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Suicide

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Suicide Back to Basics April 11, 2011 Clare Gray MD FRCPC – PowerPoint PPT presentation

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Title: Suicide


1
Suicide
  • Back to Basics
  • April 11, 2011
  • Clare Gray MD FRCPC

2
Epidemiology
  • Canadian Data
  • average rate of suicide in Canada has been
    13/100,000
  • translates to 3500 deaths/year by suicide

3
(No Transcript)
4
Epidemiology
  • 4 males1 female
  • Males -- firearms, hanging, gasses, jumping from
    high places
  • Females -- drug ingestion, firearms, gasses,
    hanging

5
Epidemiology
  • Suicide rates for males steadily increase with
    age and peak gt75 years old
  • suicide rate for white males gt85 years old is in
    the order of 65/100,000
  • for females, the suicide rate peaks in the late
    40s early 50s

6
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

7
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

8
Etiology
  • Biochemical Factors
  • Genetics and Family variables
  • Psychiatric diagnosis
  • Personality traits and disorders
  • Psychosocial and environmental factors
  • Chronic medical illness

9
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)

10
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)

11
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

12
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

13
Psychiatric Illness and Suicide
  • MDE
  • Bipolar Disorder
  • Schizophrenia
  • Alcohol Dependence
  • Borderline PD
  • Antisocial PD
  • 15 commit suicide
  • 10 - 15
  • 10
  • 2
  • 4 - 9
  • 5

14
Psychiatric Illness and Suicide
  • Psychiatric diagnosis in completers tends to vary
    with age
  • suicide completers lt30 years old
  • substance abuse disorders or antisocial PD
  • Stressors separation, rejection, unemployment,
    legal troubles
  • suicide completers gt30 years old
  • mood disorders and cognitive disorders
  • Stressors illness

15
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

16
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

17
Psychosocial and Environmental Factors
  • Bereavement
  • separation/divorce
  • early loss
  • decreased social supports
  • humiliation
  • interpersonal discord, job loss, impending
    disciplinary crisis, threat of incarceration

18
Chronic Medical Illness
  • About 5 of suicide completers have serious
    physical illness
  • elevated suicide rates in patients with
  • brain trauma, epilepsy
  • MS, Huntingtons, Parkinsons
  • AIDS, cancer
  • Cushings, Klinefelters syndrome, porphyria
  • Peptic ulcer, cirrhosis (likely related to Etoh)
  • Prostatectomy, hemodialysis

19
Attempters vs. Completers
  • Difficult to know exactly how many people attempt
    suicide
  • dont seek help, not reported
  • estimates are 8 to 10 attempters for each
    completer
  • up to 40 or more of attempters have personality
    disorders

20
Suicide Attempters
  • Female
  • Younger
  • Depression, Alcoholism, Personality D/O
  • Impulsive
  • Low lethality (overdose)
  • High availability of help

21
Suicide Completers
  • Male
  • Older
  • Depression, Alcoholism, Schizophrenia
  • Careful planning
  • High lethality (firearms)
  • Low availability of help, socially isolated
  • 30 have history of suicide attempts

22
Previous Suicide Attempts
  • Risk of a second suicide attempt is highest in
    the first 3 months following the first attempt

23
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

24
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)

25
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

26
Risk Factors
  • BUT people dont 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

27
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

28
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

29
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

30
  • 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

31
  • C) 25 (actually 23.8)

32
  • What percent of patients who commit suicide have
    been seen by their family physician within one
    month of their suicide?
  • 20
  • 35
  • 50
  • 75

33
50
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