Suicidal Behaviour

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Suicidal Behaviour

• Dr E Cassidy
• CUH
• January 2011

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Terminology
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Suicide

• Death
• by individual who died
• intentional
• act or omission
• completed rather than successful

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Self-Harm

• Attempted Suicide
• Deliberate Self-Harm
• Parasuicide
• Self-Poisoning or Self-Injury
• Self-Mutilitation
• Everything that doesnt involve death a
  behaviour not a diagnosis

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Suicide
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Deaths classified as suicide in Ireland
(1996-2009)
Year 2008 and 2009 figures are provisional
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Trends in undetermined deaths in Ireland
(1996-2009)
Year 2008 and 2009 figures are provisional
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• SUICIDE IN IRELAND
• 500 per year
• Peak M 20-24yo (34/100,000)
• Peak F 45-54yo
• Males _at_ 80
• Hanging, Poisoning, Drowning

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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

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Context

• 1 in 6 leave notes
• 1 in 2 have self harmed in the past
• Majority have told someone
• GP in previous month

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Suicide and Psychiatry

• ?90 suffer from some mental disorder
• OCD may protect

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Suicide and Schizophrenia

• 10 mortality
• Risks with
• Early in illness
• Males, younger
• Relapses
• Akathisia
• Recent discharge
• Paranoid
• ( Roy, 1982 )

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Suicide and Depression

• 5-15 lifetime risk
• Melancholic depression
• Psychotic depression
• Family History

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Self-Harm
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Incidence of deliberate self harm 2003-2009
Total number of DSH episodes 75,119Total
number of individuals involved 48,206
Year Male rate diff Female rate diff
2003 179 241
2004 170 -5 229 -5
2005 165 -3 227 -1
2006 160 -3 210 -8
2007 162 2 216 3
2008 179 10 221 2
2009 197 10 221 0.4
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Incidence of DSH by age and gender, Average
rates 2003-2009
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Main method of self harm (Average 2003-2009)
Men
Women
Alcohol was involved in 46 and 38 of male and
female acts, respectively
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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

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Associations

• Separated and divorced
• Low Socioeconomic status
• Urban gt Rural
• Childhood disadvantage
• Lack of Social Support
• Lack of Religious affiliation
• Collective (Princess Di effect, clustering)
• Availability of means (paracetamol)

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Cumulative probability of repeated DSH by DSH
method and number of previous episodes
Self-cutting overdose Self-cutting
only Other Attempted drowning Attempted
hanging Drug overdose only
Four previous DSH presentations Three previous
DSH presentations Two previous DSH
presentations One previous DSH presentation No
previous DSH presentation
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The burden of repeated deliberate self harm
Number of DSH acts in 2003-2009 Persons Persons Presentations Presentations
Number of DSH acts in 2003-2009 Number () Number ()
One 37690 (78.2) 37690 (50.2)
Two 5874 (12.2) 11748 (15.6)
Three 2023 (4.2) 6069 (8.1)
Four 881 (1.8) 3524 (4.7)
Five 496 (1.0) 2480 (3.3)
Six 345 (0.7) 2070 (2.8)
Seven 203 (0.4) 1421 (1.9)
Eight 132 (0.3) 1056 (1.4)
Nine 109 (0.2) 981 (1.3)
10 or more 453 (0.9) 8080 (10.8)
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Factors associated with repetitionindependent of
previous repetition

• Women aged 35-44 years had the highest risk of
  repetition (33)
• Among women, those who engaged in self-cutting
  only (57) and those with self-cutting with drug
  overdose (48) had the highest risk of
  repetition
• Among men, those engaging in self-cutting in
  combination with drug overdose had the highest
  risk (49)  

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Aetiology of Suicidal Behaviour
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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

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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

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Repetition
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Risk of Repetition

• Think of risk as immediate and long term
• Characteristics of attempt
• Characteristics of person
• Underlying psychiatric or physical disorder

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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

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Enquiring about suicide
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Asking about suicide

• Asking about it does NOT increase the risk
• It may decrease it!
• But do it sensitively

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Ask sensitively

• Many people
• After what youve 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 ?

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Assess suicidal risk

• Current plans and intent
• Availability
• How far down the path have they gone
• Why not yet
• Current mental state
• Previous attempts
• Planning, precautions
• Dangerousness (real and perceived)
• What happened
• Supports and ability to access them

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Initial Management

• Treat mental disorder
• Address needs
• Alcohol
• Finance
• Relationships
• Give crisis contact details

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Prevention

• Complex public health initiatives
• ? Reduce alcohol
• Identify and treat more Depression
• Lithium in Bipolar disorder
• Clozapine in Schizophrenia
• DBT in Borderline PD

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NATIONAL CONFIDENTIAL INQUIRYINTO SUICIDE AND
HOMICIDEBY PEOPLE WITH MENTAL ILLNESS

• England and Wales
• Annual report
• 2009

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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

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Psychiatric diagnosis

• Affective disorder (534)
• Schizophrenia (198 - stable)
• Personality disorder 104 - (fallen)
• Alcohol Dependence (83 - fallen)
• Drug Dependence (24 - fallen)
• Other (176)

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Method

• Hanging, OD, Jumping
• Hanging, jumping increased
• Overdose, CO poisoning decreased
• Drowning, firearms and burning stable

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• Reach Out National Suicide Strategy 2005-2014