Upload
loraine-bates
View
217
Download
2
Tags:
Embed Size (px)
Citation preview
Suicidal Behaviour
Dr E Cassidy
CUH
January 2011
Terminology
SuicideDeathby individual who died“intentional”act or omission“completed” rather than “successful”
Self-HarmAttempted 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)
Year 2008 and 2009 figures are provisional
0
50
100
150
200
250
300
350
400
450
500
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber
of d
eath
s
Men Women
Trends in undetermined deaths in Ireland
(1996-2009)
0
20
40
60
80
100
120
140
160
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Num
ber
of d
eath
s
Men Women
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 Schizophrenia10% mortalityRisks with
Early in illnessMales, youngerRelapsesAkathisiaRecent dischargeParanoid
( 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
YearYear Male rate*Male rate* % diff% diff Female Female rate*rate*
% diff% diff
20032003 179179 241241
20042004 170170 -5%-5% 229229 -5%-5%
20052005 165165 -3%-3% 227227 -1%-1%
20062006 160160 -3%-3% 210210 -8%-8%
20072007 162162 +2%+2% 216216 +3%+3%
20082008 179179 +10%+10% 221221 +2%+2%
20092009 197197 +10%+10% 221221 +0.4%+0.4%
0
100
200
300
400
500
600
7001
0-1
4yr
s
15
-19
yrs
20
-24
yrs
25
-29
yrs
30
-34
yrs
35
-39
yrs
40
-44
yrs
45
-49
yrs
50
-54
yrs
55
-59
yrs
60
-64
yrs
65
-69
yrs
70
-74
yrs
75
-79
yrs
80
-84
yrs
85
yrs+
Rat
e pe
r 10
0,00
0
Male
Female
Incidence of DSH by age and gender, Average rates 2003-2009
Main method of self harm (Average 2003-2009)
2%
2%
2%
0%1%
17%
76%
Overdose
Alcohol
Poisoning
Hanging
Drowning
Cutting
Other
60%
4%
25%
3%
6%2%1%
Men Women
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 statusUrban > RuralChildhood disadvantageLack of Social SupportLack of Religious affiliationCollective (Princess Di effect, clustering)Availability of means (paracetamol)
Cumulative probability of repeated DSH by DSH method and number of previous episodes
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0 3 6 9 12
Time to DSH (months)
K ap lan -M e ier f ailu re e st im at es
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0 3 6 9 12
Time to DSH (months)
K ap lan -M e ier f ailu re e st im at es
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0 3 6 9 12
Time to DSH (months)
K ap lan -M e ier f ailu re e st im at es
Time to DSH (months)
Self-cutting & overdoseSelf-cutting onlyOtherAttempted drowningAttempted hangingDrug overdose only
Four previous DSH presentationsThree previous DSH presentationsTwo previous DSH presentationsOne previous DSH presentationNo previous DSH presentation
The burden of repeated deliberate self harm
Number of Number of DSH acts in DSH acts in 2003-20092003-2009
PersonsPersons PresentationsPresentations
NumberNumber (%)(%) NumberNumber (%)(%)
OneOne 3769037690 (78.2(78.2%)%) 3769037690 (50.2(50.2%)%)
TwoTwo 58745874 (12.2(12.2%)%) 1174811748 (15.6(15.6%)%)
ThreeThree 20232023 (4.2(4.2%)%) 60696069 (8.1(8.1%)%)
FourFour 881881 (1.8(1.8%)%) 35243524 (4.7(4.7%)%)
FiveFive 496496 (1.0(1.0%)%) 24802480 (3.3(3.3%)%)
SixSix 345345 (0.7(0.7%)%) 20702070 (2.8(2.8%)%)
SevenSeven 203203 (0.4(0.4%)%) 14211421 (1.9(1.9%)%)
EightEight 132132 (0.3(0.3%)%) 10561056 (1.4(1.4%)%)
NineNine 109109 (0.2(0.2%)%) 981981 (1.3(1.3%)%)
10 or more10 or more 453453 (0.9%)(0.9%) 80808080 (10.8(10.8%)%)
Factors associated with repetitionindependent of previous repetition
Women aged 35-44 years had the highest risk of Women aged 35-44 years had the highest risk of repetition (+33%)repetition (+33%)
Among women, those who engaged in self-cutting only Among women, those who engaged in self-cutting only (+57%) and those with self-cutting with drug overdose (+57%) and those with self-cutting with drug overdose (+48%) had the highest risk of repetition(+48%) had the highest risk of repetition
Among men, those engaging in self-cutting in Among men, those engaging in self-cutting in combination with drug overdose had the highest risk combination with drug overdose had the highest risk (+49%) (+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
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
HPA axis
Hyperactivity predicts self-harm / completion in depressives
Cholesterol
Low cholesterol predicts
Prefrontal Cortex
Failed response inhibition
Repetition
Risk of Repetition
Think of risk as immediate and long term
Characteristics of attemptCharacteristics of personUnderlying 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 sensitivelyMany 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 intentAvailabilityHow far down the path have they goneWhy not yetCurrent mental state
Previous attemptsPlanning, precautionsDangerousness (real and perceived)What happened
Supports and ability to access them
Initial Management
Treat mental disorderAddress needs
AlcoholFinanceRelationships
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 HOMICIDEBY PEOPLE WITH MENTAL
ILLNESSEngland and Wales
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 increasedOverdose, CO poisoning decreasedDrowning, firearms and burning stable
Reach Out National Suicide Strategy 2005-2014