Transcript A comprehensive evaluation of the psychiatric case records

A comprehensive evaluation of postmortem findings and psychiatric case
records of individuals who died by
probable suicide.
A van Laar, J Kielty, M Davoren, L Conlon, C McDonald, B Hallahan
Introduction
• Approximately 500 people have died on an annual basis over last
decade by suicide
• 3 times as many men as women die by suicide in Ireland
• Rate of death by suicide is 7th lowest in Europe however rate of
suicide for individuals in 15-24 years is 4th highest in Europe1
• Rate in this group is 13.4/100,000
1National
Suicide Research Foundation, 2012
Ireland
EU total Population suicide
rates per 100,000
7th lowest
Irish suicide rates by gender
Aims of study
• To ascertain the percentage of people who previously
attended the Mental Health services in Galway and/or
Roscommon who died by probable suicide
•To examine these individuals’ method of death
•To characterise previous suicide attempts and episodes of DSH
•To examine individuals diagnoses
•To examine toxicology findings
Methods
•
All post mortem reports carried out at UCHG between Jan 06
– April 2012 reviewed and ‘’probable suicides’’ identified
(term coined by the authors as suicide can only be
determined by a Coroner)
•
Criteria of inclusion:
→ died by probable suicide
→ post mortem carried out at UHG
•
Each individual cross checked against computer records of
the associated Mental Health Services
Methods continued
•
Service users identified and psychiatric clinical case records
obtained for review
•
Various demographical, psychosocial and clinical care
characteristics were identified for the entire duration of
their psychiatric care
•
Statistical analysis performed using SPSS-20
Results
• 181 individuals had died by probable suicide
• 153 of these had addresses in Galway or Roscommon
• 57 individuals were known to the psychiatric services – 37%
Of this group.......
• Previous history of history of deliberate self harm: 25%
(n=14)
• Family history mental illness: 60% (n=34)
• Family or friend death by suicide: 21% (n=12)
Demographics: Age & gender
Age
n
%
18-34
17
29.8
34-55
22
38.6
55+
18
31.6
Mean age of 46.8 years (SD ± 17), Range 18-85 years.
Gender
n
%
Male
46
80.7
Female
11
19.3
Diagnoses (from psychiatric files)
Patient Status
Time since Inpatient Discharge
• 30% (n=17) were never admitted
Time Since Last Psychiatric Contact
• Includes as an inpatient, outpatient, ED, or day care centre.
Method of Death
• 58% hanging (n=33)
• 23% drowning (n=13)
• 12.3% overdose (n=7)
• 5.2% gunshot (n=3),
• 1.8% RTA (n=1)
History of Previous Suicide Attempts
• 65% had attempted suicide in the past (n=37)
– 73% of those who died by hanging
– 46% of those who died by drowning
– 71% of those who died by overdose
• Overdose was the most common method of previous attempt
(46% n= 14)
• 51% (19/37) employed a different method from their previous
attempts.
Previous Suicide Attempts
Method of
Death
Hanging
Attempted
Hanging
n (%)
Attempted
Drowning
n (%)
Attempted
Overdose
n (%)
No Previous
Suicide
Attempts
11 (33)
3 (9)
14 (42)
9 (30)
Drowning
1 (8)
2 (15)
6 (46)
7 (54)
Overdose
1 (14)
1 (14)
5 (71)
1 (14)
14
6
25
18
Total
58% of the cohort died by hanging (n=33)
11/14 people who had attempted hanging in the past
ultimately died by hanging.
Alcohol Level at Post Mortem
note: Irish legal driving limit WAS 80mg%, now 50mg%
•
•
•
•
None detectable:
1-79mg%:
80-199mg%:
>200mg%:
60% (n=34)
16% (n=9)
12.3% (n=7)
10.5% (n=6)
Toxicology
Toxicology
n
%
No drugs detectable
25
44
Antidepressants
19
33.3
Benzodiazepines
16
28
Analgesics
9
16
Antipsychotics
7
12.3
Opiates
4
7
Mood Stabilisers
4
7
Hypnotics
4
7
Cocaine
2
3.5
49%(n=28) of individuals were diagnosed with depression but only 33% of these
had antidepressants in blood toxicology
Discussion
Service Contact & Diagnoses
• 37.3% of probable suicides were known to the psychiatric
services, which is higher than results of some previous
studies(27% - Hunt et al, 2010)
• Most common diagnosis was of depressive illness (49%) with
alcohol dependence or harmful use second most frequent –
35%
Method of Death
• Hanging was the most common method of death (58%) which
proved consistent with other studies . (1)
• Other common methods in order of frequency were
drowning and overdose
• Other methods prevalent in some previous studies (1,2) such
as jumping from heights did not feature in this study
1.Appleby et al, 1999, 2. Law et al, 2010
Last contact
• 35% had their time of last contact with MHS within the 4
weeks previous to their death
• 14% had been discharged from inpatients within their last
4weeks and a total of 23% within the last 3months. Appleby
(1999) also reported one quarter of suicides within the first
3months from discharge
• Therefore recent discharges from impatient services indicates
that this is a high risk time for patients completing suicide
Toxicology at Post-Mortem
• 60% of individuals had NO alcohol detectable at time of death
• Depressive Illness: of those still within Mental Health Services,
(71%) , 7/19 (37%) anti-depressants detectable at time of
death
• Schizophrenia: only 1 patient had anti-psychotics detectable
at post-mortem out of 5 diagnosed as being within the
schizophrenia spectrum
Conclusions
• Attempted hanging is an important predictor of completed
suicide by hanging therefore local policy for admission must
reflect this risk
• Alcohol not present in 60% of individuals however is an
indicator of increased risk of suicide
• Concordance with medication is an important consideration
as toxicology reports show many people were not taking meds
at time of death
• Recent discharge from inpatient service is a time of increased
risk of completing suicide
Limitations
• Relatively small number of participants
• Coroners final reports not accessed at this point , however our
methods of assessing for suicide are more likely to ascertain
individuals who died by suicide.
Acknowledgements
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•
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•
Jennifer Kielty
Mary Davoren
Louise Conlon
Colm McDonald
Brian Hallahan