A comprehensive evaluation of post- mortem findings and psychiatric case records of individuals who died by probable suicide. A van Laar, J Kielty, M Davoren, L Conlon, C McDonald, B Hallahan

Introduction Approximately 500 people have died on an annual basis over last decade by suicide 3 times as many men as women die by suicide in Ireland Rate of death by suicide is 7 th lowest in Europe however rate of suicide for individuals in years is 4 th highest in Europe 1 Rate in this group is 13.4/100,000 1 National Suicide Research Foundation, 2012

Ireland EU total Population suicide rates per 100,000 Irish suicide rates by gender 7 th lowest

Aims of study To ascertain the percentage of people who previously attended the Mental Health services in Galway and/or Roscommon who died by probable suicide To examine these individuals’ method of death To characterise previous suicide attempts and episodes of DSH To examine individuals diagnoses To examine toxicology findings

Methods All post mortem reports carried out at UCHG between Jan 06 – April 2012 reviewed and ‘’probable suicides’’ identified (term coined by the authors as suicide can only be determined by a Coroner) Criteria of inclusion: → died by probable suicide → post mortem carried out at UHG Each individual cross checked against computer records of the associated Mental Health Services

Methods continued Service users identified and psychiatric clinical case records obtained for review Various demographical, psychosocial and clinical care characteristics were identified for the entire duration of their psychiatric care Statistical analysis performed using SPSS-20

Results 181 individuals had died by probable suicide 153 of these had addresses in Galway or Roscommon 57 individuals were known to the psychiatric services – 37% Of this group Previous history of history of deliberate self harm: 25% (n=14) Family history mental illness: 60% (n=34) Family or friend death by suicide: 21% (n=12)

Demographics: Age & gender Agen% Mean age of 46.8 years (SD ± 17), Range years. Gendern % Male Female1119.3

Diagnoses (from psychiatric files)

Patient Status

Time since Inpatient Discharge 30% (n=17) were never admitted

Time Since Last Psychiatric Contact Includes as an inpatient, outpatient, ED, or day care centre.

Method of Death 58% hanging (n=33) 23% drowning (n=13) 12.3% overdose (n=7) 5.2% gunshot (n=3), 1.8% RTA (n=1)

History of Previous Suicide Attempts 65% had attempted suicide in the past (n=37) – 73% of those who died by hanging – 46% of those who died by drowning – 71% of those who died by overdose Overdose was the most common method of previous attempt (46% n= 14) 51% (19/37) employed a different method from their previous attempts.

Previous Suicide Attempts Method of Death Attempted Hanging n (%) Attempted Drowning n (%) Attempted Overdose n (%) No Previous Suicide Attempts Hanging11 (33)3 (9)14 (42)9 (30) Drowning1 (8)2 (15)6 (46)7 (54) Overdose1 (14) 5 (71)1 (14) Total % of the cohort died by hanging (n=33) 11/14 people who had attempted hanging in the past ultimately died by hanging.

Alcohol Level at Post Mortem note: Irish legal driving limit WAS 80mg%, now 50mg% None detectable: 60% (n=34) 1-79mg%: 16% (n=9) mg%:12.3% (n=7) >200mg%:10.5% (n=6)

Toxicology n% No drugs detectable2544 Antidepressants Benzodiazepines1628 Analgesics916 Antipsychotics712.3 Opiates47 Mood Stabilisers47 Hypnotics47 Cocaine %(n=28) of individuals were diagnosed with depression but only 33% of these had antidepressants in blood toxicology

Discussion

Service Contact & Diagnoses 37.3% of probable suicides were known to the psychiatric services, which is higher than results of some previous studies(27% - Hunt et al, 2010) Most common diagnosis was of depressive illness (49%) with alcohol dependence or harmful use second most frequent – 35%

Method of Death Hanging was the most common method of death (58%) which proved consistent with other studies. (1) Other common methods in order of frequency were drowning and overdose Other methods prevalent in some previous studies ( 1,2) such as jumping from heights did not feature in this study 1.Appleby et al, 1999, 2. Law et al, 2010

Last contact 35% had their time of last contact with MHS within the 4 weeks previous to their death 14% had been discharged from inpatients within their last 4weeks and a total of 23% within the last 3months. Appleby (1999) also reported one quarter of suicides within the first 3months from discharge Therefore recent discharges from impatient services indicates that this is a high risk time for patients completing suicide

Toxicology at Post-Mortem 60% of individuals had NO alcohol detectable at time of death Depressive Illness: of those still within Mental Health Services, (71%), 7/19 (37%) anti-depressants detectable at time of death Schizophrenia: only 1 patient had anti-psychotics detectable at post-mortem out of 5 diagnosed as being within the schizophrenia spectrum

Conclusions Attempted hanging is an important predictor of completed suicide by hanging therefore local policy for admission must reflect this risk Alcohol not present in 60% of individuals however is an indicator of increased risk of suicide Concordance with medication is an important consideration as toxicology reports show many people were not taking meds at time of death Recent discharge from inpatient service is a time of increased risk of completing suicide

Limitations Relatively small number of participants Coroners final reports not accessed at this point, however our methods of assessing for suicide are more likely to ascertain individuals who died by suicide.

Acknowledgements Jennifer Kielty Mary Davoren Louise Conlon Colm McDonald Brian Hallahan