people who mistakenly injected toxic substances. The degrees of severity of suicide have remained a controversy in psychiatric medicine since classifications could not predict the outcome of suicide care well. Survey statistics report that about 7% of adults who undergo medical treatment for suicidal ideation and attempt, regardless of the severity classification, try to attempt suicide again, although in a different setting or due to a different Upon admission to the facility, William’s speech was slow, he avoided eye contact, and he did not respond with simple information when asked. He was passively cooperative, with a facial expression of sadness. During this period his thought process was logical and coherent with no indications of delusion or hallucinations. In one of his many counseling sessions, William tearily talked about how hopeless he was and his wish to be dead. His mood was one of anxiety and depression, and his intelligence was judged as average. He was diagnosed with dysthymic disorder and posttraumatic stress disorder (PTSD). Three days later, William was discharged with a counseling schedule of two visits per week. His Suicide Attempt Case Study (continued) William’s Struggle with Depression According to his foster parents, William continued to be withdrawn, keeping only to himself and avoiding school. He moved around the park often and would occasionally contribute to family discussions. “Maybe everything else was becoming normal,” they thought. However, 15 days after he was discharged, tragedy struck. William was brought to the local emergency department of the Municipal Care Center after being found unconscious on the floor of the family’s kitchen, with a knife and a pill container nearby. He had reportedly overdosed on a tricyclic antidepressant that had been prescribed for him. Although it had been locked away in a cabinet, William had somehow gained access to it and swallowed a handful of pills. He exhibited shallow breathing and no spontaneous movement but reacted to deep, noxious stimuli by moving his extremities. His blood Arguably the most referenced suicidal ideation and behavior (SIB) classification globally, the Columbia Classification Algorithm of Suicide Assessment (C-CASA) was introduced by the U.S. Food and Drug Administration (FDA). This assessment classifies suicidal events, drawing a clear distinction between non- suicidal and potently suicidal actions as illustrated in Figure 1. Since its introduction, the C-CASA has been used in social behavioral assessment studies, clinical trials, psychiatric care, and the reliable collection of safety data for clinical studies. This classification includes operational guidelines for assessing suicidal intent. The criteria classification divides suicidal ideation and behavior into nine domains:
trigger. Among those with at least two attempts, psychiatry studies suggest that about 24% make a subsequent attempt (Lee et al., 2019). In many cases, a strong wish to die has also been linked to an objectively nonlethal action, including jumping from low heights and deliberately overdosing on nontoxic medications. Many widely referenced classifications of suicide severity have been published by different healthcare agencies. pressure was 110/70 mmHg, his respiration rate was 18 breaths per minute, and his pulse was 125 beats per minute. A few hours later, he was admitted to the intensive care unit, intubated, and watched. Two days later, his foster parents found a handwritten suicide note in his room. William had carefully documented his wish to die and be reunited with his father. His tone was one of despair and resignation. The note read: “Linda [his social worker] had tried her best on her many visits, but I wish all I needed was just her many talks about hope and optimism. Just like the last time I couldn’t follow through with the knife [apparently William had tried on many occasions to end his life but could not follow through], I hope by the time you find this, the pills will have ended everything. I hope so.” Forty-eight hours after his admission into intensive care, William became physically stable. He was transferred to the regular floor with a sitter assigned to his room as a precaution. He was put under routine medical care with additional observations and consultations. His diagnosis was updated to borderline personality disorder and likely major“. William was subsequently transferred to the inpatient psychiatric service for further evaluation. He was later discharged to an outpatient mental health clinic for medication management and follow-up psychotherapy.
William’s case is one of many instances of attempted suicide among the global youth population. In his case, a suicide attempt was predicated on the childhood trauma of losing his parents without an immediate support system to help him through the psychological crisis that followed. ASSESSMENTS AND CLASSIFICATIONS OF SUICIDAL IDEATION AND BEHAVIORAL SEVERITY Columbia Classification Algorithm of Suicide Assessment (FDA-CASA 2012)
1. Completed suicides 2. Suicide attempts 3. Preparatory acts toward imminent suicidal behavior 4. Suicidal ideation 5. Self-injurious behavior, intent unknown 6. Fatal event (not enough information to classify as suicide) 7. Self-injurious behavior without suicidal intent 8. Other injuries with no intent for self-harm (accident, psychiatric and medical) 9. Non-fatal event; however not enough information is available to classify as a suicide
Figure 1. Suicidality Classification System
Color key : blue boxes = FDA “Primary Analysis” (Events Deemed Suicidal); blue and green boxes = FDA “Sensitivity Analysis” (Any Event That Could Possibly Be Suicidal) Note . From ‘Columbia Classification Algorithm of Suicide Assessment (C-CASA): Classification of suicidal events in the FDA's pediatric suicidal risk analysis of antidepressants,” by Posner, K. et al., 2007. American Journal of Psychiatry, 164(7): 1035-43. (https://doi.org/10.1176/ajp.2007). In the Creative Commons.
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