diabetes mellitus ( dm ) is a medical disorder which affects an increasing large proportion of the population across different age groups . though it is prevalent globally , it poses a particular health challenge in resource constrained low and middle income countries .
the two commonest forms of the disorder , diabetes type i ( t1 dm ) and type ii ( t2 dm ) have different pathophysiological mechanisms .
dm affects multiple organ systems and is associated with poor quality of life and even reduced life expectancy .
it has been suggested that diabetes ( both t1 dm and t2 dm ) is associated with increased occurrence of certain psychiatric disorders .
suicidal ideas as well as suicide attempts are potentially life threatening psychiatric emergencies that occur more frequently in patients with dm than in the general population .
many studies have focused on the relationship that dm shares with psychiatric disorders , especially depressive disorder .
this narrative review was conducted to understand the existing literatures on relationship between diabetes and suicide . we aimed at reviewing the literature on rates of occurrence of suicidal ideas and attempts in patients with diabetes , the risk factors for suicidality , the common and unique methods for suicidal attempts in such patients , and management of such patients .
pubmed ( including pubmed central ) and google scholar were used to identify published studies .
searches were carried out using medical subject headings ( mesh ) terms  diabetes mellitus and  suicide. additional searches were carried out using related keywords of 
articles were evaluated and were classified according to the broad subject related to suicidality in dm .
further studies were identified using cross - references from the identified text and by going through the related citations .
the full - texts of the identified studies were obtained and assessed for their content .
the manuscripts were categorized according to broad themes like epidemiology , elaboration of risk factors for suicide , and management issues .
discrepancies in the interpretation of the literatures were resolved through mutual discussion between the authors .
the studies that have assessed the occurrence of suicidal ideas , attempts and deaths in patients with dm have been summarized in [ table 1 ] .
studies assessing occurrence of suicidal behaviour in patients with diabetes mellitus studies have assessed suicidal ideations using different tools including structured interview schedules such as mini international neuropsychaitric interview ( mini ) , rating scales ( such as beck depression scale suicidality item ) , and a single question relating to suicidal ideations . the size of the population assessed have varied from less than 100 to over 80,000 .
studies have come mainly from scandinavian countries and usa , though there are few studies from other countries too .
the rates of suicidal ideation and suicidal attempt has been reported to be as high as 26.4% and 13.3% , respectively .
some of the studies focusing on suicidal ideation and attempts in patients with dm have found that suicidal risk is higher in patients with diabetes .
however , two studies have found that patients with diabetes had lower rate of suicidal ideation as compared to healthy controls and patients with other medical disorder .
depression has been reported to be the most common psychiatric disorder in persons with dm who attempted suicide .
data about suicide completers among the patients with dm have primarily come from cohort studies and studies based on health registries .
the proportion of cases reported to be due to suicide has varied from 0.55% to as high as 40% .
most of the studies which have reported rates of suicides in t1 dm population has given vales in the range of 5 - 15% .
the low rate found in one specific study could be ascribed to the fact that this study looked exclusively at t2 dm cases where mortality can result due to a host of medical complications due to diabetes or other concurrent medical illnesses .
standardized mortality rate ( smr ) provide a better approximation in such situations as it looks at comparison with the age specific mortality .
there too , diabetes has been associated with smr of more than one , which suggests greater mortality rates in this population especially males .
many demographic variables have been explored for putative association with suicidality in patients with dm .
males seems to have a greater risk in completing suicides . in a sample of patients from nigeria ,
the study conducted on 646 patients with dm found suicidality to be significantly associated with poorer glycemic control .
a large korean study has shown that depression acts synergistically with diabetes in increasing the chances of having suicidal ideations .
other psychological factors like stress have also been suggested to play a role in suicidal ideations and attempts in patients with dm .
multivariate analyses has showed that female sex , severity of childhood abuse , history of alcohol abuse , and depression were significantly and independently associated with having attempted suicide .
the literatures relating to risk factors for suicidal behavior among patients with dm is not very extensive .
however , it has been reported that probably risk factors related to suicide in general and those of chronic medical illnesses do apply in context of dm as well .
risk factors can be inherent to the patient 's characteristics like coping skills , personality profile , additional psychiatric illness including depression and alcohol use disorder , and presence of hopelessness . past history of suicide attempt and family history of completed suicide present additional risk factors .
this is compounded by illness related and situational risk factors like lack of social support , adverse life events , exacerbation of the illness and gradual accrual of diabetes related complications .
access to means of self harm is another factor which determines whether a suicidal plan is executed or not .
a range of risk factors and protective factors determine the overall suicidal risk in a particular patient and the reader is referred to more comprehensive sources for understanding of suicide risk factors in general .
[ figure 1 ] provides a simplistic model of how different factors aggregate to confer suicidal risk . a simplistic model to explain how different factors aggregate towards risk of suicidal behaviour patients with dm present some unique characteristics of suicide attempts .
this can be ascribed to easy availability and accessibility to a potentially lethal means of suicide in the form of injectable insulin .
subcutaneous or intravenous injection of insulin can cause hypoglycemia which can cause death if it is severe and lasts for a prolonged period of time .
biguanides , like metformin , can cause lactic acidosis when taken in larger than necessary amounts .
[ table 2 ] provides a list of the medications that have been used for suicidal attempts .
medications for diabetes treatment that have been reported to be used for suicidal attempts as evident from the table , insulin has been widely used in suicidal self - harm attempts in patients with dm .
probably , the first report of use of high dose of insulin with a suicidal intent in a diabetes patient dates back to 1934 when a 50-year - old female patient consumed 400 u of insulin apparently being depressed due to financial issues .
subsequently , there have been reported cases of suicidal self - administration of insulin where the patients had recovered fully after prompt medical treatment .
not only regular insulin , but its congeners like insulin glargine and lispro have also been used for self - harm attempt .
use of insulin as a means of suicidal attempt seems to be more common in patients with t1 dm than t2 dm .
this could be due to the fact that t1 dm can only be treated with insulin and consequently is more regularly accessible to these patients . for treatment of patients with t2 dm ,
many other pharmacological agents are prescribed which can not be administered through an invasive route .
information about the use of oral anti - diabetic mediations for self harm has come mainly from case reports .
oral medications like glipizide and gliclazide have been used for attempted suicide in patient with dm .
metformin has been used in massive quantities with an intent to self - harm in a few patients .
use of excess doses of metformin results in lactic acidosis which may result in cardiac arrest and even death .
other medications that have been used in excess quantities with suicidal intent include liraglutide , phenformin , and sitagliptin .
apart from the above , suicidal attempts in patients with dm have involved excess consumption of sugary substances leading to hygerglycemic state .
a case of fatal self - induced hyperglycemia by drinking excess amounts of sugared tea has been reported for a 15year - old boy with diabetes .
similarly , a case of fatality has been reported with the use of sugary solution in a patient with dm .
there have been reports of use of other medications , notably psychotropics , like antidepressants and antipsychotics , for suicidal attempt by patients with dm .
danger of abuse of antidiabetic therapy for suicidal attempts is not confined to the patient , but even extends to the other family members who live along with the patient .
use of insulin and other medications for treatment of dm has also been described in family members who had taken the patient 's medications for suicidal attempt .
suicide risk assessment can be conducted as a part of screening for depression or otherwise .
many brief screening questionnaires for depression like primary health questionnaire-9 ( phq- 9 ) and beck depression inventory ( bdi ) have questions relating to suicidal ideation . specifically asking about current suicidal ideas directly ( and not in a roundabout indirect manner )
it has been seen that asking about suicidal ideas do not implant such ideas in the person assessed , but missing on such questioning due to hesitation on the part of the therapist may lead to missed opportunities to screen for suicidal behavior .
specific instruments to assess suicidality are also available for comprehensive assessment of patients with suicidal ideation sad persons is a mnemonic that can be used for remembering the risk factors for suicide and includes male sex , older age , depression , previous attempt , ethanol abuse , rational thinking loss ( hopelessness ) , social supports lack , organized plan , no spouse and , sickness ( presence of medical illness ) .
it is important to conduct a detailed psychiatric evaluation to assess for the presence of disorders like depression , anxiety disorders , substance use disorders , and personality disorders .
medical history focusing on complications due to diabetes and other medical co - morbidities should be documented and treatment reviewed .
adherence to treatment in the past and the present can give pointers towards presence of underlying depression . in case a diagnosis of depression is made in patients with diabetes showing suicidality , appropriate treatment should be initiated .
attention must be paid towards drug interactions and impact of the psychotropic medications on glucose levels .
some of the selective serotonin reuptake inhibitors ( ssris ) would be preferred choice as they improve glycemic control , while tricyclic antidepressants ( tcas ) and mirtazapine should be avoided .
second generation antipsychotics usually have the propensity to cause impaired glucose metabolism and first generation antipsychotics should be preferred when antipsychotics need to be given for control of psychotic symptoms .
this may include hospitalization , 24-hour surveillance and monitoring , and avoidance of potentially fatal articles like sharps and medications in the vicinity of the patient .
medications for the treatment of diabetes like insulin and oral hypoglycemic agents should be supervised and kept away from easy accessibility of the patient .
suicide risk assessment should be conducted frequently and high risk precautions should continue till risk is deemed to be consistently low .
management of patients who have attempted self - harm in recent past should be given priority as an emergency .
if a patient has consumed excess doses of oral hypoglycemic agent or injected insulin in large amounts , then regular blood sugar monitoring should be conducted .
dextrose infusion is utilized to prevent blood glucose from falling too low . in some situations , insulin levels
can be monitored over time to determine the critical period and when the dextrose infusions can be slowly tapered away .
lactic acidosis is a potential problem for patients who have been receiving biguanides like metformin .
supportive measures like fluid correction and electrolyte balance should continue for the management of the patient .
after stabilization of the patient , a psychiatric consultation should be sought for assessment and management .
the salient features of management of patients with suicidality in patients with dm are highlighted in table 3 .
pubmed ( including pubmed central ) and google scholar were used to identify published studies .
searches were carried out using medical subject headings ( mesh ) terms  diabetes mellitus and  suicide. additional searches were carried out using related keywords of 
articles were evaluated and were classified according to the broad subject related to suicidality in dm .
further studies were identified using cross - references from the identified text and by going through the related citations .
the full - texts of the identified studies were obtained and assessed for their content .
the manuscripts were categorized according to broad themes like epidemiology , elaboration of risk factors for suicide , and management issues .
discrepancies in the interpretation of the literatures were resolved through mutual discussion between the authors .
the studies that have assessed the occurrence of suicidal ideas , attempts and deaths in patients with dm have been summarized in [ table 1 ] .
studies assessing occurrence of suicidal behaviour in patients with diabetes mellitus studies have assessed suicidal ideations using different tools including structured interview schedules such as mini international neuropsychaitric interview ( mini ) , rating scales ( such as beck depression scale suicidality item ) , and a single question relating to suicidal ideations . the size of the population assessed have varied from less than 100 to over 80,000 .
studies have come mainly from scandinavian countries and usa , though there are few studies from other countries too .
the rates of suicidal ideation and suicidal attempt has been reported to be as high as 26.4% and 13.3% , respectively . some of the studies focusing on suicidal ideation and attempts in patients with dm have found that suicidal risk is higher in patients with diabetes .
however , two studies have found that patients with diabetes had lower rate of suicidal ideation as compared to healthy controls and patients with other medical disorder .
depression has been reported to be the most common psychiatric disorder in persons with dm who attempted suicide .
data about suicide completers among the patients with dm have primarily come from cohort studies and studies based on health registries .
the proportion of cases reported to be due to suicide has varied from 0.55% to as high as 40% .
most of the studies which have reported rates of suicides in t1 dm population has given vales in the range of 5 - 15% .
the low rate found in one specific study could be ascribed to the fact that this study looked exclusively at t2 dm cases where mortality can result due to a host of medical complications due to diabetes or other concurrent medical illnesses
. standardized mortality rate ( smr ) provide a better approximation in such situations as it looks at comparison with the age specific mortality .
there too , diabetes has been associated with smr of more than one , which suggests greater mortality rates in this population especially males .
many demographic variables have been explored for putative association with suicidality in patients with dm .
males seems to have a greater risk in completing suicides . in a sample of patients from nigeria ,
the study conducted on 646 patients with dm found suicidality to be significantly associated with poorer glycemic control .
a large korean study has shown that depression acts synergistically with diabetes in increasing the chances of having suicidal ideations .
other psychological factors like stress have also been suggested to play a role in suicidal ideations and attempts in patients with dm .
multivariate analyses has showed that female sex , severity of childhood abuse , history of alcohol abuse , and depression were significantly and independently associated with having attempted suicide .
the literatures relating to risk factors for suicidal behavior among patients with dm is not very extensive .
however , it has been reported that probably risk factors related to suicide in general and those of chronic medical illnesses do apply in context of dm as well .
risk factors can be inherent to the patient 's characteristics like coping skills , personality profile , additional psychiatric illness including depression and alcohol use disorder , and presence of hopelessness . past history of suicide attempt and family history of completed suicide present additional risk factors .
this is compounded by illness related and situational risk factors like lack of social support , adverse life events , exacerbation of the illness and gradual accrual of diabetes related complications .
access to means of self harm is another factor which determines whether a suicidal plan is executed or not .
a range of risk factors and protective factors determine the overall suicidal risk in a particular patient and the reader is referred to more comprehensive sources for understanding of suicide risk factors in general .
[ figure 1 ] provides a simplistic model of how different factors aggregate to confer suicidal risk . a simplistic model to explain how different factors aggregate towards risk of suicidal behaviour
this can be ascribed to easy availability and accessibility to a potentially lethal means of suicide in the form of injectable insulin .
subcutaneous or intravenous injection of insulin can cause hypoglycemia which can cause death if it is severe and lasts for a prolonged period of time .
biguanides , like metformin , can cause lactic acidosis when taken in larger than necessary amounts .
[ table 2 ] provides a list of the medications that have been used for suicidal attempts .
medications for diabetes treatment that have been reported to be used for suicidal attempts as evident from the table , insulin has been widely used in suicidal self - harm attempts in patients with dm .
probably , the first report of use of high dose of insulin with a suicidal intent in a diabetes patient dates back to 1934 when a 50-year - old female patient consumed 400 u of insulin apparently being depressed due to financial issues .
subsequently , there have been reported cases of suicidal self - administration of insulin where the patients had recovered fully after prompt medical treatment .
not only regular insulin , but its congeners like insulin glargine and lispro have also been used for self - harm attempt .
use of insulin as a means of suicidal attempt seems to be more common in patients with t1 dm than t2 dm .
this could be due to the fact that t1 dm can only be treated with insulin and consequently is more regularly accessible to these patients . for treatment of patients with t2 dm ,
many other pharmacological agents are prescribed which can not be administered through an invasive route .
information about the use of oral anti - diabetic mediations for self harm has come mainly from case reports .
oral medications like glipizide and gliclazide have been used for attempted suicide in patient with dm .
metformin has been used in massive quantities with an intent to self - harm in a few patients .
use of excess doses of metformin results in lactic acidosis which may result in cardiac arrest and even death .
other medications that have been used in excess quantities with suicidal intent include liraglutide , phenformin , and sitagliptin .
apart from the above , suicidal attempts in patients with dm have involved excess consumption of sugary substances leading to hygerglycemic state . a case of fatal self - induced hyperglycemia by drinking excess amounts of sugared tea
similarly , a case of fatality has been reported with the use of sugary solution in a patient with dm .
there have been reports of use of other medications , notably psychotropics , like antidepressants and antipsychotics , for suicidal attempt by patients with dm .
danger of abuse of antidiabetic therapy for suicidal attempts is not confined to the patient , but even extends to the other family members who live along with the patient .
use of insulin and other medications for treatment of dm has also been described in family members who had taken the patient 's medications for suicidal attempt .
depression and adjustment problems are common in patients with dm and require attention . suicide risk assessment can be conducted as a part of screening for depression or otherwise .
many brief screening questionnaires for depression like primary health questionnaire-9 ( phq- 9 ) and beck depression inventory ( bdi ) have questions relating to suicidal ideation . specifically asking about current suicidal ideas directly ( and not in a roundabout indirect manner )
it has been seen that asking about suicidal ideas do not implant such ideas in the person assessed , but missing on such questioning due to hesitation on the part of the therapist may lead to missed opportunities to screen for suicidal behavior .
specific instruments to assess suicidality are also available for comprehensive assessment of patients with suicidal ideation sad persons is a mnemonic that can be used for remembering the risk factors for suicide and includes male sex , older age , depression , previous attempt , ethanol abuse , rational thinking loss ( hopelessness ) , social supports lack , organized plan , no spouse and , sickness ( presence of medical illness ) .
it is important to conduct a detailed psychiatric evaluation to assess for the presence of disorders like depression , anxiety disorders , substance use disorders , and personality disorders .
medical history focusing on complications due to diabetes and other medical co - morbidities should be documented and treatment reviewed .
adherence to treatment in the past and the present can give pointers towards presence of underlying depression . in case a diagnosis of depression is made in patients with diabetes showing suicidality , appropriate treatment should be initiated .
attention must be paid towards drug interactions and impact of the psychotropic medications on glucose levels .
some of the selective serotonin reuptake inhibitors ( ssris ) would be preferred choice as they improve glycemic control , while tricyclic antidepressants ( tcas ) and mirtazapine should be avoided .
second generation antipsychotics usually have the propensity to cause impaired glucose metabolism and first generation antipsychotics should be preferred when antipsychotics need to be given for control of psychotic symptoms .
this may include hospitalization , 24-hour surveillance and monitoring , and avoidance of potentially fatal articles like sharps and medications in the vicinity of the patient .
medications for the treatment of diabetes like insulin and oral hypoglycemic agents should be supervised and kept away from easy accessibility of the patient .
suicide risk assessment should be conducted frequently and high risk precautions should continue till risk is deemed to be consistently low .
management of patients who have attempted self - harm in recent past should be given priority as an emergency .
if a patient has consumed excess doses of oral hypoglycemic agent or injected insulin in large amounts , then regular blood sugar monitoring should be conducted .
dextrose infusion is utilized to prevent blood glucose from falling too low . in some situations , insulin levels
can be monitored over time to determine the critical period and when the dextrose infusions can be slowly tapered away .
lactic acidosis is a potential problem for patients who have been receiving biguanides like metformin .
supportive measures like fluid correction and electrolyte balance should continue for the management of the patient .
after stabilization of the patient , a psychiatric consultation should be sought for assessment and management .
the salient features of management of patients with suicidality in patients with dm are highlighted in table 3 .
suicidal thoughts and behaviors are a clinical and public health challenge in patients with dm . there are studies to suggest that dm is associated with greater frequency of suicidal thoughts and attempts , though there are a couple of studies which report to the contrary . the standardized mortality ratio due to suicide seems to be higher for patients with dm .
easy access to lethal means in the form of insulin and oral hypoglycemic agents seems to make attempt easy .
regular screening for suicidal ideas and appropriate psychiatric management of the symptoms can help in reducing potentially fatal outcomes .
 relationship of diabetes mellitus ( dm ) with metal health disorders such as depression has been explored extensively in the published literatures . 
 however , association of diabetes mellitus with suicidal tendencies has been evaluated less extensively . the present narrative review aimed to assess the literature relating to diabetes mellitus and suicide . as a part of the review , pubmed and 
 google scholar databases were searched for english language peer reviewed published studies with keywords relating to diabetes and suicide . 
 additional references were identified using cross - references . 
 the available literature suggests that suicidal ideas and attempts are more frequent in patients with diabetes mellitus than healthy or medically ill controls . 
 although , a few studies report evidence to the contrary . 
 suicide accounts for a large proportion of deaths in patients with diabetes mellitus type i ( t1 dm ) , and their mortality rate is higher than that of age matched control population . 
 psychological morbidity , including depression , precedes suicidal ideas and attempts ; though many other factors can be hypothesized to impact and modulate this association . 
 a common method of suicide attempt in patients with diabetes includes uses of high doses of insulin and its congeners or medications to treat the disease . 
 regular screening and prompt treatment of depression and suicidality is suggested for patients with dm . 