Most common in females and in those aged below 35 years. People aged 15–24 years account for 40 % of cases, 25- to 34-year-olds for 25% of cases. Some 60% of parasuicide cases are females. The person-based incidence of parasuicide is approximately 170/100,000 population/year in Europe. In the USA and Canada, the figures are 225/100,000/year and 304/100,000/year respectively. 80-90% of cases involve deliberate self-poisoning with drugs. Self-injury accounts for 10–15% of presentations; of these, three-quarters involve cutting to the arm or wrist. Paracetamol is employed in some 40% of overdoses, antidepressants (mainly SSRIs) in 30%, minor tranquillizers in 20%. In a study by Odejide et al in Ibadan, 76.9% of patients with DSH were below 30yrs of age, 51% of them were students, 60% of them ingested chemicals. In a South African study of suicidal behaviors among 435 Secondary school adolescents in 2004, Madu & Matla found that 21% had attempted suicide. Of this, self-poisoning was the most frequent method used (44%). Stabbing, hanging, jumping off bridge accounted for the remainder. Parasuicide is usually repeated. In clinical population, 16 per cent of parasuicide cases repeat self-harm within 6 months and 25 per cent over 10 years. Completed suicide occurs in 1–2 per cent of cases in the first year after parasuicide and in 3–7 per cent over 10 years.

Genetic factors: Many studies have described strong associations between personality traits and parasuicide. These traits include aggression, anxiety, neuroticism, impulsivity, hostility and psychoticism. Personality traits are influenced by genetics and polymorphisms coding for the serotonin transporter, 5-HT1A receptors. Thus, it is plausible that the effect of ‘parasuicide genes’ is mediated through an intermediate effect on personality. Decreased CSF 5-HIAA is the most consistent finding in patients with DSH.

Biological Factors: It is estimated that about 30–70 per cent of people who present with parasuicide are depressed at the point of presentation. Anxiety, stress-related and somatoform disorders are found in approximately 25 per cent of cases and eating disorders in 10 per cent. Diagnoses of distinct and severe mental illness (e.g. bipolar disorder, schizophrenia) are found in no more than 5 per cent of parasuicide cases. It is highly associated with personality disorder, especially borderline.

Psychosocial factors: Common clinical experience is that there has usually been some emotional problem preceding parasuicide. Hawton and colleagues found these problems to be with partners (in 50% of cases), family members (40%), employment (30%) and finances (20%). Alcohol had been consumed in the 6 h preceding parasuicide by 45 per cent of women and 55 per cent of men. A qualitative study done by Mpiana et al in 2004 found that contributory factors to suicide attempts were emotional pain, unpleasant life feelings.

A thorough assessment should address the following areas; i.) Ongoing suicidal intent ii.) Evidence of mental illness and iii.) Perpetuating social factors present. The treatment then focused on identified areas.

Emergency Intervention: includes resuscitation following ABC, provide supportive therapy through oxygen administration, IVF, cardiac monitoring. ICU admission may be necessary if patient is not hemodynamically stable. Consider use of activated charcoal for gastric decontamination especially if patient presents within 2 hours of ingestion, surgery for persons who inflicted direct physical trauma like stab wound, reduction of fractures for persons who jump off bridge etc. Asking about suicide does not provoke act of suicide. It often reduces thoughts or acts associated with self-harm and helps the person feels understood. However, try to establish relationship with the person before asking about self-harm.

Assess if there is evidence of self-injury and/or signs/symptoms requiring urgent medical treatment: – Signs of poisoning or intoxication – Bleeding from self-inflicted wound – Loss of consciousness – Extreme lethargy. If Yes, Management of the medically serious act of self-harm is required till clinically stable. Ask the person and carers if there are ANY of the following: Current thoughts or plan of self-harm/suicide, History of thoughts or plan of self-harm in the past month or act of self-harm in the past year in a person who is now extremely agitated, violent, distressed or lacks communication; Is there a history of thoughts or plan of self-harm in the past month or act of self-harm in the past year? If Yes, Risk may still persist; Does the person have concurrent Mental health conditions? Consider use of SAD PERSONS SCALE for Suicide risk assessment.

1. Previous attempts or fantasized suicide
2. Anxiety, depression, exhaustion

• Availability of means of suicide

1. Concern for effect of suicide on family members
2. Verbalized suicidal ideation
3. Preparation of a will, resignation after agitated depression

• Proximal life crisis, such as mourning or impending surgery
• Family history of suicide

1. Pervasive pessimism or hopelessness

Act done in isolation, act timed so that intervention is unlikely, violent, near-lethal or premeditated attempt, precautions taken to avoid rescue or discovery, persistent plan and or intent is present (making a will), distress is increased or patient regrets surviving, communicating intent to others beforehand, leaving a note and admission of suicidal intent.

The patient should be admitted. Place the person in a secure and supportive ward in the hospital. Check the vital signs including blood oxygen saturation level and ensure ABC of resuscitation. Medically treat injury or poisoning/overdose. If there is acute pesticide intoxication, use activated charcoal if within an hour and give atropine (0.02mg/kg) for features of cholinergic intoxication. It is recommended that the patient is referred to a specialty team for the management of Organophosphate poisoning/drug overdose but not until some resuscitative measures have been instituted. Open suicide caution chart and ensure patient’s bed is at a very close range to Nurses’ station. Manage the underlying psychiatric conditions if present. SSRI medications are recommended especially for intentional overdose and ECT is a viable option. Activate psychosocial support. Psychotherapy through CBT, group therapy, family therapy, relaxation techniques. Link patients up with support groups e.g. Suicide Research Prevention Initiative (SURPIN). Environmental modification e.g. removal of ligature points and other harmful metal sharp objects.

In the case of chronic suicidal ideation without lethal attempt, no plans or means to carry out an act, there is a need for provision of safe and supportive living situation for such patient. Involvement of close family or friends following approval of the patient. Ongoing outpatient care; short appointments, frequent follow ups. Ensure patients are not discharged with enough drugs they could overdose on. Recognizing high-risk cases and taking them seriously. Asking patients about their suicidal ideas. Not removing hope. Prescribing the safest drugs. Treating underlying illness adequately.

Parasuicide remains the most disturbing pointer to imminent suicide, and it is a matter of public health significance. Though standardized terminology describing parasuicide is lacking, in managing parasuicide, the clinician must identify risk factors and where an underlying mental health condition is found it must be treated appropriately with a view to preventing a repeat or worse suicide itself.

1. Making mental health services more available and accessible
2. Legislation by restricting means of suicide common in the environment
3. Responsible reporting of suicide by the media
4. Health education programs focused on suicide and other mental health issues of public health importance
5. Improved care for high-risk groups
6. Functional telephone hotline and crisis centers made accessible to the people.