1. PREDICTING SUICIDE Specificity Of Parasuicidal Behaviour, Communication Of Intent, And Proximal Vs Distal Precursors Angus H Thompson Dept of Public Health, Flinders University Adelaide, Australia IFPE 11 th International Congress Göteborg, May 5, 2007

2. PREDICTION OF SUICIDE “ Too Rare to be Usefully Predicted ” 11 per 100,000 Australia & Canada (< one-ninetieth of one percent)

3. ATTEMPTS vs COMPLETIONS DUAL ENTITY MODEL Many Attempters do not wish to die Very few attempters take their own lives Differences between the two groups

4. SINGLE DIMENSION MODEL Attempts signify higher risk Escalation in lethality if no resolution Observed differences between the two may be due to differences in escalated intensity

5. SUICIDAL PROGRESSION MODEL Thoughts of Death Suicidal Thoughts Plans/Serious Ideation Suicide Attempts Completed Suicide

6. CAN WE PREDICT SUICIDE?

7. MORTALITY DUE TO SUICIDE (% of All Deaths) 2000200120022003 Canada1.7 Australia1.81.91.7 Versus 0.011% (11 per 100,000 annual rates) Additional dimension – Lifetime

8. PREDICTING SUICIDE STUDY 1 Canadian University Students N = 227 65% Female

9. QUESTIONS Q1Has there ever been a period when you felt like you wanted to die? Q2Have you felt so low you thought of committing suicide? Q3Have you ever made definite plans to commit suicide (even though you did not actually make an attempt)? Q4Have you ever attempted suicide?

10. Persons at a particular level who also displayed a “lower” level of suicidal behaviour Preceded by: Index LevelPlanSuic WishDeath Wish Attempt91%100% Plan100% Suic. Wish96% RESULTS

11. Response frequency of each level of suicidal behaviour None Death Wish Suicide WishPlanAttempt 108 (48%) 115 (51%) 80 (35%) 26 (12%) 12 (5%) RESULTS

12. STUDY ONE OBSERVATIONS This Apparently Mundane Dimension, Isn’t! Orderly Decline in Frequency From Lower to Higher Levels of Suicidality Virtually All Cases of Any Level Are Captured by the Next Lowest Level Presumably These Are Chronologically Ordered

13. PREMISE If an attempt is a communication, then attempts could be grouped with other forms of expression of suicidal intent for the purposes of prediction.

14. STUDY 2 Expression of Intent/Attempts Review: Psychological Autopsy Studies Suicides with Prior Communication and/or Attempts

15. EXPRESSED INTENT INCLUDES: Direct Statements Dire Predictions, Allusions to Being Better off Dead, Expressing a Wish to be Dead

16. PSYCHOLOGICAL AUTOPSY STUDIES N% MaleAgeAttempt Expr. Intent Attempt & Expr ‡ Robins et al.13477%Broad22%-69% Wroblenski & McIntosh 11276%Broad92% Rich et al.28382%<30/30+42/35%-71/63 % † Åsgård104 All female Broad63%59%97% Runeson5872%15-2966%78% Heila et al. (Schizophrenia) 7377%Broad52%84% Heila et al. (No Schizophrenia) 106577%Broad55%70% † This, assuming that attempts were included (underestimate?). ‡ Median = 75%

17. On “average” 75% of suicides were preceded by a communication of intent (Range: 63%-97%) Not a predictive value (how many communicators complete?)

18. StudiesLifetimeYear 1 Post Yr 1 (per year) Sakinofsky (2000)281.61%.47% Owens et al. (2002)901.80%.47% Maris (1992)10-15% PROPORTION OF ATTEMPTORS WHO COMPLETE

19. ESTIMATING THE PROPORTION OF COMMUNICATORS WHO COMPLETE Among Completed Suicides: Expressers + Attempters = 1.69 Attempters Only

20. PREDICTION OF OUTCOMES PREDICTED VALUES PREDICTORSThoughtsPlans Commun. Intent Death 1st-Yr. Death Lifetime DEATH WISH67.0%22.8%17.6%0.32%1.76% SUICIDAL THOUGHTS 32.9%25.4%0.46%2.54% PLANS 65.1%1.17%6.51% COMMUN. OF INTENT 5.14%28.56%

21. 14%3%FEMALES 43%8%MALES 29%5%BOTH SEXES Death Lifetime Death 1st-Yr.Communicated Intent CONSIDERING GENDER (Male:Female Completion Ratio = 3:1)

22. OBSERVATIONS Suicide is predictable (with minimal data) Minimal Data  Potential for Improvement Interventions: Proximal & distal predictions Meaningful commonality with Social problems / Injury / Mental illness

23. FUTURE RESEARCH Replicate with longitudinal data Test the intensity-chronology hypothesis Determine precursors to 1 st death wish Add risk-factors to prediction equation Discover why most life trajectories move away from suicide

24. For More Information: Angus H Thompson, Ph.D. Dept of Public Health, Flinders University angus.thompson@flinders.edu.au www.socialproblemindex. ualberta.ca Many Thanks

26. COMMONALITY

27. THE ASSOCIATION BETWEEN SOCIAL PROBLEMS AND PSYCHIATRIC DIAGNOSES IN THE EDMONTON AREA EPIDEMIOLOGICAL STUDY OF PSYCHIATRIC DISORDERS Source: Thompson A & Bland RC (1995). Social dysfunction and mental illness in a community sample. Canadian Journal of Psychiatry 40, 15 – 20.

28. THE CANADIAN SOCIAL PROBLEM INDEX COMPONENTS Murder Attempted Murder Assault Sexual assault Robbery Suicide Divorce Alcoholism Source: Thompson AH, Howard AW, Yin J (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51.

30. (r = 0.81) Source: Thompson AH, Borden K, Belton KL. (2004). Intentional & unintentional injuries across health regions in Alberta, Canada: An implication for policy. Crisis 25(4) 156-160.

31. TO DO LIST Improve Prediction Add MI, PTSD, Risk factors, … Match Proximal/Distal & Intervention Type Predictability should include associated mental and social problems Note that children with a death wish are likely already in trouble

32. TO DO LIST Discover Precursors to Thoughts of Death Sub-optimal Brain Development Childhood Trauma / PTSD Disrupted Attachment Oppositional / Avoidant Temperament

33. TO DO LIST Discover Precursors to Thoughts of Death Sub-optimal Brain Development Childhood Trauma Child Abuse & Neglect

34. TO DO LIST Discover Why Life Trajectories Move Away From Suicide Addition of Other Coping Strategies Social Support Formal Attention to Transitions Treatment

35. TO DO LIST Discover Causes in Common With Other Social Problems, Injury & Mental Illness Social Structure Genetic Vulnerability Cultural Stance / Social Inclusion Healthy public policy approach to alcohol use, gambling, media, education

36. THREE IMPORTANT SLIDES Serotonin Polymorphism & Abuse Increases in Childhood Trauma Cultural Continuity

37. Figure 3 THE PREVALENCE OF TWO OR MORE TRAUMATIC CHILDHOOD EVENTS BY “COHORT YEAR” AND SEX “Cohort Year” = Date when the youngest person in each group would have been about 15 years of age Source: Thompson AH, Cui X (2000). Increasing Childhood Trauma in Canada: Findings From the National Population Health Survey, 1994/95. Canadian Journal of Public Health, 91(3), 197-200.

38. Serotonin Transporter Gene, Early Life Experience, & Depression at Age 26 No AbuseModerate AbuseSevere Abuse.30.50.70 A. Caspi, Science, 18 July 2003, Vol 301. Depression Risk LL SS SL S = Short Allele L = Long Allele Founders Network

39. CULTURAL CONTINUITY