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Epidemiology Canadian Data average rate of suicide in Canada has been
13/100,000 translates to 3500 deaths/year by suicide
Epidemiology 4 males:1 female Males -- firearms, hanging, gasses, jumping
from high places Females -- drug ingestion, firearms, gasses,
hanging
Epidemiology Suicide rates for males steadily increase with
age and peak >75 years old suicide rate for white males >85 years old is
in the order of 65/100,000 for females, the suicide rate peaks in the late
40’s early 50’s
Epidemiology
Higher suicide rates in single, widowed and divorced individuals vs. married
Marital Status Widowed 24/100,000 Divorced 40/100,000 Divorced men 69/100,000 Divorced women 18/100,000
Epidemiology 1952 to 1992 the rate of suicides in
adolescents and young adults tripled (4 to 13.2/100,000)
1992 to 2002 rates decreased (13.1 to 9.9/100,000)
But more recently we have seen a rise in suicide rates in this age group
Etiology Biochemical Factors Genetics and Family variables Psychiatric diagnosis Personality traits and disorders Psychosocial and environmental factors Chronic medical illness
Etiology- Biochemical Factors 5HT (serotonin) dysregulation
association between aggression, impulsivity and 5HT dysregulation
relative deficiency of 5HT has been found in CNS of suicide completers
5HIAA (metabolite of 5HT) is decreased in the CSF of depressed patients and even more decreased in suicide attempters and completers (especially violent suicides)
Genetics
Roy and colleagues (1991) Reviewed the world literature of case reports
of twin suicides Found a much higher concordance for
suicide among monozygotic than dizygotic twins (11.3 percent vs. 1.8 percent)
Etiology - Genetic and Family Variables Family history of suicide is a significant risk
factor for suicide identification with/imitation of family member family stress/contagion effect transmission of genetic factors for suicide transmission of genetic factors for psychiatric
illness
Psychiatric Illness and Suicide 90% of suicide completers have a major
psychiatric illness 50% to 80% are clinically depressed 25-50% are substance abusers
BUT it is a small percentage of patients with psychiatric illness who commit suicide
Psychiatric Illness and Suicide MDE Bipolar Disorder Schizophrenia Alcohol Dependence Borderline PD Antisocial PD
15% commit suicide 10 - 15% 10% 2% 4 - 9% 5%
Psychiatric Illness and Suicide Psychiatric diagnosis in completers tends to
vary with age suicide completers <30 years old
substance abuse disorders or antisocial PD Stressors: separation, rejection, unemployment,
legal troubles suicide completers >30 years old
mood disorders and cognitive disorders Stressors: illness
Psychiatric Illness and Suicide Up to 60% of psychiatric inpatients who kill
themselves do so within 6 months of discharge from hospital (esp. first month)
recently discharged patients require close follow up
Personality Traits and Disorders Important contributory risk factors antisocial and borderline personality
disorders are particularly associated with suicidal behaviour in adults
conduct disorder and borderline traits in adolescent suicides
add depression to any of these -- lethal combination
Psychosocial and Environmental Factors
Bereavement separation/divorce early loss decreased social supports humiliation
interpersonal discord, job loss, impending disciplinary crisis, threat of incarceration
Chronic Medical Illness About 5% of suicide completers have serious
physical illness elevated suicide rates in patients with
brain trauma, epilepsy MS, Huntington’s, Parkinson’s AIDS, cancer Cushings, Klinefelter’s syndrome, porphyria Peptic ulcer, cirrhosis (likely related to Etoh) Prostatectomy, hemodialysis
Attempters vs. Completers
Difficult to know exactly how many people attempt suicide don’t seek help, not reported
estimates are 8 to 10 attempters for each completer
up to 40% or more of attempters have personality disorders
Suicide Attempters Female Younger Depression, Alcoholism, Personality D/O Impulsive Low lethality (overdose) High availability of help
Suicide Completers Male Older Depression, Alcoholism, Schizophrenia Careful planning High lethality (firearms) Low availability of help, socially isolated 30% have history of suicide attempts
Previous Suicide Attempts
Risk of a second suicide attempt is highest in the first 3 months following the first attempt
Suicide completers Approximately 1 in 6 completers leave a
suicide note 50% of people who commit suicide have
been seen by a primary care MD within one month prior to their deaths
with older suicide victims, this rises to 70%
Risk Factors for Suicide-- SADPERSONS scale Sex (Male) Age (very young or very old) Depression Previous attempt Ethanol abuse Rational thinking loss (psychosis) Social supports lacking Organized plan No spouse Sickness (chronic illness)
SADPERSONS Scale 1 point for each if present 7-10 points then hospitalize or commit 5-6 points strongly consider hospitalization,
depending on confidence in follow up arrangement
3-4 points then close follow up, consider hospitalization
0-2 points send home with follow up
Risk Factors BUT people don’t kill themselves because
statistics suggest they should people kill themselves because of
unbearable psychological pain statistics are good for large populations, but
not so good when applied to an individual patients can have very few risk factors and
still decide to kill themselves
Assessment Ominous signs
concrete suicidal plans, with access to means a wish to be reunited with a dead loved one putting affairs in order “things would be better for everyone if I were
dead”
When to send suicidal patients to the Emergency Department Acute suicidal ideation
With plan and intent With poor social supports With lack of future orientation Use of scales from 1-10 Hopelessness Contracts
When to refer suicidal patients to a mental health professional Patients not at imminent risk Use of contracts Always ensure patient knows they can use
the ED if situation changes Ensure close follow up or bridging until
appointment
In the 15 – 24 year old age group, what percentage of all deaths were due to suicide?
a) 5%
b) 15%
c) 25%
d) 35%
What percent of patients who commit suicide have been seen by their family physician within one month of their suicide?
20% 35% 50% 75%
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