the personal reality and one's emotional state. If responses evoke a positive emotional tone, 'a state of well being', an individual feels endorsed about himself leading to the growth of self-esteem (Kohut, 1971, 1977). However, many elements can cause disorders of self. The impact on the self can alter the structural and functional dimensions of self in many different ways, including the possibility of/or potential for self-destruction. The components of self can undergo changes, which result in a loss of functional integrity, affectivity, sense of self worth, loss of autonomy, and so forth. When the basis of the self-structure and its organization is damaged, the result can be different forms and degrees of self-dissolution, fragmentation, disintegration, and 'implosive' self-destructiveness and suicidal behavior (Vito, 2009).
Psychodynamics of Suicide
Hendin (1991) found that the psychodynamic meaning of suicide for a patient derives from both affective and cognitive components. Rage, hopelessness, despair, and guilt are important affective states in which young
patients commit suicide. The meanings of suicide can be usefully organized around the conscious (cognitive) and unconscious meanings given to death by the suicidal patient: death as reunion, death as rebirth, death as retaliatory abandonment, death as revenge, and death as self-punishment or atonement Jacobs et al. (2003) further added that there are 4 dimensions influencing suicide: 1. Psychological Dimensions Hopelessness; psychic pain/anxiety; psychological turmoil; decreased selfesteem; fragile narcissism & perfectionism . 2. Behavioral Dimensions Impulsivity; aggression; severe anxiety; panic attacks; agitation;
intoxication; prior suicide attempt. 3. Cognitive Dimensions Thought constriction; polarized thinking. 4. Childhood Trauma Sexual/physical abuse; neglect; parental loss. Farberow (1997) stated that most recent psychological theories of suicide accept a multi factorial causation of suicide resulting from an interaction of predisposing and precipitating factors. A person moves towards a suicidal crisis depending on the stressors and presence or absence of protective factors in his or her life. Webb (2003) said that the self is central to the suicidal crisis and must be central to our efforts to understand it. It is the sui in suicide and it is the self that is both victim and perpetrator in any suicidal act; how can we understand suicidality without also understanding the self that suicide seeks to destroy?
Shneidman (1993) theorized that psychache (i.e., intolerable psychological pain) is the key cause of suicide, and accounts for the effect of all other psychological factors even more than hoplessness. Hendin et al. (2004) claims that his own experience with patients seen a few days before their suicide suggests that the acute affective state most associated with a suicide crisis was desperation. Hopelessness, rage, abandonment, and self-hatred, were also significantly more frequently evidenced in the suicide patients. Moreover, certain cognitive aspects among depressed subjects such as perfectionism, low self-esteem and negative cognitive bias, may contribute to the prospective prediction of suicidal ideation (Hendin et al., 2004). Shneidman (1996) said, That it is the words that suicidal people say about their psychological pain and their frustrated psychological needs, that make up the essential vocabulary of suicide. Webb (2003) added that hopelessness is one of the key indicators of suicidality or the main one, hopelessness arises from an absence of meaning or purpose in a life; the fundamental question that suicidality confronts you with is What does it mean to me that I exist? If a satisfactory answer to this question cannot be found then suicide becomes a logical and appealing option. When you add helplessness, the second key indicator of suicidality, which is the false belief that there is no way out of this meaningless hopelessness, then suicide becomes the only option. A recent study conducted by (Andrew et al., 2000) found that a loss event, have independent effects on suicide. The most important type of a loss event for the risk of suicide is the loss of a cherished idea .It is interesting to find
that the loss of a cherished idea which frequently coexisted with the loss of a person, health and material possession; exerted the strongest effect.
The Interpersonal-Psychological Theory of Suicidal Behavior

The interpersonal-psychological theory of suicidal behavior (Joiner, 2005) proposes that an individual will not die by suicide unless s/he has both the desire to die by suicide as well as the ability to do so. What is the desire for suicide, and what are its component parts? What is the ability to die by suicide and in whom and how does it develop? In answer to the first question of who desires suicide, the theory asserts that when people hold two specific psychological states in their minds simultaneously, and when they do so for long enough, they develop the desire for death. The two psychological states are perceived burdensomeness and a sense of low belongingness or social alienation (Joiner et al., 2009). In answer to the second question regarding capability for suicide, selfpreservation is a powerful enough instinct that few can overcome it by force of will. The few who can have developed a fearlessness of pain, injury, and death, which, according to the theory, they acquire through a process of repeatedly experiencing painful and otherwise provocative events, often through previous self-injury, but also through other experiences e.g., repeated accidental injuries; numerous physical fights; occupations like physician and front-line soldier in which exposure to pain and injury is common(Joiner et al., 2009). Joiner et al. (2002) showed that raters detected more expressions of burdensomeness: 1) in the notes of people who had died by suicide vs. notes
from those who intended to die but survived; and 2) in the notes of those who died by violent means vs. those who died by less violent means. In a study of psychotherapy outpatients, Van Orden et al. (2006) showed that a measure of perceived burdensomeness was a robust predictor of suicide attempt status and of current suicidal ideation, even controlling for powerful suicide-related covariates like hopelessness. A low sense of belongingness is the experience that one is alienated from others, not an integral part of a family, circle of friends, or other valued group. As with the research base on perceived burdensomeness, there is abundant evidence that this factor was implicated in suicidal behavior (Joiner et al., 2009).
Acquired Ability to Enact Lethal Self-Injury

While feelings of burdensomeness and low belongingness may instill a desire for suicide, they are not sufficient to ensure that desire will lead to a suicide attempt. Indeed, in order for this to occur, the theory suggests a third element must be present: namely, the acquired ability for lethal self-injury. This aspect of the theory suggests that the body is generally not designed to cooperate with its own early demise; therefore, suicide entails a fight with self-preservation motives. According to the theory, having fought this battle repeatedly and in different domains instills the capacity to stare down the self-preservation instinctshould an individual develop the desire to (Joiner et al., 2009). The basis for this proposition rests primarily on the principles of opponentprocess theory, which suggests that with repeated exposure to an affective stimulus, the reaction to that stimulus shifts over time such that the stimulus
loses its ability to elicit the original response and, instead, the opposite response is strengthened (Solomon, 1980). In light of this, it is hypothesized that the capability for suicide is acquired largely through repeated exposure to painful or fearsome experiences. This results in habituation and, in turn, a higher tolerance for pain and a sense of fearlessness in the face of death. Acquired capability is viewed as a continuous construct, accumulating over time with repeated exposure to salient experiences and influenced by the nature of those experiences such that more painful and provocative experiences will confer greater capacity for suicide (Joiner et al., 2005; Joiner et al.,2009).
Neurobiology of Suicide
Retrospective and cross-sectional studies have identified a number of biologic anomalies associated with suicide and suicide attempts: Hypothalamo-Pituitary-Adrenal (HPA) Axis and DST Non-Suppression Van Heeringen (2003) emphasized that there is clear evidence that the activity of certain neurobiological systems has a role in the patho-physiology of suicidal behaviour. This includes hyperactivity of the hypothalamopituitary-adrenal axis, and excessive activity of the noradrenergic system; these two systems appear to be involved in the response to stressful events. While Mann and Currier (2007) ; Jokinen et al. (2008) found that the most promising biologic predictor HPA axis dysfunction as demonstrated by dexamethasone non-suppression that are each associated with about 4.5 fold greater risk of suicide. On the other hand, Jokinen et al. (2009) proved that DST non-suppression is orthogonal biologic risk factor for suicide in male mood disorder, whereas dysregulation of the hypothalamic-pituitary-adrenal axis seems to be a longterm suicide predictor whereas all males who committed suicide after 1 year were DST non-suppressors. Jokinen et al. (2008) also found positive correlation between low CSF 5HIAA and DST non-suppression, which means that they are relatively independent biomarkers of suicide risk in suicide attempters. The interrelation of the two systems seems to be different in suicide attempters compared to depressed patients without suicide attempt.
Serotonergic System and Suicide Vulnerability Research to date would suggest the possible involvement of the serotonin (5-HT) system in the pathophysiology of suicide (Marazziti et al., 2001) While Mann and Currier (2007); Jokinen et al. (2008) found that the most promising biologic predictors are low CSF 5-HIAA. Sher (2004); Jokinen et al.(2009) proved that Low CSF 5-HIAA is biologic risk factor for suicide in male mood disorder and CSF 5-HIAA is associated with short-term suicide risk; Low CSF 5-HIAA predicted all early suicides (within 1 year). Van Heeringen (2003) added that dysfunction of the serotonergic system is thought to be trait-dependent and associated with disturbances in the regulation of anxiety, impulsivity, and aggression. Uchitomi et al. (2002) also proved the presence of increased density of 5HT2A receptors in the platelets of depressive patients with suicidal ideation. Schiffer et al. (2003) concluded that decreased platelets 5-HT uptake appear to place patients at especially high risk of future suicide. Yet Lauterbach et al. (2006) proved that the use of platelet 5-HT2A receptor activity as biological marker for suicidality in depressed patients could not be proven an appropriate tool. Another finding by Dracheva et al. (2008) was increased serotonin 2C receptor mRNA editing and over expression of the VSV isoform (Val156Ser158-Val160) in the prefrontal cortex may represent an additional risk
factor for suicidal behavior, because the VSV isoform of 5-HT 2C R exhibits low functional activity). Platelets Imipramine Binding Schiffer et al. (2003) concluded that decreased platelets imipramine binding appear to place patients at especially high risk of future suicide. Binding Sites of Tritiated Paroxetine Also Marazziti et al. (2001) carried a study which showed decreased number of specific binding sites of tritiated paroxetine( [3H]Par) in suicide attempters, which suggests the involvement of the presynaptic 5-HT transporter in self-aggressive behavior. Tryptophan Availability Lauterbach et al. (2006) proved that the use of tryptophan availability as biological marker for suicidality in depressed patients could not be proven as an appropriate tool. Serum Lipid Levels Numerous studies described suicide in relation to serum lipid profile, five found an association between low cholesterol levels and subsequent suicides (Zureik et al., 1996; Partonen et al., 1999; Ellison and Morrison, 2001). Two, however, found no difference (Smith et al., 1992; Tamosiunas et al., 2005) and two demonstrated an inverse association (Iribarren et al., 1995; Tanskanen et al., 2000). In (2007); Coryell & Schlesser found that with the use of age-appropriate thresholds, serum cholesterol concentrations may be combined with DST
results to provide a clinically useful estimate of suicide risk; and low cholesterol values were associated with subsequent suicide when age was included as a covariate. Recent evidence found by Kim and Myint (2004); Mekawi et al. (2005) supports that significant differences in total serum cholesterol levels were found between the suicide patients and non-suicide depression patients and between violent suicide patients and non-violent suicide patients when age, sex, BMI and total serum protein levels were controlled. The cutoff point of 180 mg/dl gave a high sensitivity (82%), and the cutoff point 150 mg/dl gave a high specificity (72%). These points can be used as discriminative cutoffs between suicidal and non-suicidal depressive patients; & total cholesterol level may be a useful biological marker for the risk of suicide in depression patients (Sher et al., 2001). EL-shawarby et al. (2008) added that as regards relation of serum lipids with suicide, mean values of all lipid profile measurements (total serum cholesterol, HDL, LDL and CHO/HDL ratio) were lower in the suicidal patients than among non-suicidal patients. In addition, among the suicidal patients, mean values of all lipid profile measurements were lower in attempters than among those with suicidal ideation. On the contrary, Fiedorowicz and Coryell (2007) recently found that low serum cholesterol levels did not predict subsequent suicide attempts and the high cholesterol group was associated with increased risk of suicide attempts.
Suicide Genes Bondyet al. (2006) found two genes thought to be involved in the vulnerability to suicidality , the tryptophan hydroxylase 1 (TPH1)gene , as a quantitative risk factor for suicidal behavior and serotonin-transporter-linked promoter region gene (5HTTLPR), which is also consistently associated with impulsive-aggressive personality traits. Furthermore convergent evidence from a multitude of research designs (adoption, family, genomescan, geographical, immigrant, molecular genetics, surname, and twin studies of suicide) suggests genetic contributions to suicide risk; the totality of evidence from twin studies of suicide strongly suggests genetic contributions to liability for suicidal behavior (Goldsmith et al., 2002;Voracek & Loibl ,2007) Sanghyeon et al. (2007) found two genes, PLSCR4 (phospholipid scramblase 4) and EMX2 (empty spiracles homolog 2) which were differentially expressed in suicide groups vs. non-suicide groups. These differentially expressed, candidate genes are neural correlates of suicide, not necessarily causal. While suicide is a complex endpoint with many pathways, these candidate genes provide entry points for future studies of molecular mechanisms and genetic association studies to test causality.
Suicide and Mental illness

Mental health problems are a major risk factor in suicide as Bertolote et al. (2003) said from a worldwide perspective we do not know nearly enough about the association of suicide and mental disorders to make recommendations on a broader scale. A study carried by Hawton et al.(1998); Ernst et al. (2004) suggested that probably all suicide cases are associated with some form of a psychiatric disorder rather than being psychiatrically normal ,and that most of the individuals who committed suicide and appeared psychiatrically normal after a psychological autopsy may probably have an underlying psychiatric process that the psychological autopsy method, failed to detect. Approximately 90% of suicide cases have a detectable psychiatric disorder in psychological autopsy studies, most of which have been focusing on the presence of axis I disorders (Henriksson et a.l, 1993 ; Vijayakumar and Rajkumar, 1999 , Cheng et al, 2000). Cavanagh et al. (2003) found that about 90% of people who have completed suicide have a psychiatric disorder at the time of death. Jacobs (2000); Sher (2004) mentioned that many psychiatric disorders culminate in the tragic outcome of suicide and that psychiatric patients are at highest risk for suicidal behavior and completed suicide. Bertolote and Fleischmann (2003); Cavanagh et al. (2003) detected over 90% occurrence of psychiatric comorbidity among suicide completers. Comorbidity greatly increases risk of suicide (Payne et al., 2008).
Affective Disorders Hawton et al. (2009) found that almost 90% of people who take their own life are believed to have some kind of psychiatric disorder. Depression increases the risk of suicide by 15 to 20 times, and about 4% of people with depression die by suicide. One of the major mental disorders with high risk for suicide in case-control analysis was according to ICD-10; a major depressive episode as found by (Andrew et al., 2000; Cheng et al., 2000; Sher, 2004) Haw et al. (2003) further noted that a higher suicidal intent was associated with the presence of psychiatric disorder mostly major depression. In
addition, patients with a history of MDD use more lethal methods regardless of age and gender (Astruc et al., 2004) . Clinical predictors of suicide in depressed people as found by Hawton et al. (2009); include previous self-harm, hopelessness, and suicidal tendencies, while delusions have been considered a risk factor for suicidal behavior as said by Krakowski &Czobor (2004). Yet, the impact of psychotic manifestations in MDD on suicidal risk has been a debate till now. Recent studies found no significant evidence that the presence of delusions in MDD patients might influence the suicide risk. Suicide attempts among patients with MDD are strongly associated with the duration of illness. Reducing the time spent depressed is a credible preventive measure (Sokero et al., 2005). Suicide may be the first and the last symptom of depression. It occurs mostly when retardation is slight and anxiety is not too great. So, a proposed slower suicidal process occurs in patients with a severe depression and
psychomotor retardation. The retarded depressed cannot begin the attempt and the very anxious cannot think it out (Bradvik, 2003). Moreover, multiple recurrences and relapses increase the risk of suicidal behavior. About 44% of patients attempt suicide at least once during the course of their illness (Fombonne et al., 2001). This was confirmed by Bradvik (2003), who found that suicidals had more frequent depressive episodes compared to other suicidals and retarded controls. Although recurrent brief depressive disorder (RBD) and MDD share the same diagnostic picture of full-blown depression and are both associated with increased suicide attempt rates. However, longitudinal diagnostic shifts from RBD to MDD or vice versa, called "combined depression" (CD), have demonstrated a substantially higher risk of suicide attempts in epidemiologic and clinical studies (Pezawas et al., 2002). Severity of depression is of particular importance in predicting suicide attempts (Sokero et al., 2003) In fact, suicidal symptoms in depression are often thought to predict a higher severity of illness and a worse prognosis (Malhotra et al., 2004). Grunebaum et al. (2004) found that melancholia at baseline assessment was associated with more serious past suicide attempts and with the probability of future suicide attempts. There are other features of MDD that highly correlate with overall depression severity, and are associated with a greater likelihood of suicide attempts and poorer functional status. Among those are Irritability (Perlis et al., 2005), hopelessness (Hendin et al., 2004; Vedel Kessing, 2004; Sokero et al., 2005). This finding is particularly important for patients with
treatment-resistant depression. They may experience an even greater tendency to become hopeless and to underestimate the benefits of the next treatment. It was found that about half of those patients reported thoughts of death, whereas approximately one third reported significant suicidal ideas or gestures (Papakosras et al., 2003) Qin and Nordentoft (2005) found that major depression patients with a history of admission to a psychiatric hospital are at high risk for suicide. This is relatively more in women than in men. It was found that there are 2 main sharp peaks of risk for suicide around psychiatric hospitalization, one in the first week after admission and another in the first week after discharge (Qin and Nordentoft,2005). Comorbid psychiatric diagnosis with depression markedly increased suicidality, Dumais et al. (2005) found that alcohol abuse, current drug abuse, and cluster B personality disorders increased the risk of suicide in individuals with major depression. Also, higher levels of impulsivity and aggression were associated with suicide. Around 10-15% of patients with bipolar disorder die by suicide, with risk at its highest during the early part of the illness (Hawton et al., 2009). Prospective and retrospective studies of suicides and suicide attempts have shown that factors associated with high suicide risk in patients with affective disorders include; an agitated state, severe psychic anxiety, severe panic attacks, severe or global insomnia, and severe anhedonia (Simon and Hales, 2006). In addition, the risk of completed suicide is higher in bipolar disorder than in unipolar depression as proved by (Hoyer et al., 2000; Raja and Azzoni, 2004).
Baldessarini et al. (2006) said that in bipolar patients, there is one suicide for every three attempts, which confirms the increased risk of suicide in patients with bipolar disorder their attempts are 10 times more lethal particularly if the patient is experiencing severe anxiety, such as anxious thoughts the patient can't stop. This could be a serious risk factor for suicide death than just a suicide attempt. In a recent study of 32,000 bipolar patients the highest risk factor for suicide was being male and having a comorbid anxiety disorder (Fawcett, 2008). Psychotic Disorders Near 5% of people with schizophrenia also die by suicide. Suicidal behavior remains a major source of morbidity and mortality among schizophrenics. The National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia found that over an average of 6 years, 38% of the patients had at least one suicide attempt and 57% admitted to substantial suicidal ideation (Roy, 2009) Suicide was found to be the most common cause of premature death in schizophrenia. It has been estimated that up to 9-13% of all patients with schizophrenia commit suicide and, at least 20-40% make suicide attempts (Raymont, 2001). Risk factors for suicide among patients with schizophrenia were evaluated, and the following were the most important and frequently observed predictors: male gender, young age, short duration of illness, many admissions during last year, current inpatient, short time since discharge, previous and recent suicide attempt, co-morbid depression, drug abuse, poor
compliance with medication, poor adherence to treatment, high IQ, and suicidal ideations(Nordentoft, 2007). Depression occurring either as part of schizoaffective disorder or post psychotic depression; is known to be both a precursor and a concomitant feature of hopelessness and suicidal thinking (Tandon, 2005). Furthermore, Taiminen et al. (2001) found that persistent auditory hallucinations and delusions were associated with suicidal ideation or suicidal behavior. He also noted a greater suicide risk among paranoid schizophrenics and an apparently lower risk among those with negative or deficit subtypes. Adjustment Disorders Polyakova et al. (1998) ; Portzky et al. (2005) found that the suicidal process was significantly shorter in suicide victims diagnosed with adjustment disorder compared with suicide cases diagnosed with other disorders. Furthermore, suicide attempts of people with AD frequently were not planned (Polyakova et al., 1998). In a study by Pelkonen et al. (2005), of the 89 patients who received a diagnosis of AD, those who showed suicide attempts, suicidal threats, or ideation compared to those with the same diagnosis but no suicidal tendencies were characterized by previous psychiatric treatment, poor psychosocial functioning at treatment entry, suicide as a stressor, dysphoric mood, and psychomotor restlessness. Patients with AD engage in deliberate self-harm at a rate that surpasses most other disorders, in a study by Mitrev (1996) he found that of cases of
deliberate self-poisoning among persons with AD, suicidal thoughts persisted in only 11% of patients. Suicide risk was higher in patients with chronic AD and in individuals with previous suicide attempts. Recent findings by (Portzky and Van Heeringen,2006) suggest that the suicidal process (from first indications of suicidal ideation to completed suicide) is significantly shorter and rapidly evolving without any prior indications of emotional or behavioral problems in cases diagnosed with adjustment disorder compared to cases diagnosed with other disorders. This underlines the importance of assessing suicide risk in patients diagnosed with adjustment disorder. Determinants of suicidal behavior in AD lay the blame on (co-morbidity with personality disorders or substance abuse, parent-child conflict, school stress etc..) thus probably the findings of research carried out on psychiatric clinical records show a high rate of suicide due to selection bias. Unfortunately, data from community surveys is lacking (Carta et al., 2009) Anxiety Disorders page et al. (2009); Payne et al . (2008) in their studies found that highest percentage for attempted suicide was for anxiety disorders, their study results suggest that one third of suicide attempts in both males and females are attributable to anxiety disorders Ozkan and Altindag (2005) found that patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning; the rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. Moreover, they
found that the predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects. While non-comorbid panic disorder in particular, seems to be rare among completed suicides. Suicide in persons with panic disorder is mostly associated with superimposed major depression and substance abuse, and with personality disorders (Vickers and McNally, 2004). Social Phobia appears to be a true and frequently severe pathological condition. Patients with Social Phobia are at risk of developing further depression, alcoholism or suicidal behavior (Stein et al., 2000). The risk factors for suicidal behaviour in obsessive-compulsive disorder (OCD) have been less studied compared than in other anxiety disorders as reported by Balci & Sevincok (2009); who also found that associated depression, hopelessness, and aggressive obsessions might play an important role in the occurrence of suicidal ideation in patients with OCD. Tynan (2006) added that one of the leading causes of death of patients with OCD is suicide and estimates reflect that as many as 10% of patients with OCD make suicide attempts in adolescent and adult years. Post Traumatic Stress Disorder (PTSD) An emerging literature suggests that posttraumatic stress disorder (PTSD) patients are at an increased risk for suicide; findings suggest that persons with PTSD are at higher risk for suicide and that in assessing suicide risk among persons with PTSD, careful attention should be paid to levels of
impulsivity, which may increase suicide risk, and to social support, which may reduce the risk (Kotler et al., 2001). Gradus et al. (2010) carried a study where he confirmed the association between PTSD and completed suicide after controlling for psychiatric and demographic confounders ; and proved additionally that persons with PTSD and depression had a greater rate of suicide than expected based on their independent effects. Personality Disorders One of the major mental disorders with high risk for suicide in casecontrol analysis was according to ICD-10; emotionally unstable personality disorder as found by (Andrew et al. ,2000; Cheng et al., 2000; Sher, 2004) . Studies have confirmed that personality disorders and their co-morbidity with other psychiatric conditions are risk factors for both fatal and nonfatal suicidal behaviors (Payne et al., 2008). Self-mutilation, negative life events, childhood sexual abuse, difficulties in social functioning, deficits in future-directed thinking and time perception, as well as familial and neurocognitive factors may be related to increased suicide risk in individuals with borderline and other personality disorders(Krysinska et al., 2006) Emotionally unstable personality disorder (EUPD) is the only personality disorder that includes suicidal behavior as a criterion. Recurrent suicidal behavior is a defining characteristic of EUPD. Among borderline patients, who attempt suicide, concomitant major depression has been associated with an increase in the seriousness and frequency of suicide attempts (Soloff et
al., 2000). Other studies have found that such comorbidity is not predictive of a history of suicide attempts and measures of suicidal intent, lethality, or risk among patients with EUPD (Yen et al., 2004). Mehlum (2009) said that self-injurious and suicidal behaviours are highly prevalent in patients with borderline personality disorder and the risk of completed suicide is high. Oumaya et al (2008) added that borderline personality disorder have high rate of suicide that reaches up to10% this rate is about 400 times that of the general population; Krysinska (2006) confirmed that personality disorders and their co-morbidity with other psychiatric conditions are risk factors for self-mutilation. Zinka (2005) also observed higher auto-aggressive behavior in borderline personality disorder. He described their injuries as noticeably uniform, arranged in parallel, superficial and on body locations that are easily reached. Oumaya et al. (2008) illustrated that the relationships between selfmutilation and suicide in borderline personality disorder are paradoxical. Some authors identify self-mutilation as a protective factor against suicide. Self-mutilation behavior can be defined as an attenuated form of suicide ("focal suicide"). In this way, self-mutilation plays the role of an anti-suicide act, allowing patients to emerge from their dissociation and to feel that they are living again. The risk of suicide will not increase so long as selfmutilation produces the expected relief. Nevertheless, most of the authors exhibit self-mutilation as a risk factor of completed suicide. Verona et al. (2004) found dissocial personality disorder to be the most prevalent personality disorder in suicide. Several authors tried to
explain the dynamic etiology of suicidal behavior in antisocial patients. It was mostly concluded that, it a way of externalizing feelings such as depression, anxiety and frustration in a self-destructive manner. Blasco-Fontecilla et al. (2009) believed that Suicide attempters diagnosed with antisocial personality disorder, histrionic personality disorder, and borderline personality disorder were significantly more impulsive than suicide attempters without these diagnoses; and in contrast to suicide attempters with other cluster B personality disorders, suicide attempters diagnosed with narcissistic personality disorder are less impulsive and have suicide attempts characterized by higher lethality; and patients with narcissistic personality disorder can be at high risk for suicide during periods when they are not suffering from clinical depression. These episodes can seem to be unpredictable as proved by Links et al. (2003) ; who also proved that patients with antisocial or borderline personality disorder are likely to be at increased risk for suicidal behavior when they demonstrate such comorbid disorders; as major depressive episodes or substance abuse disorders, when they experience recent negative life events, or when they have a history of childhood sexual abuse. Alcohol and Drug Abuse One of the major mental disorders with high risk for suicide in case-control analysis was according to ICD-10; substance dependence as found by (Andrew et al., 2000; Cheng et al., 2000; Hunt et al., 2002; Sher , 2004) . The Substance Abuse and Mental Health Services Administration SAMHSA (2009) stated that more recently, the impact of both alcohol and drug abuse
on suicide risk particularly when accompanied by mental illness has been gaining greater traction in the literature. Bilban and Skibin (2005) found that the prevalence rates of suicide due to alcohol intoxication are up to 87.1% in men, and 12.9% in women. Alcoholism and suicidal risk was detected more often in men as in women. Cocaine dependence was associated with most cases of completed suicide and rates are higher for men (94.6%) as found by Garlow (2002); amphetamines, tranquilizers, barbiturates and hallucinogens were more often in suicide attempters. Hunt et al. (2002) found that comorbid personality disorders especially antisocial and borderline eventually increases the risk of suicide attempts in addicts. The availability of lethal amounts of drugs, chaotic life-style and impulsivity, higher neuroticism, hostility and introversion are some of the important factors that predispose drug-dependent persons to suicidal behavior, particularly when they are depressed or intoxicated (Roy, 2001). Other Mental Disorders Anorexia nervosa, attention deficit hyperactivity disorder, and body dismorphic disorder all increase suicide risk (Hawton et al, 2009) Franko et al. (2004) found that 15% of patients with eating disorders reported at least one suicidal attempt over the course of their illness. Significantly more in anorexics (22.1%),than in bulimics (10.9%). The eating disorders patients have more negative feelings towards their bodies, and elevated depression and anxiety. Their self-destructive
tendencies are highly associated with a pervasive sense of disturbance of body image and experience (Stein et al., 2003). Comorbidity in EDs patients may contribute to the risk of suicidal behavior. In particular, MDD and Bipolar disorders (Milos et al., 2004). Subjects with anorexia nervosa or bulimia nervosa often experience self-punishing thoughts and behaviors, including self-mutilation, and suicidal ideation and attempts. These arise out of their profound depression and despair Manley and Leichner (2003), said. Stein et al. (2004) added that substance misuse frequently occurs with eating disorders subjects. It is used as a method to decrease their weight or to relieve the accompanied depression and anxiety. The misuse of substances may aggravate the problem of impulse control and may increase the suicidal risk in those patients.
Suicide Related Phenomena

Suicidal Behavior Shneidman (1981) classified people who engage in suicidal behavior into 4 categories; first, there is: 1. The "death-chancer" who gambles with death by doing things that leave death "up to chance." Suicidal behavior in which there appears to be a calculated expectation for intervention and rescue are examples of this form of subintentional suicidal behavior. 2. The "death-hasteners" are individuals who unconsciously aggravate a physiological disequilibrium to hasten death. Death-hasteners may engage in a dangerous lifestyle, such as abusing the body, using alcohol or drugs, exposing themselves to the elements, or not eating a proper diet. 3. The "death-capitulators," by virtue of some strong emotion, play a psychological role in hastening their own demise. These people give in to death or "scare themselves to death." Shneidman includes in this category voodoo deaths and other deaths in which psychosomatic illness and higher risk of complications (e.g., high blood pressure and anxiety) increase the probability of an early death. 4. Shneidman's fourth and final category is the "death-experimenter," who does not wish consciously to end his or her life but who appears to wish for a chronically altered or "befogged" state of existence. This includes alcoholics and barbiturate addicts.
Deliberate Self-Harm The term Deliberate self-harm (DSH) is an intentional, self-inflicted, nonfatal act commonly affected by physical means, including attempted hanging, impulsive self-poisoning, and superficial cutting in response to intolerable tension(Skegg, 2005). For an individual who has engaged in self-harm, the risk of dying by suicide is significantly higher than for the general population (Sakinofsky, 2000; Owens et al., 2002) especially during the first 12 months following self-harm. Suicidal intent at the time of self-harm was associated with risk of subsequent suicide, especially among female patients (Hawton et al., 2003). Cooper et al. (2005) found that risk was highest in the first 6 months in male subjects, compared to females. Many risk factors have been identified for non-fatal repetition of self-harm. Studies of self-harmers who present to hospitals that used standard diagnostic criteria have shown that more than 90% of these people had at least one psychiatric disorder, most commonly depression, followed by substance abuse ,borderline personality disorder, anxiety disorders (Haw et al., 2001) schizophrenia and affective psychosis (Coleman et al., 2004; Forman et al., 2004). Other independent predictors of a later suicidal risk were: not living with a close relative, avoiding discovery at the time of selfharm, and alcohol misuse (Cooper et al., 2005). Attempted Suicide and Parasuicide From the psychological point of view, Stengal and Cook (1958) mentioned that attempted suicide may represent something other than
incomplete suicide. Those authors were the first to define attempted suicide as "Every act of self-injury consciously aiming at self-destruction". Both verbal threats and self-destructive intention were excluded. On the other hand, trivialities of the physical harm did not exclude the patient, provided that the self-harm intent criterion was met. Kreitman and Philip (1969) then introduced the term "parasuicide" in a way to indicate a behavioral analogue for suicide but, without considering the psychological orientation towards death being in a way essential to the definition. Later, Kreitmann (1977) defined parasuicide as a non fatal act in which an individual deliberately causes self-injury or ingests a substance in excess to any prescribed or generally recognized therapeutic dosage. Recently, 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 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. Attempted suicide is the most powerful predictor of future completed suicide, particularly in the presence of untreated major mood disorders (Rihmer et al., 2006)
Self - Mutilation Self-mutilation is a behavior distinct from suicidal behavior and can be conceptualized as a physically damaging act without the intention to die. It tends to involve repetitive, minor, self-damaging acts and often has a compulsive quality. The patient often performs the act in a dissociative state, feeling no pain. Common forms of self-mutilation include superficial cutting or burning. Patients with Emotionally Unstable Personality Disorder (EUPD) may attribute this behavior to an attempt to manage distressing affects, such as anxiety, anger, or feeling dissociated. Patients with EUPD who practice self-mutilation often also manifest suicidal behavior (Oquendo and Mann, 2000). Suicidal Ideation Suicidal ideation and attempts are common reasons for visits to the emergency department and critical care hospitalizations and a common public health problem all over the world. Most patients who make a suicide attempt have a psychiatric disorder, most frequently a mood, psychotic, or substance abuse (Dubovsky , 2008) Oquendo and Mann (2000) said that suicidality includes thoughts and acts. Suicidal thoughts, or thoughts about wanting to be dead, may be active (i.e., thoughts about the method or timing of killing oneself) or passive (i.e., thoughts or wishes to be dead). These suicidal thoughts may lead to suicidal acts. Suicidal acts that end in death are termed suicide or completed suicide
The presence of previous suicidal ideation and/or attempts significantly elevates suicide risk and worsens self-esteem in depressed subjects (Palmer, 2004). Suicide Gamble Patients gamble their lives that they will be found in time and that the discoverer will save them; for example,to ingest a fatal amount of drugs with the belief that family members will be home before death occurs (Soreff, 2009) Suicide Equivalent In this situation the person does not attempt suicide. Instead, he or she uses behavior to get some of the reactions their suicide would have caused. For example, an adolescent boy runs away from home. He wants to see how his parents respond. Do they care? Are they sorry for the way that they have been treating him? It can be seen as an indirect cry for help(Soreff, 2009) Suicidal Note A suicide note or death note is a message left by someone who later attempts or commits suicide. It is estimated that 1220% of suicides are accompanied by a note, the finding that the incidence of note-leaving remains constant despite increasing suicide rates may suggest that the reasons for suicide do not affect note-leaving as found by (Shiori et al., 2005) Suicide notes provide direct information from suicide victims about their psychological status and often written shortly before the suicide act (Eisenwort et al., 2006; Shiori et al., 2005).
Callanan & Davis (2009) found in a study they carried that the only differences found were that note writers were more likely to have lived alone, had made prior suicide threats, other than this suicide cases with, and without notes are essentially similar. Furthermore, Eisenwort et al. (2006) found that suicide victims who leave suicide notes do not differ significantly from non-note-leavers in sex, age, family status, psychiatric care, motive, or method. This means they are representative for all suicide victims concerning important demographic factors (Brr et al., 2007), considered that the presence of a suicide note is an indication of a failed but serious attempt of suicide.
Suicide Types
The first thought that comes to mind on mentioning the word suicide ;is that suicide by its meaning to kill one self ,yet there are several types of suicide: Durkheim's Typology of Suicide Durkheim (1952) analysis led him to identify four distinct patterns of suicide in the year 1897. The three patterns most commonly referred to are egoistic suicide, altruistic suicide and anomic suicide: 1. Egoistic suicide: Is committed by people who are not strongly supported by membership in a cohesive social group. As outsiders, they depend more on themselves than on group goals and rules of conduct to sustain them in their lives. In times of stress, they feel isolated and helpless. 2. Altruistic suicide: Is committed by people who are deeply committed to group norms and goals and who see their own lives as unimportant. Basically, these suicides involved dying for a cause. 3. Anomic suicide: Is committed by people when society is in crisis or rapid change. In such times, customary norms may weaken or break down. With no clear standards of behavior to guide them, many people become confused, their usual goals lose meaning, and life seems aimless. 4. The final type of suicide is Fatalistic suicide, "at the high extreme of the regulation continuum". This type Durkheim only briefly describes, seeing it as a rare phenomena in the real world. Examples include those with overregulated, unrewarding lives such as slaves, childless married women, and young husbands. Durkheim never
specifies why this type is generally unimportant in his study (Durkheim, 1952). Recent criticism by (Breault, 1994) though, argues that Durkheim's theories of suicide actually have not been empirically supported given the lack of psychological variables included in sociological research on suicide rates such as laws of family influence on suicide rates. While Fernquist, (2007) suggest the continued usefulness of Durkheim's work in analyses of suicide. Copycat /Imitative Suicide Is defined as a duplication, imitation or copycat of another suicide that the person attempting suicide knows about either from local knowledge or due to accounts of the original suicide on television and in other media. Imitative suicide have reported suicide clustering in the general population, either temporal clustering following media reporting of suicide or case studies of geographically localised clusters as found by(Mckenzie et al. ,2005; Cheng et al, 2007; Shoval et al., 2005). They further added that evidence proved that imitative suicide occurs among people with mental illnesses and may account for about 10% of suicides by patients. Goueli et al. (1999) found significantly high reports of imitation and influence by media as the source of suicidal ideation in younger female attempters than their intermediate and older counterparts. He also detected high levels of hysteria and histrionic key traits in those patients which may explain the high prevalence of imitation in their attempts and may suggest a level of immaturity and suggestibility that causes contagion, modeling and copycat suicidal behavior on facing stress.
Which assures the need for more restrained reporting of suicides as part of suicide prevention strategies to decrease the imitation effect. Familicide and Filicide Recently, familial homicide-suicides in particular are of great concern because they often result in the death of family members, young children, and cause additional morbidity, family disruption and childhood psychological trauma. Mathews et al. (2008) stated that femicide-suicide (the killing of women by men who then take their own lives) is the most common form of familial homicide-suicide (Koziol- McLain et al., 2006). Risk factors associated with increased risk of intimate partner femicide included mainly jealousy problems, infidelity, the victim having been left for another partner, forced sex, and abuse during pregnancy are among other risk factors (Campbell et al., 2003). Filicide is the tragic crime of murdering one's own child. Previous research has found that the offending parents are commonly depressed and that suicide is often associated as an actual act or an intention (Putkonen et al., 2009a). Previous studies have demonstrated an association between filicide and parental psychiatric illness, specifically major depression with psychotic features (Bourget et al., 2007; Hatters Friedman and Resnick , 2007; Webb et al., 2007) Chiu (2010) reported repeated filicide-suicide attempts by patients with bipolar II depression.
Indeed, suicide is commonly associated with filicide, both attempted and fulfilled suicide (Putkonen et al., 2009b) Cult / Mass Suicide A cult suicide is a term used to describe the mass suicide of a larger number of people who kill themselves together for the same ideological reason by the members of groups that have been considered cults, a number of paradigmatic cases exemplifying this phenomenon including Jonestown, Waco, The Order of the Solar Temple and Heaven's Gate , and there are some other examples of suicides involving group (e.g., cult suicides) and dyadic (e.g., suicide pacts) processes but these are very rare Townsend (2007) stated. Such as the Apocalyptic suicide a form of suicide amongst a group which believes that the world will end imminently(Dein&Littlewood, 2005).
Pact
A suicide pact is an agreement between two or more people to kill themselves. They represent 0.6-4.0% of all suicides, the vast majority being double suicides (Altindag &Yanik, 2005). The agreement may be to die together, or separately and closely timed , it usually involve small groups of people (such as married or romantic partners, family members, or friends) whose motivations are intensely personal and individual(Schwartz et al., 2009). Hunt et al. (2009) found that pact cases were more likely than solitary suicide cases to have experienced recent adverse life events, typically family problems. Measures that may prevent suicide pacts in the mentally ill
include the effective treatment of depression and closer supervision in both in-patient and community settings. Internet Suicide An Internet suicide pact (cyber-suicide pact), also known as net suicide, is a phrase which has become one of the most notorious terms in recent times. Net suicide refers to suicide pacts that are prearranged between strangers who meet over the internet. Naito (2007) and although cases of suicides or murders planned through the internet have been published in other countries with high internet access rates, such as the USA or Korea, the scale of chain suicide or net suicide seems to be peculiar to Japan. Hagihara et al. (2010); Ozawa (2008) adds the most striking in the recent rise of suicide in Japan are the increase in suicide among young Japanese and the emergence of Internet suicide pacts. Euthanasia There is general consent that assistance with dying by way of intentional killing (active direct euthanasia) is a crime whereas palliative treatment of the terminally ill while accepting the unintentional and inevitable side effect of hastening the patient's death is justified (so-called indirect euthanasia). The so-called passive euthanasia which is characterised by withholding/ withdrawing treatment measures (Ulsenheimer, 2008) assistance in dying, i.e., the actual euthanasia, has to be distinguished from help to die", that is, euthanasia in a broader sense. Euthanasia has to be distinguished from assisted suicide; euthanasia: is the intentional killing by act or omission of a dependent human being for his or
her alleged benefit. (The key word here is "intentional". If death is not intended, it is not an act of euthanasia) Assisted suicide: Someone provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose. When it is a doctor who helps another person to kill themselves it is called "physician assisted suicide." Rich and Butts (2004) stated that with the evolution of advanced medical technology extending life expectancy in older, disabled, and terminally ill people, rational suicide has become a critical issue of debate and its various aspects should be investigated. McLachlan (2010) reported that there is not a significant moral difference between killing and letting die and, by implication, between active and passive euthanasia. He concludes that doctors should not make a distinction between them. However, whether or not killing and letting die are morally equivalent is not as important a question as he suggests. One can justify legal distinctions on non-moral grounds. One might oppose physicianassisted suicide and active euthanasia when performed by doctors on patients whether or not one is in favor of the legalization of assisted suicide and active euthanasia. Furthermore, McLachlan (2010) added one could consider particular actions to be contrary to appropriate professional conduct even in the absence of legal and ethical objections to them. Someone who wants to die might want only a doctor to kill him or to help him to kill himself. However, we are not entitled to everything that we want in life or death. A doctor cannot always fittingly provide all that a patient wants or needs. It is
appropriate that doctors provide their expert advice with regard to the performance of active euthanasia but they can and should do so while, as doctors, they remain no longer able to participate. Kelly and Mcloughlin, (2002) found that although psychiatrists specializing in geriatric or liaison psychiatry may have regular experience in the management of patients in the end stages of dementia or other terminal conditions, most general psychiatrists have little experience of euthanasiarelated issues. The psychiatrist may also be expected to provide an assessment of the patient's decision-making ability and to support staff in their own decision-making process Bannink et al.(2000)added. Euthanasia/Assisted Suicide are viewed differently by moral and religious references. In a religious way, cardinal confessions (Christianity, Judaism, Islamism, Buddhism) condemn euthanasia/assisted suicide and, in the same time have a more relaxed attitude regarding passive euthanasia (Chiri et al., 2009) The various roles of the psychiatrist in this situation, however, may not rest easily with each other. Notably, the concept of assisting rather than preventing suicide counters the core aims of psychiatric practice. The shift of therapeutic role from alleviating psychic despair to facilitating suicide would be a dilemma to many psychiatrists (Kelly and Mcloughlin, 2002). Suicide Attack (Also known as suicide bombing, homicide bombing), is an attack intended to kill others and inflict widespread damage, while the attacker expects or intends to die as well in the process
Schweitzer, (2000) defined terrorism as a motivated violent attack, perpetrated by a self-aware individual or individuals who actively and purposely kill themselves along with their chosen targets. Two main motivations can be identified in the vast majority of suicide terrorist acts: the first is anger and a sense of hopelessness; the second is a deep religious belief that a better life awaits in paradise (Martyrdom) (Salib, 2003) Beliefs held by suicide terrorists may be seen as alien and irrational and probably delusional, by people who do not accept their views. The same beliefs however are rational and shared by the group or people who supports their views (Colvard, 2002).
Methods of Suicide
In general, men tend to choose more violent means for suicide (eg, hanging or shooting and women less violent methods (eg, self-poisoning). Nonviolent suicide includes poisoning, drowning, drug overdose, and violent suicide includes cutting, hanging, jumping from a height or in front of a moving vehicle, or shooting or other means (Busko, 2008). Different populations use differing suicide methods, eg , women in South Asia commonly set fire to themselves to commit suicide. Access to specific methods might be the factor that leads to translation of suicidal thoughts into action. In the USA, firearms are used in most suicides, with risk of their use being highest where guns are kept in households. In rural areas of many developing countries, ingestion of pesticides is the main method of suicide, reflecting toxicity, easy availability, and poor storage. As many as 30% of global suicide deaths may involve ingestion of pesticides (Hawton et al. 2009) . The high suicidal intent (Suomimen et al., 2004) and use of more violent, immediately lethal methods of suicide is characteristic of males (Denning et al., 2000; Skogman et al., 2004). Men are more likely to choose immediately lethal methods such as firearms and hanging. Women tend to choose methods that are less likely to be fatal, like drug overdoses or the ingestion of poisons, making discovery and successful treatment more likely (Goueli et al., 1999). This may to some extent explain why men more often die after a suicide attempt, and have a higher frequency of completed suicide (Skogman et al., 2004).
Previous studies have reported an elevated risk for suicide attempts in youths who were short at birth and in short male conscripts, Busko (2008) found that men who had been born prematurely (who were thus short and underweight at birth) were 4 times more likely to attempt violent suicide than men born after a full-term pregnancy Lonnqvist (2009) states that firearms, hanging and carbon monoxide inhalation are active suicide methods with the highest potential to cause death; wile jumping from a height or leaping infront of a moving vehicle are more passive ways but very damaging as well. On the otherhand drowning, poisoning or wrist cutting are typically methods which leave more time for help seeking and intervention. Comparing suicide methods in different regions revealed that poisoning by pesticide was common in many Asian countries and in Latin America; poisoning by drugs was common in both Nordic countries and the United Kingdom. Hanging was the preferred method of suicide in eastern Europe, as was firearm suicide in the United States and jumping from a high place in cities and urban societies such as Hong Kong Special Administrative Region, China. Correspondence analysis demonstrated a polarization between pesticide suicide and firearm suicide at the expense of traditional methods, such as hanging and jumping from a high place, which lay in between (Ajdacic-Gross et al., 2008).
Prevention of Suicide and Integrated Management of Suicidal Behaviour A. Prevention of Suicide

The American Psychiatric Association (2004) Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors stated, Suicide cannot be predicted and in some cases cannot be prevented, but an individuals suicide risk can be assessed and a treatment plan can be designed with the goal of reducing that risk. WHO (2005), found that about 30 types of suicide preventive interventions were evaluated in the published research, which covered the whole spectrum of primary and secondary prevention efforts. More than half of these interventions fall into the domain of treatment rather than prevention and maintenance. Krysinska and Martin (2009) reported that Population Attributable Risk (PAR) estimates has been used in suicide research to evaluate the impact of psychosocial and socioeconomic risk factors, including affective disorders, traumatic life events, and unemployment; allowing for estimation of the impact of protective factors and effectiveness of preventive interventions. Local studies might have been instrumental in informing local action but they are not enough to assist generalized global action. Using a common methodology to study larger numbers of completed cases of suicide, particularly if they come from different countries, cultural and social environments is also important to allow further analysis of the age and gender distribution of different psychiatric diagnoses. Gaps in knowledge
need to be filled, particularly with regard to different cultural settings, because little information is available on a global basis(Bertolote et al ., 2003). Figure (C) highlights the targets of suicide prevention interventions starting with raising the awareness of the public and screening of high-risk groups (Mann et al., 2005). The three main approaches for reducing the number of suicides in the population are: (Sher, 2004) 1. Preventive strategies that can be applied to the population as a whole so preventing the appearance of new cases an example of this is to sell paracetamol in smaller size packs (primary prevention). 2. High risk groups targeting (secondary prevention) as found by Ginn (2010) which involves targeted strategies, such as evidence based treatments, aimed at high risk groups about whom healthcare professionals should be aware. 3. Tertiary prevention is aimed at diminishing the consequences of suicide attempts. Improvement in professional education how to assess and treat suicidal persons may help rapidly detect and limit the damage that has occurred. Tertiary interventions include the assessment of family members who may be influenced by the suicide attempt-to-attempt suicide themselves (postvention).
1-Population Strategies:
(Goldsmith et al., 2002; Mann et al.,
2005; Hawton &van Heeringen , 2009; Hawton &Taylor , 2009). a) Improving the ability of primary care doctors to recognise and treat depression and other psychiatric disorders has been shown to be valuable, because studies have reported that 16-40% of people who die by suicide
have visited a family doctor in the week before their death (Pirkis and Burgess, 1998; Conwell, 2001; Muzina, 2004; Nutting et al.,2005). Hopelessness predicts suicide, people kill themselves when they fail to find alternative to ease up their anguish together with lack of positive view of the future (Conwell, 2001). b) School based programmes aimed at improving psychological wellbeing could contribute to suicide prevention in young people by increasing knowledge of psychological symptoms and help seeking behavior. Given that teachers are in a key position to recognize adolescents at risk for emotional disorders and potential self-harm, their education seems vital in suicide prevention at that age group (MacDonald, 2004). School-based suicide prevention programmes focusing on behavioral change and coping strategies in the general school population indicated lowered suicidal tendencies, improved ego identification and coping skills. Programmes focusing on skill training and social support for at-risk students were effective in reducing risk factors and enhancing protective factors (WHO, 2005). c) Gatekeepers are community members, such as clergy, whose contact with potentially vulnerable populations provides an opportunity for them to help identify at risk individuals and then direct them towards appropriate assessment and treatment (Ginn, 2010): d) Suicide screening aims to identify people at risk and direct them towards treatment as seen in figure C. Valid, brief and easy-to-administer screening tools can be utilized to detect risk of suicide in children and adolescents. Targeted suicide
screening in schools, and universal suicide screening in primary care clinics and emergency departments s may be the most effective way to recognize and prevent self-harm (Horowitz et al., 2009). Screening instruments for depression, suicidal ideation, or suicidal acts have reliability and validity in identifying individuals at increased risk for suicidal behavior and were reported to double the number of known atrisk individuals (Scott et al., 2004). There is no evidence that screening youth for suicide induces suicidal thinking or behavior (Gould et al., 2003). Given the rarity of suicide attempts in the primary care population, finding an accurate screening strategy for suicide risk for the general population in a primary care setting is an intimidating challenge (Gaynes et al., 2004) screening is targeted towards 3 groups: 1) Screening for the General Primary Care Population The Suicidal Intent Scale (SIS) (Beck et al., 1974) is a well-established clinician-rating scale. It has proven to be helpful to identify patterns of parasuicidal behavior over periods of time, and can also predict eventual suicide (Holi et al., 2005); greater use of SSRI's and other less toxic preparations in patients thought to be at suicidal risk seems to be essential (Gibbons et al., 2005). A related measure with documented predictive validity in adult psychiatric outpatients, the Scale for Suicidal Ideation Worst (SSI-W), indicated that patients scoring in the higher risk category were 14 times more likely to commit suicide than patients in the lower risk category
(Brown et al .,2000)
Cooper-Patrick et al. (1997) used stepwise logistic regression to create retrospectively a 4-item, interviewer-administered screen, the Suicidal Ideation Screening Questionnaire. The authors derived this tool from a subgroup of patients who had received care in the general medical sector within the past 6 months. Assessing sleep disturbance, mood disturbance, guilt, and hopelessness correctly identified 84% of patients who endorsed suicidal ideation within the prior 12 months 2) Screening for the General Primary Care Population: Children and Young Adolescents Despite a plethora of instruments to assess suicide risk specifically among children and adolescents, we did not find any appropriately evaluated screening tools to assess for risk of suicide among adolescents in general primary care clinic populations (Goldston, 2000). One recent report by Horowitz et al. (2001) described the development of a 4-item screening instrument to identify adolescents at risk of suicide in emergency room settings .The items were "Are you here because you tried to hurt yourself? In the past week, have you been having thoughts about killing yourself? Have you ever tried to hurt yourself in the past, other than this time? and Has something very stressful happened to you in the past few weeks?" The leading screening tool used in school settings is the Columbia Suicide Screen (CSS), an 11-item self-report measure embedded in a general health questionnaire that investigates lifetime suicide attempts, suicidal ideation, negative mood and substance abuse issues (Shaffer et al., 2004)
3) Screening in a High-Risk Primary Care Population Instruments that screen for suicide risk in high-risk primary care populations such as persons with a history of self-harm, those with depressive illness, or those with substance abuse (Gaynes et al., 2004). Masango et al. (2008) found that there were two standardized tools developed to assist in assessing suicide risk; Tool for Assessment of Suicide Risk (TASR) and Suicide risk assessment guide (SRAG). Kutcher and Chehil (2007) further added that TASR helps to ensure consideration of the most important issues concerning suicide risk so that the best-informed decision as to how to proceed can be made Biochemical screening has been advocated as an alternative or complementary strategy to identify high risk groups. Low concentrations of 5-hydroxytryptamine and 5-hydroxyindoleacetic acid have been found to be related to suicidal and aggressive behavior, but no evidence currently exists as to their usefulness as adjuncts to other screening tools (Gunnell and Frankel, 1994). Coryell and Schlesser (2007) reported that serum cholesterol concentrations may be combined with DST results to provide a clinically useful estimate of suicide risk. The failure to fully suppress plasma cortisol after a 1mg. dose of dexamethasone is one of the most widely investigated of potential measures. Screening instruments that detect suicide risk include the Hopelessness Scale, which differentiates between those who threaten suicide and those who may attempt suicide (Joe et al., 2008). The Index of Potential Suicide , and the Reasons for Living Inventory and Suicide Attempt Self-Injury Interview measure the suicide potential of those who are thinking about suicide and those who may attempt suicide (Linehan et al., 2006)
Lang et al. (2009) found that routinely screening psychiatric outpatients for suicide risk was feasible and without apparent unintended consequences or ill effects such as suicide or attempted suicide. e) Public education campaigns have been aimed at improving understanding of the causes and risk factors for suicidal behavior and reducing the stigmatisation of mental illness and suicide, with the aim of improving the recognition of suicidal risk and increasing help seeking, education through radio, television, newspapers may reduce the risk of suicide (Browne et al., 2005). Online training is a another valuable option to help meet suicide prevention training needs employing flexible, easy-to-use, and inexpensive Internet technology (Stone et al., 2006). f) Restricting the availability of the means by which people commit suicide, such as installing safety barriers on bridges, limiting avilability of antidepressants and analgesics, etc..; substitution of one method for another can happen, but studies indicate that many people have a preference for a given method (Appleby et al., 2002; Daigle, 2005; Florentine and Crane, 2010). A recent study was conducted by Yip et al. (2010) to examine the efficacy of restricting access to charcoal in preventing suicides from carbon monoxide poisoning, and revealed the suicide rate from charcoal burning was significantly reduced. In Egypt, access to most forms of drugs and poisons seems easy as there is no prescription-regulation law, and almost all drugs could be obtained without prescription (Goueli et al., 1999).
In the developing world ingestion of pesticides is one of the most common methods for committing suicide. Social-educational campaign should publicize the fatal and lethal effects of those materials especially on rural areas (Khan, 2005). g) The media can help educate the public about suicide, but it can exacerbate matters by glamorising suicide. Restrictions on reporting and codes of conduct can help lower suicide rates. Media coverage of suicides has been shown to significantly increase the rate of suicide, and the magnitude of the increase is related to the amount, duration, and prominence of coverage (Appleby et al., 2002). Gould (2001) reported that the media contagion of a behavioral disorder is generally defined as increased risk upon affliction of someone in the same social sphere. This definition, however, is limited according to Dr. Gould because it assumes that direct interpersonal experience with the incident and the suicide victim is necessary for contagion to occur and that is not necessary. h) Befriending agencies and telephone help-lines A very important component of suicide prevention policy in many countries. A key principle on which such services are based is that people in distress and at risk of suicide will benefit from being able to discuss their problems with someone entirely confidentially. An examination of changes of suicide rates between areas with and without crisis intervention services in the USA suggests that suicide rates may have been reduced in areas where such services were developed (Hawton &Taylor, 2009; Hegerl et al., 2009).
2-Strategies Applicable to High Risk Groups:

(Goldsmith et al., 2002; Mann et al., 2005; Hawton &van Heeringen 2009; Hawton &Taylor,2009). a. Risk identification Some people are at particular risk of suicide, and healthcare professionals should provide these people with treatments that reduce the risk of suicide attempts. Patient groups at particular risk of suicide include; people with psychiatric disordersthose who have just been admitted or just been discharged from psychiatric hospital in particular; elderly people; high risk occupational groups, such as medical practitioners, pharmacists, farmers, and vets; and prisoners. Major risk factors for suicide in prisoners are previous attempts, recent suicidal ideation, being in a single cell, presence of a psychiatric disorder, and a history of alcohol problems (Mann et al., 2005; Hawton &van Heeringen, 2009). In recent years, it has been argued that recognizing and treating mental illness is a more viable option than treating attempts at directly preventing suicide (Lesage, 2005). b. Preventive strategies Psychiatric disorders should be treated in high risk patients, and pharmacotherapy and psychotherapy are key treatments. Because of the chronic and recurrent nature of mental illness, and the difficulties in engaging patients with treatment, the best possible acute and long term psychiatric care needs to be available (Sher, 2004).
Hegerl et al. (2009) found that the following interventions have been shown to be effective in reducing suicidal behavior: (1) training sessions and practice support for primary care physicians,(2) public relations activities and mass media campaigns, (3) training sessions for community facilitators who serve as gatekeepers for depressed and suicidal persons in the community and treatment and (4) outreach and support for high risk and self-help groups (e.g. help-lines). Yet even with near perfect care and risk assessment, and despite the best efforts of friends and professionals, suicide is not something that can be entirely predicted or prevented . In developing countries A major drawback in developing countries is that public funded primary health-care facilities are not well established .Government run primary health-care facilities are poorly staffed and poorly run. Many lack basic essential drugs and are accessed only by the poorest of the society. There is no system of referral to secondary or tertiary care. The 'gatekeeper' role that primary health-care facilities play in developed countries does not exist in developing countries. Similarly, mental health services are poorly developed. The mental health professional to population ratio is extremely low .Also, most psychiatrists are located in large urban centers while, the majority of the population lives in rural areas, devoid of any access to mental health facilities. These problems have to be tackled properly in order to be able to follow a suicide prevention problem (Khan, 2005). Also in many developing countries, especially Islamic countries, suicide and Deliberate self-harm are illegal acts. Although prosecution is rare, the
act is frequently exploited by the police in order to blackmail the victim and his/her family and extort money from them (Khan and Prince, 2003).
3- Postvention (Suicide Bereavement):

Suicide always has a major impact on the survivors, dealing with the shame; guilt feelings and the stigma are crucial challenges after suicide (Lonnqvist, 2009). In many cases people bereaved by suicide do not know where to turn for help or how to find support; support groups for suicide survivors (those individuals bereaved following a suicide) are widely used Peters (2009) said; but little research evidence is available to determine their efficacy. There is a compelling need to conduct research and determine effective ways to identify and meet the needs of suicide survivors, particularly through survivor support groups; despite the inherent challenges there is a need to develop a research agenda that sheds more light on the experiences of survivors and the help provided by survivor support groups(Cerel et al., 2009).
B) Management of High-Risk Patients

Once an assessment of the patients suicide risk has been made, an individual treatment plan must be designed. Treatment planning is a dynamic process, and because suicidality can be an acute (state) or chronic (trait) condition, treatment planning may need to consider both short and long-term goals. Treatment planning takes into account the patients potential for suicide, capacity to form a treatment alliance, and range of available treatment alternatives from outpatient follow-up to hospitalization with constant observation (Jacobs et al., 2003)
Steps for Management: (Jacobs, 1998; Gutheil et al., 2000; Jacobs

et al., 2003; Hawton and Taylor 2009; Valente, 2010) I. Collect Data& assess properly before Treatment Planning
Jacobs et al. (2003) reported that success is more likely when the treatment plan rests on a firm foundation of data and assessment; involve caregivers in light of changing information or behaviors. Sometimes it may be possible and clinically indicated to include significant others in treatment planning. Assessing suicidal potential in the setting of psychiatric emergencies is crucial. First the risk factors predisposing to the acting out are to be taken into account (depression, addictive disorders, psychotic disorders,
personality disorders, previous history of suicide attempts) (Valente, 2010). Secondly, emergency factors immediately preceding the suicidal act (presence of active suicidal ideas and suicidal scenario) and thirdly
dangerousness factors (lethality and accessibility of the means) are important to be detected. This assessment has to enable a better estimation of the intervention to be set up (Walter, 2003). Bloch et al. (2005) further mentioned the importance of the proper evaluation of the means of the suicide attempt used and that more emphasis should be placed on how bizarre it might be as a possible sign of a psychotic psychopathology II. Identify a Range of Treatment Alternatives
1. Weigh the risks and benefits of each alternative, including the alternative no treatment. 2. There is no unique correct plan. Select a plan based upon assessment and judgment (Jacobs, 1998) III. Involve the Patient and Family in the Treatment Planning Process to the Degree Possible 1. When a patient lacks the capacity to participate in treatment planning, the clinician must make judgments about the most appropriate treatment plan. 2. Information from the patients significant others and family may be of use in the planning process, Family members, who themselves have had to endure a patient's suicidality, will feel supported by being brought into such an alliance (Packman and Harris, 1998; Paris, 2002) IV. Incorporate Existing Treatment Modalities Into the Plan
1. Involve a current treating clinician and/or appropriate significant others in planning and follow-up.
2. Continue or reassess ongoing pharmacotherapy, with involvement of prescribing physician. Electro Convulsive Therapy (ECT): used to treat acute suicidal behavior, is the most effective biological treatment for major depression (Dombrovski et al., 2005), and is highly effective in reduction of suicide risk in patients with mood disorders (Sharma, 2001; Kellner et al., 2005) and the Occurrence of further attempts become less common (Bradvik and Berglund, 2006). Benzodiazepines: may reduce risk by treating anxiety (Fawcett, 2001) Antidepressants: a mainstay in treatment of suicidal patients with depressive illness / symptoms, mono-therapy with antidepressants has limited efficacy, while combination of antidepressants and other augmentive therapy seems to be more effective (Sackeim et al., 2001). Certain SSRI's have been alleged to increase the suicide risk, particularly Fluoxetine. Actually in March 2004 the U.S. Food and Drug Administration (FDA) warned physicians and patients regarding increased risk of suicide with 10 newer antidepressant drugs. Available data leave considerable uncertainty regarding actual risk of suicide attempt and death by suicide during antidepressant treatment. A study was conducted by Simon et al. (2006) to assess this fact and found that the risk of death by suicide was not significantly higher in the month after starting medication than in subsequent months. The risk of suicide attempt was highest in the month before starting antidepressant treatment and declined progressively after starting medication. Furthermore they concluded that the risk of suicide during acute-phase antidepressant treatment is approximately one in 3,000
treatment episodes, and risk of serious suicide attempt is approximately one in 1,000, and no evidence was found to support such allegations in follow up studies (Jick et al., 2004; Simon et al., 2006). In contrast, a recent national study by Gibbons et al. (2005) yielded that prescriptions for SSRIs and other new-generation non-SSRI antidepressants (eg, Nefazodone Hydrochloride, Mirtazapine, Bupropion Hydrochloride, and Venlafaxine Hydrochloride) are associated with lower suicide rates than TCA prescription. Lithium, Anticonvulsants: Lithium has a demonstrated anti-suicide effect (Cipriani et al., 2005); anticonvulsants do not. Antipsychotics: evidence for Clozapine reducing suicidality in schizophrenia and schizo-affective disorders (Meltzer, 2001). Kraus and Sheitman(2005) added that clozapine, especially has been found to be effective in reducing aggression, violent episodes in suicidal patients. Furthermore factors were considered to decrease suicidality with clozapine include: a direct antidepressant action, improved cognitive function and insight, diminished negative symptoms, reduced substance abuse, and improved compliance (Meltzer, 2002). Two meta-analyses showed a reduction in self-harm (suicidal behavior) rates in patients with a history of deliberate self-harm upon provision of flupenthixol therapy(WHO, 2005). Psychotherapeutic intervention: Regardless of theoretical basis, key element is a positive and sustaining therapeutic relationship: 1-To target issues: Denial of symptoms, Lack of insight
2-To manage high risk symptoms : Hopelessness, Anxiety 3-Effective treatment in high risk diagnoses: Depression use of cognitive therapy, personality disorders use of dialectical behavior therapy (Jacobs et al., 2003),and aggressive/ impulsive traits may be amenable to other types of psychotherapy, such as dialectical therapy and serotonergic agents including SSRI's or Lithium (Mann, 2004). However, Hendin et al. (2006) have found that most clinicians employ a relatively open-ended, eclectic psychotherapeutic approach that incorporates cognitive behavior and interpersonal techniques and varying degrees of reliance on psychodynamic principles, Yet Brown et al.(2005); Tepper and Whitehead(2005) found that cognitive therapy profoundly reduces both negative views of self (self-concept) and negative views of the future (hopelessness than pharmacotherapy, thus it may be more effective than other psychotherapeutic interventions in reducing suicide attempts and preventing completion of suicide . Two meta-analyses showed a reduction in self-harm (suicidal behavior) rates in patients with a history of deliberate self-harm, for the following interventions: problem-solving therapy dialectic behavioral therapy cognitive behavioral therapy (WHO,2005) V. Be Aware that Contracts Will Not Guarantee the Patients Safety
1. Patients ability to understand and participate in treatment should be assessed. 2. Treatment focus should be on alliance with the patient.
3. Contracts can play a role if utilized as part of a comprehensive evaluation and treatment plan. A no suicide contract is an agreement in which patients promise not to kill or harm themselves (Weiss, 2001; SIEC 2002; Mcmyler, and Pryjmachuk 2008), contracts may be verbal or written, and therapists can renegotiate or renew contracts as needed. 4. However, contracts can give staff a false sense of security and interfere with a thorough suicide assessment (Jacobs, 1998; Gutheil et al., 2000; Jacobs et al., 2003), they might be useful but carry a lot of problems: Problems: commonly used, but no studies demonstrating ability to reduce suicide, not a legal document, whether signed or not, used proforma, without evaluation by psychiatrist. Possibilities: useful when there is positive therapeutic relationship (do not use when covering for colleague), rejection of contracts have significance. VI. Choose Appropriate Levels of Observation, Supervision, and Privileges 1- The inpatient unit is especially effective in the treatment of acute rather than chronic suicidality. It offers safety, support, and hope (although no unit is suicide proof) (Mackay et al., 2005). Inpatient treatment planning is determined on an individual basis to meet the patients need for maximal safety in the least restrictive environment. Although precautions and privileges have restrictive elements, they are applied in the context of a treatment plan that aims to enable patient to tolerate suicidal feelings.
2- Inpatient treatment of suicidal patients relies upon a progression through a hierarchy of observation levels, supervision levels, privileges, and therapeutic passes. 3- With clinical improvement, suicidality may still persist. Although the ultimate goal is toward a less restrictive environment, the clinical decision must be based on an assessment that the suicide risk has been reduced .Other measures to prevent in-patient suicide might include regular risk assessments during recovery and prior to granting leave, adequate monitoring of patients, staff training programmes in the management of risk, and improved staff communication. (Pompili et al., 2009; Tishler and Reiss, 2009; Hunt et al., 2010) VII. The Levels of Observation, Supervision, and Privileges Parallel the Patients Potential for Suicidal Behavior (Jacobs , 1998; Gutheil et al., 2000; Jacobs et al.,2003) Examples of observation levels are: (Cleary et al., 1999) a. Continuous observation (1:1 or remaining in sight of staff members) b. Restricting the patient to an area where he or she can be seen at all times by staff c. Restricting the patient to public areas; not allowing him or her to be alone in room d. Checks at intervals of 5, 15, or 30 minutes e. Periodic checks at intervals greater than every 30 minutes
Examples of when staff supervision is necessary include during the patients use of: Sharps (nail cutters, razors, scissors), Cigarettes and matches, Poisons (cleaning supplies), Bathroom, Kitchen, Occupational therapy Examples of privilege levels are: a. Restricted to unit b. Accompanied off-unit by staff (specify 1:1 versus group, number and gender of staff person, legal status of patient when relevant) c. Accompanied off-unit by non-staff (reliable family member or friend) d. Unaccompanied off-unit VIII. Document the Treatment Planning Process and the Plan (Jacobs , 1998; Gutheil et al., 2000; Jacobs et al., 2003) 1. Document the range of options considered and why one was chosen over others. 2. Document communication with the patient. With suicidal inpatients, documentation of suicidality occurs, at (but not limited to) the following treatment stages: a. Admission b. First unaccompanied pass c. Discharge (Especially at discharge, the issue of chronic suicide risk must be considered. The chronic risk can be assessed according to the same model, though a longer view is taken of the risks and benefits of various treatment options.) 3. Document discharge planning to include: a. Living arrangements, work, communication with significant others b. Follow-up appointments or contact with outpatient provider
c. Medications (include prescriptions) d. Current suicide assessment IX. In Planning Treatment for a Chronically Suicidal Patient, some of the Following Considerations May Apply: (Hawton and Taylor ,2009) 1. Safety may wax and wane. 2. Despair over treatment failure may increase suicide potential. 3. The treatment team may decide to tolerate short term risk to foster longterm growth. a. Such a decision should include informed consent. b. Documentation should make clear the choices and rationale. 4. Assess the risk of continued hospitalization , training of staff should include information about suicide risk during apparent recovery (Meehan et al., 2006). 5- Community outreach Several studies have been conducted to assess the impact of community outreach either for all patients or for those who have not attended treatment sessions, and proved effectiveness in reducing repetition of attempted suicide (Hawton and Taylor, 2009). In other studies telephone contact (Vaiva et al., 2006) and contacting patients regularly by post (Carter et al., 2005) have also produced promising results 6- Provision of emergency cards In the United Kingdom there has been recently interest in providing suicide attempters with cards which indicate how they might get emergency
help at times of crisis. Two initial studies of this approach provided encouraging results Evans et al. (2005) stated; but there needs to be careful selection of patients who are offered this facility for fear of it possibly being abused. Two meta-analyses showed a reduction in self-harm (suicidal behavior) rates in patients with a history of deliberate self-harm upon provision of an emergency contact card (WHO,2005).
Figure (C): Targets of Suicide Prevention Interventions (Mann et al., 2005).
Summing Up
Suicide is defined as the intentional act of taking one's life either as a result of mental illness (these illnesses frequently though not always causing distress to the individual carrying out the act) or as a result of various motivations which are not necessarily part of any designated mental illness but which outweigh the instinct to continue to live Sir Thomas Browne first used the word suicide in 1642. The word originated from SUI (of oneself) and CAEDES (murder). In the late 17th and 18th century England, suicide became to be considered as non compos mentis which means not of sound mind and not mentally competent. Prior to 1660, the vast majority of suicides reported by juries were judged as selfmurders and punished. Fewer than two percent were acquitted as persons non compos mentis. The study of suicide had 'become the subject of intensive scientific research in 1897 with the publication of Emile Durkheim's classic Suicide: A Study in Sociology. WHO (2009) rates of suicide per 100.000 for most recent year available as of 2009; in the first rank came Lithuania (2005) with the highest rates of suicide for males 68.1, and for females 12.9. While Haiti 2003, Honduras 1978,Jordan 1979 and Saint Kitts and Nevis (1995) ranked the last with lowest rates of suicide 0.0 for both males and females. In the year 2000, suicide was estimated to be the 25th leading cause of death in the countries of the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), but was ranked 7th in the European
Region, 8th in the Western Pacific Region and 16th in the South-East Asia Region. Egypt recorded 0.1 suicides per 100 000 in men and none in women in the late 1980s. Egypts extrapolated annual incidence of suicide according to US Census Bureau (2004) was 8,171 per 76 million approximate population. Risk factors of suicide are a combination of individual, relational, community, and societal factors contribute to the risk of suicide. Risk factors are those characteristics associated with suicide; they may or may not be direct causes: Male, Family history of suicide, Family history of child maltreatment, previous suicide attempt, History of mental disorders, particularly depression, History of alcohol and substance abuse, Feelings of hopelessness, Impulsive or aggressive tendencies, Isolation, a feeling of being cut off from other people, Barriers to accessing mental health treatment, Loss (relational, social, work, or financial), Physical illness, Unwillingness to seek help because of the stigma attached to mental health, etc... Protective factors from suicide are those, which buffer individuals against suicidal thoughts and behavior, they decrease the probability of an outcome in the presence of elevated risk. To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors. Examples of protective factors: Effective clinical care for mental, physical, and substance abuse disorders, Easy access to a variety of clinical interventions and support for help seeking, Family and community support, Skills in coping strategies, problem solving, conflict
resolution, and nonviolent way of handling disputes, religious beliefs that discourage suicide and support instincts for self-preservation Psychological theories of suicide focused on the concept of the self. Freuds theory assumed that self destructive behavior in depression represents aggression directed towards a part of the self that has incorporated a loss or rejection of a love object, also the psychodynamic meaning of suicide for a patient derives from both affective and cognitive components. Rage, hopelessness, despair, and guilt are important affective states in which young patients commit suicide. Recently the interpersonal-psychological theory of suicidal behavior asserts that when people hold two specific psychological states in their minds simultaneously, and when they do so for long enough, they develop the desire for death. The two psychological states are perceived burdensomeness and a sense of low belongingness or social alienation There is clear evidence that the activity of certain neurobiological systems has a role in the patho-physiology of suicidal behaviour. This includes hyperactivity of the hypothalamo-pituitary-adrenal axis, and excessive activity of the noradrenergic system; these two systems appear to be involved in the response to stressful events. Furthermore convergent evidence from a multitude of research designs (adoption, family, genomescan, geographical, immigrant, molecular genetics, surname, and twin studies of suicide) suggests genetic contributions to suicide risk. Also two genes are thought to be involved in the vulnerability to suicidality , the tryptophan hydroxylase 1 (TPH1)gene , as a quantitative risk factor for suicidal behavior and serotonin-transporter-
linked promoter region gene (5HTTLPR), which is also consistently associated with impulsive-aggressive personality traits. Probably all suicide cases are associated with some form of a psychiatric disorder rather than being psychiatrically normal. One of the major mental disorders with high risk for suicide in case-control analysis was according to ICD-10; a major depressive episode. Near 5% of people with schizophrenia also die by suicide. Adjustment disorders, anxiety disorders, personality disorders and other psychiatric disorders carry a variable risk for suicidality. The term Deliberate self-harm 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. For an individual who has engaged in self-harm, the risk of dying by suicide is significantly higher than for the general population. While attempted suicide is every act of self-injury consciously aiming at self-destruction. parasuicide is a non fatal act in which an individual deliberately causes self-injury or ingests a substance in excess to any prescribed or generally recognized therapeutic dosage. There are several types of suicide e.g. Durkheim's Typology of Suicide, Copycat, Euthanasia, Familicide,Internet , Martyrdom, Mass/cult,etc.. There are various methods for suicide; nonviolent suicide includes poisoning, drowning, drug overdose, and violent suicide includes cutting, hanging, jumping from a height or in front of a moving vehicle, or shooting or other means.
In general, men tend to choose more violent means for suicide (eg, hanging or shooting and women less violent methods (eg, self-poisoning). Prevention measures of suicide include three main approaches for reducing the number of suicides in the population are: 1. Preventive strategies that can be applied to the population as a whole so preventing the appearance of new cases an example of this is to sell paracetamol in smaller size packs (primary prevention). 2. High risk groups targeting (secondary prevention) such as evidence based treatments, aimed at high risk groups about whom healthcare professionals should be aware. 3. Tertiary prevention is aimed at diminishing the consequences of suicide attempts. Once an assessment of the patients suicide risk has been made or actual suicide attempt was made, an individual treatment plan must be designed. Treatment planning is a dynamic process, shaped by and communicated between the patients and because suicidality can be an acute (state) or chronic (trait) condition, treatment planning may need to consider both short and long-term goals. Treatment planning takes into account the patients potential for suicide, capacity to form a treatment alliance, and range of available treatment alternatives from outpatient follow-up to hospitalization with constant observation.

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Chapter 1 Suicide Learning From The Past To Improve The Fut

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Chapter 1: Suicide 5

military/civilian status, and economic conditions (Durkheim, 1952)

Epidemiology of Suicide& Cultural Variations

Figure (A): a Worldview of Suicide (Bertolote et al., 2005)

Risk Factors of Suicide

Protective Factors Against Suicide

Social Support and Integrity

Do you not know that your body is a

(NIV 1 Corinthians, 3:16-17)

Don't you know that you yourselves are

Figure (B): Protective Factors against Suicide. (Gunnell, et al., 2005)

Psychology of Suicide and Theories of Suicidal Behavior

Psychological theories of suicide

The Concept of Shattered Self and Suicide

The Interpersonal-Psychological Theory of Suicidal Behavior

Acquired Ability to Enact Lethal Self-Injury

Suicide and Mental illness

Suicide Related Phenomena

Prevention of Suicide and Integrated Management of Suicidal Behaviour A. Prevention of Suicide

(Goldsmith et al., 2002; Mann et al.,

2-Strategies Applicable to High Risk Groups:

3- Postvention (Suicide Bereavement):

B) Management of High-Risk Patients

Steps for Management: (Jacobs, 1998; Gutheil et al., 2000; Jacobs

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Figure (C): Targets of Suicide Prevention Interventions (Mann et al., 2005).

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