Transcript Suicide and Deliberate Self Harm

Suicide and
Deliberate Self Harm
Raquin Cherian
Specialty Registrar(ST4)
Sentil soubramanian(ST5)
The plan…
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Terms used
Practical skills you need
Epidemiology of suicide
Suicide and Psychiatry
Deliberate Self Harm
Important clinical subgroups
Theories
• Some ISQs
Terms
• Suicide
– Death
– Death achieved by individual who died
– Death was “intentional”
– Active / Passive agent (ie act or omission)
– Say “completed” rather than “successful”
Terms
• Deliberate self harm
– Everything else that doesn’t involve death
– Morgan in 1975
– Includes
• Overdoses, cutting, hanging, jumping etc. etc.
Terms best avoided
• Parasuicide
• Attempted suicide
Why ?
– Unclear definitions
– Hazy borders
– Often imply underlying intent without basis
Range of suicidal behaviour
Completed Suicide
Attempts
Plans
Risky lifestyles
A&E setting
• DSH major risk factor for future suicide(1/4
had self harmed within past year)
• Experience of A&E attendence:major
safety implications!
• Comprehensive assessment
invaluable:assessment of need as well as
risk.
Key Skills
• Asking about suicide
• Assessing suicide risk
Asking about suicide
• Asking about suicide does NOT increase
the risk of suicide
(and may decrease it !)
Asking about suicide
• Don’t forget that there is a stigma
• People often feel “weak” or ashamed
• Lots of people with depression have
suicidal thoughts but no intent
Ask gently
• Many people…
• After what you’ve told me…
• How do you think things will turn out ?
• Do you ever wish it would all just go
away ?
Ask gently
• Do you ever go to sleep and wish you
would never wake up ?
• Have you thought about ending it all ?
• What would you do ?
Assessing risk –
You must find out…
• Current plans and intent
– Availability
– How far down the path have they gone
– Why not yet
• Previous attempts
– Situation
– Dangerousness (real and perceived)
– What happened
A brief note…
• Psychiatric illnesses are serious illnesses
• Most have a significant mortality
• You will have patients who kill themselves
• This is not your fault
Suicide - Some epidemiology
• ~1% of all deaths
• 4000+ / year
• Rates falling recently (?except young men)
• Leading cause of death in young men
(with RTAs)
• Incidence 1:10,000 per year
Epidemiology
• More common in men than women
Epidemiology
• More common in men than women
• Now more common in the young than the
elderly
Associations and risks
• High
– Divorced
– Widows / Widowers
– Never married
– Married
• Low
Associations and risks
• Unemployed and retired
• Professions
– Vets
– Doctors
– Farmers
– Pharmacists
– Dentists
Associations and risks
• Seasonal variation
– Highest April to June
– More seasonal variation in women
Associations and risks
• Social class :
I and V
Associations and risks
• For what it’s worth (1)…
Protestants > Catholics
(comes up in exams sometimes – note that
Ireland is higher than UK though)
Associations and risks
• For what it’s worth (2)…
Suicide rates go down in war
(comes up in exams sometimes)
Associations and risks
• Country variation
Suicide Rates by Country
Associations and risks
• 1 in 6 leave notes
• 50% have self harmed in the past
• 16% are Psychiatric in-patients
• Majority have told someone
• 2/3rds have seen GP in previous month
Suicide and Psychiatry
• 90% suffer from psych disorder
• Depression (50%)
• EtOH (25% - prob higher)
• Schizophrenia (5%)
• Also physical illnesses
Suicide and Psychiatry
• High
– Previous attempt
– Anorexia
– Depression
– Schizophrenia
– Personality disorder
• Low
Suicide and Psychiatry
• Note…
• OCD / obsessional symptoms reduce
suicide rate
(but compared with …)
Suicide and Schizophrenia
• 10% mortality
• Risks with
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Early in illness
Males, younger
Relapses
Akathisia
Recent discharge
Paranoid
( Roy, 1982 )
Suicide and Depression
• Check that the figures add up
• Suicide rate 15%
Method
• Men use more violent methods
• Women more overdoses
Deliberate Self Harm
Deliberate Self Harm
• Incidence 3/1000
• More common in women and aged <35
• Under-reported (even if goes to hospital)
• 90% are self-poisoning
What drugs ?
• Paracetamol
• Antidepressants (now SSRIs – thankfully)
• Anything that’s available
Associations and Risks
• Life events more common in previous 6
months
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Divorced, Single
Unemployed
Lower social classes
Urban
DSH and Psychiatry
• Often thought less significant
• Previously quoted figure of 10% had psych
morbidity
THIS IS NOT TRUE
DSH and Psychiatry
• Recent study…
92% had ICD-10 diagnosis
DSH and Psychiatry
• High rates of
– Depression (72%)
– Personality disorder (partic. if repeated) (45%)
– Alcohol and substance misuse
– Psychosis over-represented
DSH repetition
• 1% will die by suicide within a year
• 10% will ultimately die by suicide
• 20-30% repeat within 1 year
• Risk highest in first year
Risk
• Think of risk as immediate and long term
• Characteristics of attempt
• Characteristics of person
• Underlying psychiatric or physical disorder
Clinical Subgroups-Elderly
• Elderly over represented in suicide
statistics
• Less able to share
thoughts/somatisation(nursing
homes/medical wards)
• Depressive illness most important
predictor(60-90%)
• Physical illness esp pain
Prominent sx prior to elderly
suicide
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Insomnia
Weight loss
Guilt feelings
Hypochondraisis
• Less likely to c/o certain depressive sx and
suicidal feeling!!
• Attempted suicide-most likely to be failed
suicide bid:much stronger predictive value
Elderly
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Depression:strongest association
SUD ?less likely
Non affective psychosis less common
Well established dementia likely to be
protective?early dementing illness
• Personality:lower OTE score compared
with younger suicide victims
Elderly-typical high risk profile
• Elderly male living alone following recent
bereavement who may have coexistent
painful chronic health problem.He may
have made serious previous suicide
attempts and be currently depressed.
Clinical techniques in assessment and
management are same !
Subgroups-Young adult males
• Only population (also young Asian
females) where suicide rates have risen
• Reluctance to seek help
• Rapidly escalating distress after recent
upset ,failed to seek outside help
• Increase in use of CO Poisoning
• Substance misuse
Subgroup-personality disorder
• Often linked with SUD
• Short lasting crisis of depressive nature
with serious suicide risk
• Risk of malignant-overdependence vs
grossly impaired judgement
Theories of suicide
• Durkheim
• Biological
• Process
• Holistic
Durkheim
• Sociologist, wrote in 1897
• 4 types of suicide
– Altruistic
– Egoistic
– Fatalistic
– Anomic
Altruistic
• Captain going down with sinking ship
• Suicide bomber
Egoistic
• Arranging assisted suicide in terminal
illness
• Has severed ties with society
Fatalistic
• Rare
• Suicide of a slave after death of master
Anomic
• The one of interest to psychiatrists…
• Down and out alcoholic
• Fallen thought society’s net
• The socially-excluded
Biology of Suicide
• Low 5-HIAA in CSF
• Increased 5HT-2 in prefrontal cortex
• Low cholesterol (!?)
• Serotonin involved in impulsivity
• Genes
Process theories
Risk / Protective factors
Cultural / Social / Psych / Biol
Situation factors
Stressors / Availabilty
Intent
Attempt
Death / Survival
Altogether…
• Need to include
– Recent vs Distant factors
– Biological / Psychological and Social factors
– Risks and protective elements
– Areas for intervention
Preventing suicide
Individual basis
• Recognize high risk individuals
• Treat mental illness
• Change other risk factors as appropriate
Preventing suicide
Public health basis
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Reduce availability of means
Decrease unemployment (!)
Invest in mental health care (?)
Reduce stigma to seeking help
More information
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Textbooks
Lancet review – July 27th, 2002
Pubmed / Google search
Samaritans website
• Confidential enquiries
ISQs
1. Anomie explains suicide bombing.
2. Anomie occurs due to the discrepancy
between identification and rules.
3. An intentional overdose taken by a 14year old girl is more likely than not to be
repeated within 6 months.
ISQs
1. Aspirin overdose by a 14-year-old girl is
highly likely to be repeated within the
next year.
2. Aspirin overdose by a 14-year-old girl
requires immediate admission to an
adolescent psychiatric unit.
ISQs
1. Deliberate self-harm is associated with drug
overdose in 50% cases.
2. Deliberate self-harm is associated with mental
illness in the majority of cases.
3. Deliberate self harm can be expected in about
10% of depressed patients each year.
4. Deliberate self harm is most common in young
women.
ISQs
1. Suicide rates are higher in social class III than
V.
2. Suicide rates are higher in those who have
high IQ.
3. Suicide rates are higher in men than in
women.
4. Suicide rates are higher in younger rather than
older men.
ISQs
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Divorced status increases the risk of suicide after
DSH.
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In a case of DSH, alcohol abuse is associated with the
likelihood of completed suicide.
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Evidence of serious intent increases the risk of suicide
after deliberate self-harm.
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Male gender increases the risk of suicide after
deliberate self-harm.
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Substance abuse is significantly associated with
completed suicide after deliberate self harm.
ISQs
1. Akathesia significantly increases the risk of
suicide in a patient with schizophrenia.
2. Anomie is a term coined by Durkheim.
3. Anomie refers to loosening of links between
the individual and his social group.
4. An intentional overdose taken by a 14-year old
girl always requires an assessment of suicidal
intent
That’s all