Suicide andSuicide and

Part I - MRC

Alex MConsultant in Liaison

d Self Harm:d Self-Harm:

Psych April 2007

Mitchelln Psychiatry, Leicester.

NHS Statistics

• 13 million first outpatient appointments

• 15 million A&E episodes15 million A&E episodes

• (4 million emergency admissions)

• (5.5 million planned admissions)

• ? Suicides

• ? DSH Episodes

s in secondary care

I: Self-Harm

Tree (nomenclature) of Har

Suicide Attempt

Intent to die

Completed Near Miss Life-Thr

Violent Self-Poisoning

Hanging Paracetamol / Aspirin C

Jumping/RTA Psychotropic/ Trq

AntidepressantAntidepressant

Physical Meds Alc

rmful Behaviours

Self-Harm Attempt Thoughts Alone

No intent to die

reatening Physically Minor

Self-injuryToxic

Cuttingarbon Monoxide g

OtherGas

ohol / Illicit Drugs

Deliberate Self-Harm - EpidDSH Rates in Oxfo

500

600

400

500

300

200

100,

000)

100

e D

SH (p

er

01974 1976 1978 1980 1982 1984 1986

Rat

e

demiologyrd City (1976-1998)

Males

Females

6 1988 1990 1992 1994 1996 1998 2000

Rates of DSH for the Leices

600

400

500

300

400Rate per100 000

100

200

015-24 25-34 35-44 45-5

Age

ster (1997/98)

malefemale

4 55-64 65-74 75-84 85+e group

Data from Leicester (Dennis)

Self-Harm by Time of Day

Data from Leeds

Deliberate Self-Harm - ComC om position of DC om position o f D

30%

15%

25%

mpositionD SH

Borde rlineP e rsona lityD SH P e rsona lity

Alcohol Disinh ition

P sychia tric

5%

P sychia tric

Accide nta l

Fa ile d S uicide

25%

Deliberate Self-Harm - CateDSH and Pa

90

100

70

80

50

60

30

40

10

20

0Single Employed Psychiatric Alco

Abu

egoriesatient Types

Single

Employed

Psychiatric

Alcohol Abuse

PersonalityDisorder

Alcoholic

Drug Abuse

holuse

PersonalityDisorder

Alcoholic Drug Abuse

Deliberate Self-Harm – ReaProblems Repo

90

100

70

80

4350

60

3529

2530

40

20

10

20

0Partner Family Alcohol Employment Finances Isolat

asons Givenorted upon DSH

Partner

Family

AlcoholAlcohol

Employment

Finances

Isolation

Housing

BereavementBereavement

Friends

Physical Health

18 1712 11 9 9

Drugs

tion Housing Bereavement Friends PhysicalHealth

Drugs

Methods of Self-Harm (No.

Paracetamol overdose

Benzodiazepine overdose

Aspirin/non-steroid anti-inflammatory drug overdose

Tricyclic antidepressant overdose

Selective serotonin re-uptake inhibitor overdose

Other antidepressant overdose

Other psychotropic overdose

Other overdose

Deliberate illicit substance overdose

Wrist cutting

Other deliberate self-injury

Non-ingestibles

Carbon monoxide poisoning

Hangingg g

Other

Total no. of episodes of DSH = 934, 241 (26%) involved more than one meth

& % shown)

386 41

160 17

101 11

75 8

50 5

10 1

90 10

205 22

4 0.5

95 10

56 6

15 2

7 1

6 0.5

1 0

Data from Leedshod

Deliberate Self-Harm – RepTime to Repe

45

50

35

40

Aft i iti l t

20

25

30

g Pe

r Yea

r After initial presentwithin one year and

10

15

20

e R

epea

ting

0

5

10

Perc

enta

ge

0

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Year 7

petition Rateeat after DSH

CumulativeProportion Repeating

ti ith DSH 10% tation with DSH, 10% repeatd 30%+ within 10 years

r 7Yea

r 8Yea

r 9Yea

r 10

Year 1

1Yea

r 12

Year 1

3

Risk factors for repetition of

Risk factor StudPrevious episode 1-6pPrevious psychiatric care 1, 3, In current psychiatric care 1 Alcohol problems 1, 2, Drug dependence 1, 2, Antisocial personality 1, 2, Crim inal record 3, 6Showed lack of co-operation 2, 7Low social class 3, 6Separated from partner 1 3Separated from partner 1, 3Sex: male 2 female 8* Age: 25-34 years 1*

35-54 years 8* 35 54 years 8Separated from mother before age 15 3 Unemployed 6 Regrets about survival 3 Unprovoked index episode 3 Impulsive self-harm act 1

* factor reported but not statistically significant

f self-harm

ies Key:

1 Kessel & McC lloch 1966 n 511 97 (19%) repeated6

3, 63, 6

1. Kessel & McCulloch, 1966: n=511, 97 (19%) repeated; follow-up 1 year

2. Greer & Bagley, 1971: n=204, 53 (26%) repeated; follow-up 1-2 years

3. Morgan et al, 1976: n=215, 56 (26%) repeated; follow-up3, 6 3. Morgan et al, 1976: n 215, 56 (26%) repeated; follow up 1-2 years

4. Bancroft & Marsack, 1977: n=141, 36 (26%) repeated; follow-up 3 years

5. Wilkinson & Smeaton, 1987: n=1376, 259 (19%) repeated; follow-u 1-2 years

6. Buglass & Horton, 1974: n= 2809, 16% repeated; follow-up 1-2 years

7. Gardner et al, 1982: n=188, 50 (27%) repeated; follow-up 1 yearup 1 year

8. Kreitman, 1976: n=822; follow-up 1 year

Management of self-poisoning

Number of deliberateself-poisoning

PropodischargeHospital self poisoning

episodes in onemonth during 1996

dischargeaccidenemerg

Leeds 101 18%Leeds 101 18%

Leicester 111 55%

M h t 100 71%Manchester 100 71%

Nottingham 165 32%

All Centres 477 43%

From: Kapur N, House A, Creed F, Fe

in 4 teaching hospitals

ortioned from

Proportion dis-charged from A&E

Proportion of patientswho received psycho-ed from

nt andency

without receivingpsychosocialassessment

social assessment atany stage during their

hospital contact

% 15% 65%% 15% 65%

% 21% 68%

% 46% 36%% 46% 36%

% 25% 48%

% 26% 54%

eldman E, Friedman T, Guthrie E. BMJ 1998; 316: 831-2

Recent National Guidance

Hazardous Outcome after

• Suicide– 0.5-1% in 12 months

3% t 8– 3% at 8 years

• Repetition of DSHA 15% i 12 th– Approx. 15% in 12 months

– Most repeats during 3 months of fi

• General Mortality• General Mortality

• Use of psychiatric services– 5-10% admitted to psychiatric unit– 20% outpatients

S b t P hi t i Ill• Subsequent Psychiatric Illness

DSH

irst episode

Data from Leicester (Dennis)

II: Suicide

http://www.nimhe.csip.org.uk/our-work/suicide-prevvention/annual-report-on-progress-2006.html

Table 13.1 Life years lost for those dyspecific type of diseasep yp

Disease category (ICD codes)Heart disease (390-429)Lung cancer (162)Lung cancer (162)Motor vehicle (E180-E189) traffic accidentsBreast cancer (174, 175)Cerbrovascular (430-438) diseaseSuicide (E950) and self-inflicted injury (E959)Chronic obstructive pulmonary disease and alli

conditionsColorectal cancer (153-154)Cervical cancer (180)Pancreatic cancer (157)( )Due to alcohol (100%)*Diabetes mellitus (250)Bladder cancer (188)Diseases of the oesophagus, stomach and

duodenum (530-537)duodenum (530 537)Accidents caused by fire (E890-E899)Homicide and assault (E960-E969Accidental drowning (E910)Prostatic cancer (185)Accidental poisoning (E859 E858)Accidental poisoning (E859-E858)Laryngeal cancer (161)

ICD, International Classification of Diseases, 9* Includes ICD codes 291, 303, 305.0, 425.3, 5

ying before age 65 (1989) ranked by

Male Rank Female Rank450,979 1 165,248 1115 751 3 68 686 3115,751 3 68,686 3123,799 2 40,195 6

429 19 150,282 264,484 5 63,350 482,161 4 24,050 9

ied 47,398 6 42,058 5

44,516 7 38,981 729,651 8

16,619 9 15,284 11, ,23,025 8 15,461 1013,896 10 12,640 1210,156 13 4,816 16

9,242 15 6,254 13

8,845 16 5,700 146,390 17 4,636 17

10,624 12 2,239 1810,942 11

9 783 14 5 168 159,783 14 5,168 154,476 18 1,028 19

th Edition571.0, 571.1, 571.2, 571.3, 980

Suicide Statistics in the UK

• Annual number of Suicides in UK

• Annual number of Homicides in UKAnnual number of Homicides in UK

• Annual number of Suicides in USA

• Annual number of Homicides in USA

• Suicide (all ages) is the

• Suicide in adolescents is the

A l S i id t i• Annual Suicide rate is

5,000

1,0001,000

30,000

15,000

8th commonest cause of death

3rd commonest cause of death

10 100 000 l ti10 per 100,000 population

Suicide Risk FactorsII - DemSuicide and P

90

100

70

80

50

60

30

40

10

20

0Psychiatric Psychotropic GP Visit Depre

mographicsPatient Types

Psychiatric

P h t iPsychotropic

GP Visit

Depressed

Physical Illness

Alcoholic

Schizophrenia

ssed PhysicalIllness

Alcoholic Schizophrenia

Suicide EpidemiologyI - TotSuicide Rate (All Ages) En

140

160

120

on)

80

100

er m

illio

40

60

Rat

e (p

e

20

40

Suic

ide

MalesFemales

01955 1960 1965 1970 1975

S

The suicide rate is much higher men, largely due to the f

talngland & Wales 1960-1998

5 1980 1985 1990 1995 2000fall in the rate in women since 1987

Trend in suicide rate for youung men (aged 20-34)

Suicide EpidemiologyI – ByMale Suicide Rate by Age E450

400

300

350

llion

)

200

250

Rat

e (p

er m

i

150

200

Suic

ide

R

50

100

01955 1960 1965 1970 1975Suicide rates previously increased with age, but now are v

AgeEngland & Wales 1960-1998

65+45-6435-4425-3425-3415-24

1980 1985 1990 1995 2000very similar in men and woman across age groups

Death rates from Intentional seUndetermined Intent 1993-2005

lf-harm and injury of 5 and target for the year 2010,

DSH – Suicide OutcomeSuicide a

18

20

14

16

10

12

6

8

cide

s (%

)

2

4

mul

ativ

e Su

i

00 1 2 3 4 5 6 7 8 9

Years afte

Cu

DSH is an important risk factor for completed suicide, in

after DSH

9 10 11 12 13 14 15 16 17 18 19

er index Episodecreasing the risk about 100 fold

DSH & Suicide Overview

1%

DSH(150,000)

Sui(50

Depressed(30%)

30%

(30%)

GeneralPop’n

0.01%

Depressed

(5%)

icide000)

Depressed

70%

(5%)

d(80%)

Predictors of Poor Outcome

Risk Factor Suicid

History of Previous DSH ☯ ☯History of Previous DSH ☯ ☯

Psychiatric History ☯ ☯

Drug/Alcohol Abuse

Personality Disorder

Unemployment ☯

Lower Social Class / Stability ☯

Physical Illness ☯

Social Isolation ☯ ☯

High Suicidal Intent ☯

e after DSH

de Repeat DSH

☯ ☯ ☯☯ ☯ ☯

☯ ☯ ☯

☯

☯

☯

☯ ☯

☯

Recent warnings about (SSRI’s) in depre

• Committee on Safety of Medicines (y (SSRI’s for depressed children, exce

medicines.mhra.gov.uk/ourworkmonitorsafequalm

• FDA issues Public Health Advice onantidepressants in adults and childantidepressants in adults and childwww.fda.gov/bbs/topics/ANSWERS/2004/ANSO128

essed young people.

(December 2003) contra-indicated all ( )ept fluoxetine.

ed/safetymessages/ssrioverview_101203.pdf

n cautions for use for use of ren March 2004ren. March 2004

83.html

Antidepressants & Suicide

15%

Depression

ant

Suicide per 100,000 “depressed person years” - 141 on- 259 of

If all depressed persons were treated with antidepressan

Suicide

16% on70%

5%

antidepressants

20% ontidepressants

n antidepressantsff antidepressants [RR 1.8]p

nts, suicide rate could be reduced by 2000 deaths per year

risk

Agitation i th

uici

de increases then

decreases

Su

MoodMoodimproves1 2

w

Nutt 2003 Nutt 2003 –– Journal of PsychopharJournal of Psychophar

E i tiEnergization increases

Net effect onNet effect on suicide risk

dd s

3 4weeks

rmacology 17: 4, 355rmacology 17: 4, 355--364364

Antidepressants Prescriptioons & Suicide

What treatments are availab

Antidepressants• Antidepressants– Proven role where depression and/or

anxiety• Problem Solving

– Benefits for depression, anxiety & hopelessness but no effect on repetition

• Priority future treatmentPriority future treatment– ‘Green card studies’ showed no

benefit• Follow-up

S b fit ith d ti f– Some benefit with reduction of repetition

ble ?

• PsychotherapyPsychotherapy– Some suggestion that dialectical behaviour

therapy or IPT may reduce repetition

• Patient based self-helpp– MACT only moderately successful in

reducing repetition (confined to borderline personality disorder)

• GPs– GP guidelines of no significant benefit

Adapted from Original of Mick Dennis

III: Risk and Prediction

Predictive Scales after DSHRepetition after DSH (K

60

70

PercentageRepeating

NumberRepeating

50

on)

Repeating

30

40

s Pr

opor

tio

20

(Num

ber v

s

0

10

Rep

etiti

on

00 1 2 3 4 5

Positive Pr

R

Patients who score highly on the Kreitman & Foster scabut the majority who repeat do not score highly

H - Powerreitman & Foster Scale)

6 7 8 9 10 11 12

redictive itemsale are more likely to repeat,

Predictive Scales after DSH

• Kreitman & Foster DSH Outcome Scale

– Previous Para-suicide– Personality Disorder– Alcohol Abuse– Previous Psychiatric Treatment– Unemployment– Social Class V– Drug Abuse– Criminal Record– Violence– Age 25-54 yrs– Single, Divorced or Separated

∗ Br J Psychiatr (1991)

H - Factors

SAD PERSONS Scale

S SexA AgeD DepressionP Previous AttemptsE Ethanol AbuseR Rational Thinking LossS Social Support LackingO Organised PlanN No SpouseS Sickness

Suicide and depression: hig

• Lifetime risk is 2%– Bostwick J M Pankratz V S (2– Bostwick, J.M., Pankratz, V.S., (2

risk: a reexamination. Am. J. Psy

• Male, older [normal demographics]

• Persistent insomnia [severity]

• Previous act of deliberate self-harm [previou

• Self-neglect [severity]

• Severe Illness [severity]

• ?Impaired memory [severity]?Impaired memory [severity]

• Physical illness [co-morbidity]

• Agitation [co-morbidity]

P i k [ bidi ]• Panic attacks [co-morbidity]

gh risk factors

2000) Affective disorders and suicide2000). Affective disorders and suicide ychiatry 157 (12), 1925– 1932.

us]

Adapted from Original of Mick Dennis

Suicide and schizophrenia:

• Lifetime risk of suicide is 5% – Palmer et al (2005) AGP 62: 247( )

• Male [normal demographics]• Younger [normal demographics]• Unemployed [normal demographics]

• Previous act of deliberate self-harm [previous

• Depressive episodes [co-morbidity]• Anorexia/weight loss [co-morbidity]

• More serious illness [severity]• Recurrent relapse [severity]

• Recent diagnosis, recent discharge• Fear of deterioration, especially in those of hi

high risk factors

s]

gh intellectual ability

Adapted from Original of Mick Dennis

Suicide and alcohol addictio

• Lifetime risk of suicide is 3.4%%Murphy et al (1990) AGP

M l ( k 40 60 ) l d• Male (peak age 40 – 60 years ) normal demog

• High level of dependency [severity]

• Long history of drinking [severity]

• Disruption of major interpersonal relationsh

• Depressed mood [co-morbidity]

P h i l h lth [ bidit ]• Poor physical health [co-morbidity]

• Poor work record in previous four years [nor

• Past DSH history [previous]

on: high risk factors

% %

higraphics

ips [social]

rmal demographics]

Adapted from Original of Mick Dennis

Improving DSH Manageme

• Simple referral form

• Education for A&EEducation for A&E

• Satisfaction survey

• Quality of referral survey

• Prediction of DSH repetition study

ent in Leicester

10-Step Form Study

Frequency of Rep90

90

100 437

70

80

40

50

60

25

10

20

30

0

0 Rep

etitio

ns

1 Rep

etitio

n

2 Rep

etitio

ns

petitions of Self Harm

75 45 4

3 Rep

etitio

ns

4 Rep

etitio

ns

5+ R

epetiti

ons

5

10-Step Form Study

25

17

20

12

14

910

15

5

0

1 Day

2-7 D

ays

8-14 D

ays

15-28

Day

s

29-59

D

8 15 29

23 23

16

13

3Day

s

60-90

Day

s

0-180

Day

s

1-364

Day

s

365 D

ays+

60 90-1

181-3 3

Suicidal Plans or Conditional Threats?

Mood or Perceptions?

Previous Self-Harm?

Difficult Personal History?

Intended to die?

Housing problems?

Past Medical history?

Lack of social support?

Relationship problems?Relationship problems?

Work or Financial problems?

Admission required (if so where)?

Past Psychiatric history?

Psychosis (odd thinking or beliefs)?

Antidote, sutures required?

Dementia (memory, odd behaviour)?

Appearance or Behaviour?

Unusual or risky circumstances?

Cognition or Insight?

Believed method was dangerous/fatal?

Alcohol or Illicit Drug User?

Depression (low interest, self-esteem)?

ICU/ITU R it ti i d?ICU/ITU or Resuscitation required?

Medical Complications or detoxification?

Personality (self-destructive, impulsive)?

Current Suicidal Intent?

Refuses assessment?

Delirium (poor orientation or attention)?

Hopeless or Suicidal Thoughts?

Attempts at concealment or Final acts?

Speech or Thoughts?

4.345013258 1.65638E-05

4.109159234 4.57034E-05

3.441581787 0.000621875

3.116435435 0.001925556

2.642627391 0.008459658

1.583840408 0.113801724

1.369505014 0.171397338

1.276507103 0.202312118

1 189983947 0 2345633231.189983947 0.234563323

1.10905884 0.267886875

0.866449824 0.386619302

0.858214753 0.391145703

0.851262598 0.394990629

0.821525679 0.411700936

0.717845981 0.473154302

0.65807167 0.510764942

0.344064704 0.730928415

0.121893386 0.903027575

0.024546168 0.980425812

0.020860174 0.983364721

-0.044587427 0.964452202

0 11292289 0 910132669-0.11292289 0.910132669

-0.202967858 0.839234812

-0.311688368 0.755394419

-0.419258092 0.675189743

-0.669399303 0.503519167

-1.300189309 0.194075771

-1.658102832 0.097861755

-1.82325173 0.068804974

-1.871696803 0.061774313

Advanced Suicide Intent Sccales

IV: Extras

Mental State Examination

a. Consider whether the patient is of dejected app j p

b. Ask specifically whether the patient is depresday (i.e.. diurnal variation)

c. Does the patient have impaired sleep (difficulwaking?)

d. Is the patient experiencing feelings of guilt, u

e. Is the patient suffering impaired appetite with

f. Ask specifically about suicidal thoughts and

g. Is the patient pessimistic about his or her abi

h. Is another psychiatric syndrome present?

ppearance, agitated, restless or depressed.pp g p

ssed on waking and whether the mood lifts during the

lty in getting off to sleep, frequent or early morning

nworthiness or self-blame?

h weight loss?

intentions?

lity to resume and cope with normal life?

Adapted from Original of Mick Dennis

How to Take a DSH History

a. What were the precipitating events?

b. What were the motives for the act?

c. What were the circumstances of the act?

d. Were any precautions taken against discovery?y p g y

e. Were there any preparatory acts, e.g.. procuring meanote?

f. How violent was the method?

g. How lethal (potentially) were the drugs or poison use

h. Have there been symptoms of depression, such as li

i. Is there any sign of the use or abuse of alcohol (whic

y

ans, putting affairs in order, warning statements or suicide

ed?

istlessness or social withdrawal, preceding the act?

ch is a depressant and also a disinhibitor)?

Adapted from Original of Mick Dennis

Deliberate Self-Harm (DSH) in the e

• Usually failed serious suicide bids

• 90% self-poisoning– commonly analgesics & benzodiazepine

lderly

• Depression approx. 90%

• 2/3 physical illnesses • high suicide intent scores

• previous psychiatric history 30-55%

i lf h 30 40%• previous self-harm 30-40%

• high rates of subsequent suicide, especially those with persistent depression

Adapted from Original of Mick Dennis