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DISCONTINUITY BETWEEN SUICIDE ATTEMPTS AND COMPLETED SUICIDE Implications for Prediction Angus H Thompson Dept of Public Health, Flinders University.

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Presentation on theme: "DISCONTINUITY BETWEEN SUICIDE ATTEMPTS AND COMPLETED SUICIDE Implications for Prediction Angus H Thompson Dept of Public Health, Flinders University."— Presentation transcript:

1 DISCONTINUITY BETWEEN SUICIDE ATTEMPTS AND COMPLETED SUICIDE Implications for Prediction Angus H Thompson Dept of Public Health, Flinders University

2 EVIDENCE FOR DISCONTINUITY Many Attempters do not wish to die Very few attempters take their own lives There are some differences between the two groups

3 SINGLE DIMENSION MODEL Thoughts of Death Suicidal Thoughts Plans/Serious Ideation Suicide Attempts Completed Suicide

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 PREDICTION OF SUICIDE Too Rare to be Usefully Predicted? About 11 per 100,000 in Australia and Canada currently (< 1 Ninetieth of one percent)

6 STUDY 1 Canadian University Students N = 227 65% Female

7 STUDY 1 Q1Has there ever been a period when you felt like you wanted to die? Q2Have you ever 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?

8 Persons at a particular level who also displayed a “lower” level of suicidal behaviour “Preceded” by: Index LevelPlanSuic ThtDeath Wish Attempt91%100% Plan100% Suic Thought96% RESULTS

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

10 IMPROVING PREDICTION 1 Annual Rate (then) 0.014% Lifetime Ideator rate1.18% Lifetime (40 Yr) rate0.56%

11 STUDY 2 COMMUNICATION OF INTENT/ATTEMPTS Review: Psychological Autopsy Studies Suicides with Prior Communication and Attempts

12 STUDY 2 Premise: If an attempt is often a means of communication, then attempts should be considered along with other forms of expression of suicidal intent for the purposes of prediction and understanding.

13 COMMUNICATION INCLUDES: Direct Statements Dire Predictions, Allusions to Being Better off Dead, Expressing a Wish to be Dead

14 PSYCHOLOGICAL AUTOPSY STUDIES N% MaleAgeAttempt Comm Intent Attempt & Comm ‡ 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%

15 Thus, on “average” 75% of suicides were preceded by a communication of intent (Range: 63%-97%) Conservative?All key informants? Conservative? Drop low scores? Liberal? Retrospective bias? Not a predictive value (how many communicators complete?

16 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 ATTEMPTERS WHO COMPLETE

17 ESTIMATING THE PROPORTION OF COMMUNICATORS WHO COMPLETE Assume the Ratio of Communicators (Including Attempters) to Attempters Only Among Completed Suicides (1.69) is the Same Among All Showing Parasuicidal Behaviour We Have Estimates of the Interrelationships of: Death Wishes, Ideation, Attempts & Suicides – but Without Communication of Intent…

18 PREDICTION OF OUTCOMES PREDICTED VALUES PREDICTORSThoughtsPlans Commun. Intent Death 1st-Yr. Death Lifetime DEATH WISH67.0%22.8%17.6%0.32%1.76%

19 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%

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%

21 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%

22 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%

23 MORTALITY DUE TO SUICIDE (% of All Deaths) 2000200120022003 Canada1.7 Australia1.81.91.7

24 ARE THERE RISK FACTORS? Most cases are captured in Death Wishes We need to identify precursors of the first death wish We need to know what prevents movement to the next level of intensity

25 HONING PREDICTION Distal prediction is relatively low because of many false positives. Distal nature and absence of negatives make it ideal for population and health promotion approaches Proximal prediction is much higher, but late in the game. Lower false positives. Suited for clinical and individually-based services

26 IMPROVING PREDICTION Matching Activity & Predictability 1. Primary Prevention 2.Early Detection/Intervention 3.Crisis Intervention / Rx

27 IMPROVING PREDICTION Matching Activity & Predictability 1. Primary Prevention Population Focus1.7% 2.Early Detection/Intervention 3.Crisis Intervention / Rx

28 IMPROVING PREDICTION Matching Activity & Predictability 1. Primary Prevention Population Focus1.7% 2.Early Detection/Intervention Death Wish/ Ideation1.7% - 2.5% 3.Crisis Intervention / Rx

29 IMPROVING PREDICTION Matching Activity & Predictability 1. Primary Prevention Population Focus1.7% 2.Early Detection/Intervention Death Wish/ Ideation1.7% - 2.5% 3.Crisis Intervention / Rx Plans/Communication6.5% - 29%

30 IMPROVING PREDICTION Problem Synthesis Social problems are interrelated: Common base? Preventing one will prevent others Common Underlying Factors Childhood TraumaBrain Development Substance AbuseSecure Attachment Neglect / Abuse Heredity (Serotonin) Optimism / Helplessness

31 IMPROVING PREDICTION Adding Risk/Protective Factors Focus on Precursors Childhood TraumaBrain Development Secure Attachment Neglect / Abuse Punishment as Suppressant Focus on Trajectory Modifiers Coping StrategiesSocial Support Gene ActionTreatment Random ActsTransitions

32 WHEN I GET TO BE DICTATOR …

33 For More Information: Angus H Thompson Dept of Public Health, Flinders University angus.thompson@flinders.edu.au www.socialproblemindex.com Many Thanks

34 Serotonin Transporter Gene Experience in Early Life - Depression 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

35 The frequency of acknowledgement of each level of suicidal behaviour None Death Wish IdeationPlanAttempt Total108 (48%)115 (51%)80 (35%)26 (12%)12 (5%) Most Serious 108 (48%)38 (17%)52 (23%)16 (7%)12 (5%) RESULTS

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