Suicidal Behaviour

Dr E Cassidy CUH January 2011

Terminology

Suicide

 Death  by individual who died  “intentional”  act or omission  “completed” rather than “successful”

Self-Harm

 Attempted Suicide  Deliberate Self-Harm  Parasuicide  Self-Poisoning or Self-Injury  Self-Mutilitation 

Everything that doesn’t involve death – a behaviour not a diagnosis

Suicide

Deaths classified as suicide in Ireland (1996-2009)

500 450 400 350 300 250 200 150 100 50 0 Men Women 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year 2008 and 2009 figures are provisional

Trends in undetermined deaths in Ireland (1996-2009)

160 140 120 Men Women 100 80 60 40 20 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year 2008 and 2009 figures are provisional

SUICIDE IN IRELAND •500 per year •Peak M 20-24yo (34/100,000) •Peak F 45-54yo •Males @ 80% •Hanging, Poisoning, Drowning

Associations

 Unemployed and retired  Divorced, never married  Certain Professions  Social class: I and V  Country variation lower in LDCs than Western; China (females)  Cultural variation  Seasonal variation  Highest April to June

Context

 1 in 6 leave notes  1 in 2 have self harmed in the past  Majority have told someone  GP in previous month

Suicide and Psychiatry

 ?90% suffer from some mental disorder  OCD may protect

Suicide and Schizophrenia

 10% mortality  Risks with       Early in illness Males, younger Relapses Akathisia Recent discharge Paranoid ( Roy, 1982 )

Suicide and Depression

 5-15% lifetime risk  Melancholic depression  Psychotic depression  Family History

Self-Harm

Incidence of deliberate self harm 2003-2009

Total number of DSH episodes: 75,119 Total number of individuals involved: 48,206 Year 2003 2004 2005 2006 2007 2008 2009 Male rate* 179 170 165 160 162 179 197 % diff -5% -3% -3% +2% +10% +10% Female rate* 241 229 227 210 216 221 221 % diff -5% -1% -8% +3% +2% +0.4%

700 600 500 400 300 200 100 0

Incidence of DSH by age and gender, Average rates 2003-2009

Male Female

25% 3% 6% 2% 1% Men 4%

Main method of self harm (Average 2003-2009)

Women 2% 17% 60% 2% 2% 1% 0% 76% Overdose Alcohol Poisoning Hanging Drowning Cutting Other Alcohol was involved in 46% and 38% of male and female acts, respectively

Intentions

 Most neither want nor expect to die  1/3 no thoughts  Cry for help  Escape  Often impulsive  20-40% alcohol on board  Recent life stress  20% repeats  Self-Mutilation  Punishment, Relieve tension

Associations

        Separated and divorced Low Socioeconomic status Urban > Rural Childhood disadvantage Lack of Social Support Lack of Religious affiliation Collective (Princess Di effect, clustering) Availability of means (paracetamol)

0.70

0.60

0.50

0.40

0.30

0.20

0.10

0.00

0 Ka n-Meie ilure es s 3 6 9 Time to DSH (months)

Cumulative probability of repeated DSH by DSH method and number of previous episodes

Ka n-Meie ilure es s n-Meie r f a t ima s 0.70

0.70

0.60

0.50

0.60

0.50

0.40

0.30

0.20

0.10

12 0.00

0 3 6 9 Self-cutting & overdose Self-cutting only Other Attempted drowning Attempted hanging Drug overdose only 0.40

0.30

0.20

0.10

12 0.00

0 3 6 9 Time to DSH (months) Four previous DSH presentations Three previous DSH presentations Two previous DSH presentations One previous DSH presentation No previous DSH presentation 12

The burden of repeated deliberate self harm Number of DSH acts in 2003-2009

One Two Three Four Five Six Seven Eight Nine 10 or more

Number Persons

37690 5874 2023 881 496 345 203 132 109 453

(%)

(78.2%) (12.2%) (4.2%) (1.8%) (1.0%) (0.7%) (0.4%) (0.3%) (0.2%) (0.9%)

Presentations Number (%)

37690 11748 6069 3524 2480 2070 1421 1056 981 8080 (50.2%) (15.6%) (8.1%) (4.7%) (3.3%) (2.8%) (1.9%) (1.4%) (1.3%) (10.8%)

Factors associated with repetition independent of previous repetition

 Women aged 35-44 years had the highest risk of repetition (+33%)  Among women, those who engaged in self-cutting only (+57%) and those with self-cutting with drug overdose (+48%) had the highest risk of repetition  Among men, those engaging in self-cutting in combination with drug overdose had the highest risk (+49%)

Aetiology of Suicidal Behaviour

Vulnerability – Stress



Vulnerability

 Family history     Impulsive/aggressive personality traits Childhood adversity/abuse Hopelessness Over generalised autobiographical recall 

Stress

 Life and esp interpersonal stress  Physical illness 

Failed Inhibition

 Alcohol and Drugs  Head Injury/ cognitive impairment 

Lack of Adaptive Coping

 social support, problem solving ability 

Maladaptive coping

 with alcohol, drugs (disinhibition)

Neurobiology

  HPA axis  Hyperactivity predicts self-harm / completion in depressives  Serotonin:  Low 5-HIAA in CSF  Reduced frontal 5-HT2A receptor biding  5HT is involved in impulsivity  5-HTTLP predicts self-harm following life stress Cholesterol  Low cholesterol predicts  Prefrontal Cortex  Failed response inhibition

Repetition

Risk of Repetition

 Think of risk as immediate and long term  Characteristics of attempt  Characteristics of person  Underlying psychiatric or physical disorder

Repetition and Suicide

 15% repeat by 1 year  10%% suicide at long-term outome   Lethal prior method Psychiatric disorder   Older males Social isolation  Repeated self-harm   Avoiding discovery at time of self-harm Strong suicidal intent   Substance misuse (especially in young people) Hopelessness  Poor physical health

Enquiring about suicide

Asking about suicide

 Asking about it does NOT increase the risk  It may decrease it!

 But do it sensitively

Ask sensitively

 Many people…  After what you’ve told me…  How do you think things will turn out ?

 Do you ever wish you would never wake up ?

 Have you thought about ending it all ?

 What would you do ?

Assess suicidal risk

 Current plans and intent  Availability  How far down the path have they gone  Why not yet  Current mental state  Previous attempts  Planning, precautions  Dangerousness (real and perceived)  What happened  Supports and ability to access them

Initial Management

 Treat mental disorder  Address needs  Alcohol  Finance  Relationships  Give crisis contact details

Prevention

 Complex public health initiatives  ? Reduce alcohol  Identify and treat more Depression  Lithium in Bipolar disorder  Clozapine in Schizophrenia  DBT in Borderline PD

NATIONAL CONFIDENTIAL INQUIRY INTO SUICIDE AND HOMICIDE BY PEOPLE WITH MENTAL

Annual report 2009

Patient Suicide

 26% suicides had contact with mental health services in the 12 months prior  Suicides less common following non-compliance/loss of contact with services  14% of all suicides are Psychiatric Inpatients  70% of these occurred off the ward  Inpatient suicides falling  Fallen by 1/3 (50% less hanging/strangulation)  Belts, shoelaces, sheets, towels  Removal of non-collapsible curtain rails 2002

Psychiatric diagnosis

 Affective disorder (534)  Schizophrenia (198 - stable)  Personality disorder 104 - (fallen)  Alcohol Dependence (83 - fallen)  Drug Dependence (24 - fallen)  Other (176)

Method

 Hanging, OD, Jumping  Hanging, jumping increased  Overdose, CO poisoning decreased  Drowning, firearms and burning stable

 Reach Out National Suicide Strategy 2005-2014