Suicidal Behaviour Dr E Cassidy CUH January 2011

Terminology

Suicide  Death  by individual who died  “intentional”  act or omission  “completed” rather than “successful”

Self-Harm Attempted Suicide Deliberate Self-Harm Parasuicide Self-Poisoning or Self-Injury Self-Mutilitation Everything that doesn’t involve death – a behaviour not a diagnosis

Suicide

Deaths classified as suicide in Ireland ( ) Year 2008 and 2009 figures are provisional

Trends in undetermined deaths in Ireland ( ) Year 2008 and 2009 figures are provisional

SUICIDE IN IRELAND 500 per year Peak M 20-24yo (34/100,000) Peak F 45-54yo 80% Hanging, Poisoning, Drowning

Associations Unemployed and retired Divorced, never married Certain Professions Social class: I and V Country variation lower in LDCs than Western; China (females) Cultural variation Seasonal variation Highest April to June

Context 1 in 6 leave notes 1 in 2 have self harmed in the past Majority have told someone  GP in previous month

Suicide and Psychiatry ?90% suffer from some mental disorder OCD may protect

Suicide and Schizophrenia 10% mortality Risks with  Early in illness  Males, younger  Relapses  Akathisia  Recent discharge  Paranoid ( Roy, 1982 )

Suicide and Depression 5-15% lifetime risk Melancholic depression Psychotic depression Family History

Self-Harm

Incidence of deliberate self harm Total number of DSH episodes: 75,119 Total number of individuals involved: 48,206Year Male rate* % diff Female rate* % diff %229-5% %227-1% %210-8% %216+3% %221+2% % %

Incidence of DSH by age and gender, Average rates

Main method of self harm (Average ) MenWomen Alcohol was involved in 46% and 38% of male and female acts, respectively

Intentions Most neither want nor expect to die  1/3 no thoughts  Cry for help  Escape Often impulsive 20-40% alcohol on board Recent life stress 20% repeats Self-Mutilation Punishment, Relieve tension

Associations Separated and divorced Low Socioeconomic status Urban > Rural Childhood disadvantage Lack of Social Support Lack of Religious affiliation Collective (Princess Di effect, clustering) Availability of means (paracetamol)

Cumulative probability of repeated DSH by DSH method and number of previous episodes Self-cutting & overdose Self-cutting only Other Attempted drowning Attempted hanging Drug overdose only Four previous DSH presentations Three previous DSH presentations Two previous DSH presentations One previous DSH presentation No previous DSH presentation

The burden of repeated deliberate self harm Number of DSH acts in PersonsPresentations Number(%)Number(%) One37690 (78.2%) (50.2%) Two5874 (12.2%) (15.6%) Three2023 (4.2%) 6069 (8.1%) Four881 (1.8%) 3524 (4.7%) Five496 (1.0%) 2480 (3.3%) Six345 (0.7%) 2070 (2.8%) Seven203 (0.4%) 1421 (1.9%) Eight132 (0.3%) 1056 (1.4%) Nine109 (0.2%) 981 (1.3%) 10 or more 453(0.9%)8080 (10.8%)

Factors associated with repetition independent of previous repetition  Women aged years had the highest risk of repetition (+33%)  Among women, those who engaged in self-cutting only (+57%) and those with self-cutting with drug overdose (+48%) had the highest risk of repetition  Among men, those engaging in self-cutting in combination with drug overdose had the highest risk (+49%)  Among men, those engaging in self-cutting in combination with drug overdose had the highest risk (+49%)

Aetiology of Suicidal Behaviour

Vulnerability – Stress Vulnerability  Family history  Impulsive/aggressive personality traits  Childhood adversity/abuse  Hopelessness  Over generalised autobiographical recall Stress  Life and esp interpersonal stress  Physical illness Failed Inhibition  Alcohol and Drugs  Head Injury/ cognitive impairment Lack of Adaptive Coping  social support, problem solving ability Maladaptive coping  with alcohol, drugs (disinhibition)

Neurobiology Serotonin: Low 5-HIAA in CSF Reduced frontal 5-HT2A receptor biding 5HT is involved in impulsivity 5-HTTLP predicts self-harm following life stress HPA axis Hyperactivity predicts self-harm / completion in depressives Cholesterol Low cholesterol predicts Prefrontal Cortex Failed response inhibition

Repetition

Risk of Repetition Think of risk as immediate and long term Characteristics of attempt Characteristics of person Underlying psychiatric or physical disorder

Repetition and Suicide 15% repeat by 1 year 10% suicide at long-term outome  Lethal prior method  Psychiatric disorder  Older males  Social isolation  Repeated self-harm  Avoiding discovery at time of self-harm  Strong suicidal intent  Substance misuse (especially in young people)  Hopelessness  Poor physical health

Enquiring about suicide

Asking about suicide Asking about it does NOT increase the risk It may decrease it! But do it sensitively

Ask sensitively Many people… After what you’ve told me… How do you think things will turn out ? Do you ever wish you would never wake up ? Have you thought about ending it all ? What would you do ?

Assess suicidal risk Current plans and intent  Availability  How far down the path have they gone  Why not yet  Current mental state Previous attempts  Planning, precautions  Dangerousness (real and perceived)  What happened Supports and ability to access them

Initial Management Treat mental disorder Address needs  Alcohol  Finance  Relationships Give crisis contact details

Prevention Complex public health initiatives ? Reduce alcohol Identify and treat more Depression Lithium in Bipolar disorder Clozapine in Schizophrenia DBT in Borderline PD

NATIONAL CONFIDENTIAL INQUIRY INTO SUICIDE AND HOMICIDE BY PEOPLE WITH MENTAL ILLNESS England and Wales Annual report 2009

Patient Suicide 26% suicides had contact with mental health services in the 12 months prior Suicides less common following non-compliance/loss of contact with services 14% of all suicides are Psychiatric Inpatients 70% of these occurred off the ward Inpatient suicides falling  Fallen by 1/3 (50% less hanging/strangulation)  Belts, shoelaces, sheets, towels  Removal of non-collapsible curtain rails 2002

Psychiatric diagnosis Affective disorder (534) Schizophrenia (198 - stable) Personality disorder (fallen) Alcohol Dependence (83 - fallen) Drug Dependence (24 - fallen) Other (176)

Method Hanging, OD, Jumping Hanging, jumping increased Overdose, CO poisoning decreased Drowning, firearms and burning stable

Reach Out National Suicide Strategy