1. Suicide Back to Basics April 24, 2008 Clare Gray MD FRCPC

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

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

5. 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

6. 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

7. 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

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

9. 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)

10. 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)

11. 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

12. 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

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

14. 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

15. 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

16. 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

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

18. 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

19. 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

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

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

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

23. 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%

24. 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)