Suicide Back to Basics March 19, 2012 Clare Gray MD FRCPC

Epidemiology Canadian Data average rate of suicide in Canada has been 13/100,000 translates to 3500 deaths/year by suicide

Epidemiology 4 males:1 female Males -- firearms, hanging, gasses, jumping from high places Females -- drug ingestion, firearms, gasses, hanging

Epidemiology Suicide rates for males steadily increase with age and peak >75 years old suicide rate for white males >85 years old is in the order of 65/100,000 for females, the suicide rate peaks in the late 40’s early 50’s

Epidemiology Higher suicide rates in single, widowed and divorced individuals vs. married Marital Status  Widowed 24/100,000  Divorced 40/100,000  Divorced men 69/100,000  Divorced women 18/100,000

Epidemiology 1952 to 1992 the rate of suicides in adolescents and young adults tripled (4 to 13.2/100,000) 1992 to 2002 rates decreased (13.1 to 9.9/100,000) But more recently we have seen a rise in suicide rates in this age group

Etiology Biochemical Factors Genetics and Family variables Psychiatric diagnosis Personality traits and disorders Psychosocial and environmental factors Chronic medical illness

Etiology- Biochemical Factors 5HT (serotonin) dysregulation  association between aggression, impulsivity and 5HT dysregulation  relative deficiency of 5HT has been found in CNS of suicide completers  5HIAA (metabolite of 5HT) is decreased in the CSF of depressed patients and even more decreased in suicide attempters and completers (especially violent suicides)

Genetics Roy and colleagues (1991) Reviewed the world literature of case reports of twin suicides Found a much higher concordance for suicide among monozygotic than dizygotic twins (11.3 percent vs. 1.8 percent)

Etiology - Genetic and Family Variables Family history of suicide is a significant risk factor for suicide  identification with/imitation of family member  family stress/contagion effect  transmission of genetic factors for suicide  transmission of genetic factors for psychiatric illness

Psychiatric Illness and Suicide 90% of suicide completers have a major psychiatric illness  50% to 80% are clinically depressed  25-50% are substance abusers BUT it is a small percentage of patients with psychiatric illness who commit suicide

Psychiatric Illness and Suicide MDE Bipolar Disorder Schizophrenia Alcohol Dependence Borderline PD Antisocial PD 15% commit suicide % 10% 2% 4 - 9% 5%

Psychiatric Illness and Suicide Psychiatric diagnosis in completers tends to vary with age suicide completers <30 years old  substance abuse disorders or antisocial PD  Stressors: separation, rejection, unemployment, legal troubles suicide completers >30 years old  mood disorders and cognitive disorders  Stressors: illness

Psychiatric Illness and Suicide Up to 60% of psychiatric inpatients who kill themselves do so within 6 months of discharge from hospital (esp. first month) recently discharged patients require close follow up

Personality Traits and Disorders Important contributory risk factors antisocial and borderline personality disorders are particularly associated with suicidal behaviour in adults conduct disorder and borderline traits in adolescent suicides add depression to any of these -- lethal combination

Psychosocial and Environmental Factors Bereavement separation/divorce early loss decreased social supports humiliation  interpersonal discord, job loss, impending disciplinary crisis, threat of incarceration

Chronic Medical Illness About 5% of suicide completers have serious physical illness elevated suicide rates in patients with  brain trauma, epilepsy  MS, Huntington’s, Parkinson’s  AIDS, cancer  Cushings, Klinefelter’s syndrome, porphyria  Peptic ulcer, cirrhosis (likely related to Etoh)  Prostatectomy, hemodialysis

Attempters vs. Completers Difficult to know exactly how many people attempt suicide  don’t seek help, not reported estimates are 8 to 10 attempters for each completer up to 40% or more of attempters have personality disorders

Suicide Attempters Female Younger Depression, Alcoholism, Personality D/O Impulsive Low lethality (overdose) High availability of help

Suicide Completers Male Older Depression, Alcoholism, Schizophrenia Careful planning High lethality (firearms) Low availability of help, socially isolated 30% have history of suicide attempts

Previous Suicide Attempts Risk of a second suicide attempt is highest in the first 3 months following the first attempt

Suicide completers Approximately 1 in 6 completers leave a suicide note 50% of people who commit suicide have been seen by a primary care MD within one month prior to their deaths with older suicide victims, this rises to 70%

Risk Factors for Suicide-- SADPERSONS scale Sex (Male) Age (very young or very old) Depression Previous attempt Ethanol abuse Rational thinking loss (psychosis) Social supports lacking Organized plan No spouse Sickness (chronic illness)

SADPERSONS Scale 1 point for each if present 7-10 points then hospitalize or commit 5-6 points strongly consider hospitalization, depending on confidence in follow up arrangement 3-4 points then close follow up, consider hospitalization 0-2 points send home with follow up

Risk Factors BUT people don’t kill themselves because statistics suggest they should people kill themselves because of unbearable psychological pain statistics are good for large populations, but not so good when applied to an individual patients can have very few risk factors and still decide to kill themselves

Assessment Ominous signs  concrete suicidal plans, with access to means  a wish to be reunited with a dead loved one  putting affairs in order  “things would be better for everyone if I were dead”

When to send suicidal patients to the Emergency Department Acute suicidal ideation  With plan and intent  With poor social supports  With lack of future orientation  Use of scales from 1-10  Hopelessness  Contracts

When to refer suicidal patients to a mental health professional Patients not at imminent risk Use of contracts Always ensure patient knows they can use the ED if situation changes Ensure close follow up or bridging until appointment

In the 15 – 24 year old age group, what percentage of all deaths were due to suicide? a) 5% b) 15% c) 25% d) 35%

C) 25% (actually 23.8%)

What percent of patients who commit suicide have been seen by their family physician within one month of their suicide? 20% 35% 50% 75%

50%