1. Suicide Brian Ladds, M.D.

2. Epidemiology 8th overall cause of death in U.S. (1997 data) Still only a small proportion of all deaths Rate: ~ 11/100,000 midpoint among industrialized countries –Scandinavia, Germany (higher) –Spain, Italy (lower)

3. Associated Risk Factors

4. Gender, Methods Gender: –Suicide: more common among men –Suicide attempts more common among women Methods: –More than half of all suicides are by firearms –men: firearms, hanging, jumping –women: overdose

5. Age Age: suicide rates increase with age –But demographics determine overall number Over the past decade, the suicide rate has been rising most rapidly among young –3rd leading cause of death among 15-24 y.o.

6. Race, Religion, Marriage Suicide rate twice as high among whites Rate higher among immigrants Lower among Catholics –And among people with strong religious community affiliation Higher among those without children and especially those never married –But higher still among those previously married Especially highest: divorced men

7. Occupation In general, work protects against suicide –Higher among the unemployed Higher social status higher risk –But fall in status also increases risk Some studies suggest physicians at higher risk –Especially women physicians –Drug availability and knowledge about toxicity

8. Physical Health Physical illness is a contributing factor in many suicide victims 1/3 people who commit suicide have had medical attention within the prior 6 months

9. Physical Health Diseases associated with mood disorders may increase suicide risk –CNS disorders E.g., multiple sclerosis, Huntington’s disease, –Endocrine disorders Cushing’s disease, porphyria

10. Mental Health Almost all (95%) people who kill themselves suffer from a diagnosable mental disorder, substance use disorder or both The majority have a depressive disorder –Psychotic depression higher risk –Bipolar disorder less common than unipolar MDD, but higher suicide risk

11. Prior Suicide Attempts Among the best indicators of risk 10% of attempters will suicide within 10 years

12. Etiology Sociological theories Psychological theories –Freud: aggression turned inward –Fantasies: revenge, power, control, punishment Atonement, sacrifice Escape, sleep Rebirth, reunion with dead

13. Biological factors Genetics –familial risk may be independent of the associated mental disorders Neurochemistry –Serotonin deficiency Lower 5-HIAA among depressed suicide attempters –Especially violent means

14. Bipolarity & Creativity Bipolar disorder has been associated with creativity Evolutionary perspective

15. Genetic Marker for Suicidal Ideation ? 5-HT 2A receptor gene (allele C) polymorphism was associated with increased risk of suicidal ideation among depressed patients If replicated and confirmed: potential to develop test to identify at-risk patients Lisheng Du, et. al, American Journal of Medical Genetics, Feb., 2000

16. Evaluation Look for risk factors Ask explicitly about thoughts or feelings of death and suicide –Asking will not give patient the idea –Most patients who kill themselves give warnings of their intent –Ask re: feelings, thoughts, intent, plan –What are some of the things you’d like to live for?

17. Management Setting: In-patient or out-patient? –Constant observation? Beware the patient recovering from depression Beware the patient suddenly appearing at peace with self Crises intervention Treat underlying disorder

18. Physician-assisted Suicide Should terminally ill patients be allowed to kill themselves by overdosing on medications prescribed by a physician for this purpose? History, definitions Legal & ethical controversies –Oregon Clinical issues