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Suicide Attempt in relation to COVID-19 Crisis

Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References
Mrs.S, female, aged 38 years, married with two children , uneducated, a farmer & homemaker, hailing from a low socioeconomic nuclear family,  residing from rural area near Mysore, was referred by Department of General Medicine with history of attempted suicide by consuming multiple tablets. Tablets consumed were -Paracetamol(6), Chlorpheneramine (8), Nimesulide 100mg+Paracetamol 325mg (6)  on 10th  July 2020,10pm at her residence.
With informed consent, the patient was interviewed and she narrated that due to COVID-19 pandemic, her village with 40 houses, has been arbitrarily separated with fences overnight, even on the small roads, which has made commuting difficult.
Three days before admission when she was walking back home from her field and had to cross a fence, she had to move some of the fence. This made other villagers irritated and they scolded her for being casual and called for a Panchayat (Local administrative group) meet.
Her husband was called and was asked to apologize for not following the rules of the village for control of COVID19 infection.
The husband felt humiliated and scolded the patient, which pained her. On the same night she locked herself and took all available medications.
Family members had to break into her room and shifted the patient to tertiary care hospital.Intentionality and lethality of act was low and remorse was present.  
Patient denied family history of psychiatric illness or suicide. 
Past psychiatric and medical history: not significant.
 Pre-morbid personality is well adjusted. No history suggestive of depression or anxiety disorder.

General Physical Examination:

Moderately built and adequately nourished. General physical and systemic examination was unremarkable.

Mental status examination

The patient was adequately groomed, cooperative and oriented to time, place and person. 

She was preoccupied with thoughts about what happened and feeling guilty.

The patient expressed concern regarding lack of understanding and open discussion from villagers in these times of pandemic. 

Her mood was euthymic and insight was present

Assessment:

Hamilton depression rating scale (HAM-D) :10; Not Significant

Columbia suicide severity rating scale (C-SSRS): Not significant 

Investigations:

Liver function test:

TB:0.34

DB:0.12

Total protein:7.2

Sr Albumin:4.1

A/G ratio:1.3

AST:14

ALT:9

ALP:101

PT:16.2

INR:1.3

Ultrasound abdomen: Normal study

2D echo: Normal study 

ECG: within normal limit

CBC, RFT, SERUM ELECTROLYTES, RBS, TFT : within normal limits 

HIV, HBsAG, HCV: non-reactive 

Impulsive act of Deliberate self- harm

Pharmacological :

NS Stomach wash, Intravenous fluids, symptomatic treatment,

 Injection N-AcetylCysteine 3times a day for two days with regular monitoring of vitals.

Non-pharmacological:

Suicide Prevention contract was taken, patient educated regarding the fear and misconceptions in common public regarding the fear of COVID19. 

Supportive psychotherapy offered. 

The COVID-19 pandemic has led to significantly increased levels of stress at the community, at the families and at the individual level.

Policy measures have been formulated to address and limit the spread of infection. These measures may have led heightened vigilance, issue of isolation, limited access to basic necessities and financial stress, as well as a rapid dissemination of misinformation have led to increased levels of anxiety, fear and psychological stress across the country. [1]

Social stigma can occur in disease outbreaks, the recent outbreak of COVID19 has caused a lot of fear and panic about the disease. Suicides are increasing in India during the ongoing pandemic.[2]

The social distancing that is advocated as a preventative measure to control the spread of infection can be misinterpreted and easily manifest as social discrimination. 

Risk assessment in case of Suicide or Suicide attempt involves looking at past history of suicide attempt, family history of suicide, current and past history of psychiatry illness, medical comorbidity ( Eg; Thyroid Disorder, Epilepsy etc)  or other recognized risk factors ( Eg; Grief, Hopelessness). The index patient did not have any of the risk factors for suicide. This case demonstrates how social factors during pandemic such as COVID 19 are beyond conventional risk factors for suicide. 

1. Mental health issues during COVID19 NIMHANS [Internet]. Available from https://nimhans.ac.in/wp-content/uploads/2020/04/MentalHealthIssuesCOVID-19NIMHANS.pdf [Last accessed on 15th July 2020]

2.Suicide,the epidemic we are overlooking [Internet]. Available from https://indianexpress.com/article/opinion/suicide-the-epidemic-we-are -overlooking-6472617/ [Last accessed on 15th July 2020]

3.Thippaiah SM, Nanjappa MS, Math SB. Suicide in India: A preventable epidemic. Indian J Med Res 2019;150:324-7

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