1. Suicide Back to Basics April 2, 2013 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. Mood Disorder Schizophrenia Alcohol Dependence Borderline PD 2 – 8% commit suicide 4 – 5% 5 – 7% 5 – 10% Bostwick, JM. Pankratz VS. 2000; Hor, K, Taylor, M. 2010; Palmer BA, Pankratz VS, Bostwick JM. 2005; Inskip HM, Harris EC, Barraclough B, 1998 ; Oumaya M, Friedman S, Pham A, et al. 2008;

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. 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

16. Decreased social supports Bereavement Separation/divorce Humiliation  interpersonal discord, job loss, impending disciplinary crisis, threat of incarceration Retirement Stressful life events

17. 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

18. Elevated rates of suicide have been found in patients with diagnoses of  Neurological disorders Seizures, MS, Huntington’s chorea, Brain injury  Cancer  Asthma, bronchitis  CHF  End stage renal disease  HIV Druss, B., Pincus, H. 2000; Jurrlink, DN, Herrmann N, Szalai JP, et al. 2004; Kurella, M, Kimmel PL, Young BS, et al. 2005 ;Carrico, A, Johnson, M, Morin, et al., 2007; Berger, D. 1995 ;

19. The first week after a patient's discharge from a psychiatric hospital is of particularly high risk for a suicide (Hunt IM, Kapur N, Webb R, et al. 2009)  43% of suicides occurred within a month of discharge  47% of these patients died before their first follow- up appointment

20. 40% of those who die by suicide have made a previous attempt (Cavanagh J, Carson A. Sharpe M, et al. 2003) Of those who make an attempt  7% go on to die by suicide  23% go on to make further attempts  70% make no further attempts (Owens D, Horrocks J, House A. 2002)  In children and youth who make a suicide attempt  25 to 66% will make another attempt (Stewart SE, Manion IG, Davidson S, et al. 2001; Rosewater KM, Burr BH.1998)

21. Increases risk for suicide Study of adolescent suicide completers  Were twice as likely to have firearms in the home (Brent DA, Perper JA, Allman CJ, et al, 1991) Overall, 50.7% of suicide completers use firearms (Karch DL, Dhalberg LL, Patel N, 2007) Highlights importance of removing access to firearms in the homes of suicidal patients

22. 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

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

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

25. 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%

26. 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)

27. 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

28. 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

29. Introducing the topic in a sensitive manner  Sometimes when people are feeling down, it can be hard to get up and greet the day – do you ever feel this way?  Do you ever feel like you don’t want to go on living?  Have you ever had thoughts of wanting to end your life?  Can you tell me about these thoughts?  Have you ever thought of a plan to kill yourself?

30. Degree of hopelessness is more predictive of future suicidal behaviour than severe depression  Do you have hope that things will get better?

31. Passive  “I wish I could disappear”  “I’d like to go to sleep and not wake up”  “It would be okay with me if I were to be hit by a bus” Active  “I want to die”  I am going to go and kill myself”

32. Patient felt their attempt would kill them Low chance of being found following attempt 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” Reluctant to communicate and/or accept help Lack of social support

33. 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

34. Safety Safety Safety If at all unsure about patient’s ability to control his/her suicidal behaviour, then admit patient to hospital Can admit voluntarily or involuntarily Can order a sitter for 1:1 observation on the ward

35. 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

36. No evidence to support “contracting for safety”  Having suicidal patient agree to no longer be suicidal Safety planning makes much more sense  Developed in collaboration with the patient  List of things patient agrees to try when feeling suicidal

37. Potential triggers for suicidal thinking Potential coping strategies Social supports Phone numbers for crisis lines Instructions on when to return to ED How to make environment safe (removing firearms)

38. Suicide is a major public health issue BUT there is hope!  < 1% of people who have had suicidal ideation go on to kill themselves  suicidal ideation is transient for most people SO, if we an detect the acutely suicidal patient and provide an alternative that delays the act, there is a reasonable chance the patient will change their mind

39. 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%

40. C) 25% (actually 23.8%)

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

42. 50%

47. Antares is the 15 th brightest star in the sky and it’s more than 1000 light years away! So just remember to keep everything in perspective – Good Luck with your exams! gray_c@cheo.on.ca