Dealing With Suicidal Ideation

Dr J. Juneli, CT2 Psychiatry

Aims for session

• Awareness of the requirements for each written exam

• Learning about the epidemiology of suicide• Ability to do a suicide risk assessment• Discussion of cases seen during on call• CASC practice: assess risk of suicide, make a

plan of action, report to examiner

Written ExamsPaper 1• History and Mental State• Descriptive Psychopathology• Cognitive Assessment• Neurological Examination• Assessment• Description and Measurement • Diagnosis• Classification • Aetiology• Prevention of Psychological Disorder • Basic Psychopharmacology• Human Psychological Development • Social Psychology • Basic Psychological Processes• Dynamic Psychopathology• Basic Psychological Treatments • History of Psychiatry • Basic Ethics and Philosophy of Psychiatry • Stigma and Culture 

Paper 2• Neurosciences• Psychopharmacology• Genetics• Epidemiology• Advanced psychology

Paper 3• General adult• Old age• Addictions• CAMHS• Forensic• LD• Psychotherapy• Psychopathology

Epidemiology of Suicides

• WHO: World Mental Health Survey Initiative: Cross-national lifetime prevalence:– Suicidal ideation 9.2%– Plans 3.1%– Attempts 2.7%– Ideation to attempt max 1 year in 60% cases

Epidemiology of Suicides

• Males commit more suicides on fewer attempts

• Approximately 25 attempts per completed suicide

• Most common method UK: overdose (paracetamol/antidepressant); US: Firearms

Risk factors for repeating self harm

• Past self-harm• Psychiatric history• Unemployment• Low social class• Alcohol/drugs• Criminal history

• Antisocial PD• Lack of cooperation

with treatment• Hopelessness• High suicidal intent

Risk factors for completing suicide

• Past suicide attempt/DSH

• Serious intent• Older age• Male• Social isolation• Antisocial PD

• Unemployment• Depression• Poor physical health• Access to means• Alcohol/drugs

Depression and suicide

• >90% of persons attempting suicide have got a mental illness

• Most commonly associated with mood disorders• Risk factors in depression: insomnia, anxiety

syptoms, panic attacks, anhedonia, alcohol use (modifiable)

• Long-term factors: Hopelessness, past suicide attempt, ongoing suicidal ideation

Schizophrenia and suicide

• 11.3% of persons developing first psychotic episode will self-harm prior to initial presentation to services

• Lifetime suicide prevalence of completed suicide 4.9%

• Suicide is the major cause of death in persons <35 y

• Most commonly occurring early or during exacerbations.

Global Suicide Epidemiology

• Highest rates: Eastern Europe followed by Sri Lanka and China

• High rates: Island nations generally (Cuba, Japan, Mauritius, Sri Lanka)

• Lowest rates: Eastern Mediterranean Islamic nations and some central Asian (former Soviet)

• Largest absolute number: Asia (population size)• Number of suicides in China 30% greater than

whole Europe

• Male:female ratio 3.5:1 for completed suicides• Exeption China: Females have higher/equal

suicide rate• Rise with age• Rates are 6-8 times higher in elderly• In absolute numbers more young people dying• 55% all suicides fall within 5-44 years• Some Islamic countries near zero rate: Kuwait

Global Suicide Epidemiology

• Hindu/Christian nations have mostly low-moderate rate: India 10/100,000, Italy 11.2/100,000.

• Atheist nations have very high rates: China 25.6/100,000.

• Buddhist countries have also high rates: Sri Lanka, Japan 18/100,000

• WHO Projection for 2020: Nearly 1.53 million will die by suicide. 10-20 times more will attempt it One death every 20 seconds or one attempt every 1-2 seconds

Global Suicide Epidemiology

UK Suicide Epidemiology

• UK Household Survey (Office National Statistics) 2000:

• 14.9% had considered suicide at some point• 3.9% in past year• 0.4% in last week• Ever attempted 4.4%• Attempted last year 0.5%• White>Black/South Asian (ideation)• White=Ethnic minorities (attempt)

Suicidal thoughts

• Women– Divorced 28%– Married 13%– DSH only 3%

• Men– Divorced 25%– Married 9%– DSH only 2%

• Greatest influence

– Number of stressful life events

– psychosis

Suicide statistics

Global annual rate 1:6000/year

Male:female 2-4:1

Most common age 15-24 female

25-34 males

Common method Hanging, OD

Little influence LD, dementia, OCD

Common psych dx Major depression

Alcohol dependence

Min 1 recorded DSH 40-60%

Will repeat DSH within 1 year 30%

Suicide statistics

Contact with mental health 12/12

25%

On psychiatry OP register 25%

Seen psychiatrist in 7/7 12.5%

Seen GP in 7/7 40%

Seen GP in 4/52 66%

Seen health worker in 3/52 33%

Inpatient first 7/7 25%

On routine IP observations 80%

Suicide statistics

Disengaging with services 4/52

Nearly 33%

Non-compliant with medication 20%

Within 3/12 of discharge 25% of suicides (10% before first f/u)

Within 28 days of discharge 1 in 500-1000 patients

(0.1-0.2%)

Strongest risk history DSH history

Risk of suicide within 1 year of DSH

0.5% females, 1.1% males (66 times general population risk)

Adolescent suicidesSchool pupils self report

1 year prevalenceCommonest methods Paracetamol OD and cutting

DSH 5-10y no mental illness 0.8%

DSH 5-10y anxiety 6.2%

DSH 5-10y other mental illness

7.5%

DSH 11-15y no mental illness 1.2%

DSH 11-15y anxiety 9.4%

DSH 11-15y depression 18.8%

DSH 11-15y other mental illness

8-13%

Adolescent suicidesSchool pupils self report

1 year prevalenceRequires hospital attention <13%

DSH 15-16y 6.9%

Proportion of under 16y in

ED attendants with DSH

5%

Suicidal ideation young females in 12/12

22%

Suicidal ideation young males in 12/12

8.5%

No ethnic differences

Motives for suicide by young persons

Motive Self-cutting, % (n/N) Self-poisoning, % (n/N)• Escape from a terrible state of mind 73.3 (140/191) 72.6 (53/73)

• Punishment 45.0 (85/189) 38.5 (25/65)

• Death 40.2 (74/184) 66.7 (50/75)

• Demonstration of desperation 37.6 (71/189) 43.9 (29/66)

• Wanted to find out if someone loved them 27.8 (52/188) 41.2 (28/66)

• Attention seeking 21.7 (39/180) 28.8 (19/66)

• Wanted to frighten someone 18.6 (35/188) 24.6 (16/65)

• Wanted to get back at someone 12.5 (23/184) 17.2 (11/64)

Suicide in family

• Suicidal acts <25 y is highly familial• Greater number of affected family members is

associated with earlier age• Suicidal behaviours familially transmitted

independently of mental illness• In mood disorder, the offspring of a family with a

history of suicidal acts is 6 times more likely to attempt suicide.

• Familial suicidal behaviour is also related to familial transmission of sexual abuse and increased impulsive aggression (Cluster B personality traits) in offspring.

Homicides

• 50 homicides committed yearly by persons with recent contact with mental health services

• This is 9% of all homicides• 5% of perpetrators have schizophrenia• Perpetrators with mental illness are less likely to

kill strangers.• Alcohol and drugs contribute in 61% of cases.

Suicide Risk Assessment

• Not hard science: All measures are likely to class too many people at high risk of repetition and possible future death and to misclassify some people as low risk when in fact they are at high risk (Department of Health, 2007).

• Risk factors are used to estimate the probability of the occurrence of suicide in the immediate future. They do not predict which person will or will not commit suicide or when they might do it.

• Clinical interventions are guided by the clinician's estimation of the probability of imminent suicide using risk factors as a guide.

• The most predictive factors for imminent suicide are the presence of a suicide plan and immediate access to lethal means.

Suicide Risk Assessment

• Assessment of the 5 components of suicide: ideation, intent now, plan, access to lethal means, and history of past suicide attempts

• Evaluation of suicide risk factors (the above and epidemiology)

• Evaluation of current experience (what's going on?)

• Identification of targets for intervention. Is there a psychiatric disorder?

• What resources are available?

Patient’s intentions at time of suicide

• Planned/impulsive

• Longer, careful plans more risky

• Precautions against being found

• Seeking help

• Dangerous method (amount of drugs

• Final act (suicide note, making a will)

Intent now

• Pleased to have been recovered• Wishing had died• Genuine change of resolve (serious

intent)?• Current problems may/may not have been

resolved• More serious remaining problem more

risky• Loneliness/ill health particularly risky

Review of problems

• Systematic– Intimate relationships– Relationships with children/relatives– Employment– Finance– Housing– Legal problems– Social isolation– Bereavement– Drugs/alcohol– Other losses

Suicide risk

• Continuing risk of suicide?– 1. Had intended to die– 2. Intends to die now– 3. Trigger/Problem still present– 4. Mental disorder present– 5. You decide on support required

• Risk of DSH– DSH hx, prev psych tx, antisocial PD, alcohol/drug use,

criminal record, low social class, unemployment– Brief history and MSE

Past suicidal behaviour

• Frequency, context (e.g., time, setting, planning, substance use, impulsivity, witnesses)

• method (lethality of method, insight into lethality)• consequences (medical severity, resulting treatment,

psychosocial consequences)• and intent (expectation of lethality of method)• attitude towards life (feeling about discovery and

survival) are important characteristics of past suicidal behaviours that should be identified during the initial assessment.

Factors predicting suicide

• Evidence of serious intent• Depressive disorder• Alcoholism/drug abuse• Antisocial PD• Previous suicide attempt• Social isolation• Unemployment• Older age group• Male sex

Examples of protective factors• • Strong connections to family and community support• • Skills in problem solving, coping and conflict resolution • • Sense of belonging, sense of identity, and good self-esteem• • Cultural, spiritual, and religious connections and beliefs• • Identification of future goals• • Constructive use of leisure time (enjoyable activities)• • Support through ongoing medical and mental health care

relationships• • Effective clinical care for mental, physical and substance use

disorders• • Easy access to a variety of clinical interventions and support for

seeking help • Restricted access to highly lethal means of suicide

Practical suggestions

• Establish rapport– Calm, patient, non-judgmental, empathic– Supportive statements/open-ended questions– Do not:

• allow personal feelings interfere with assessment/treatment

• rush patient• interrogate or force patient to defend their actions

Example questions to askAsking about suicidal ideation• Have you thought that your life is not worth living?• Have you thought about ending your life?• Do you feel that your reasons for living outweigh your reasons for dying?• If you had a way, would you try to take your own life?• If you thought you were going to die, would you take steps to save yourself?• How often do you think about dying?

– How long does it usually take for the thoughts to go away?• Are thoughts about dying or taking your life overpowering to you?Asking about suicidal intent and plan• How do you feel when you start thinking about taking your own life?• Have you ever thought of ways to take your own life?• Have you ever had specific thoughts or plans about taking your own life?

– Have you set a time or place?– What are those plans?

• Do you have access to (method; e.g., pills, poisons, medication, weapon)? – Do you think you could get (method) if you needed to?

• Do you think you would die if you used (method)?• Have you done anything or taken steps to prepare to take your own life (e.g., writing suicide note

or will, arranging method, giving away possessions)?• Do you think that you could take your own life?• Do you feel ready to die?

Support

• Is further assessment/treatment required– Admission voluntary/not– GP/CPN– Counselling– PCLT– Emergency support contact details

Oncall cases

• Any you want to discuss?

Risk Assessment of Violence

Violence risk

HistoricalPast (static) documented

Clinical Present (dynamic)

Observed

Risk ManagementFuture

(speculative)Projected

Risk of violence

Historical (Past)

• •Previous violence• •Young age at first violent incident• •Relationship instability• •Employment problems• •Substance misuse problems

• •Major mental illness• •Psychopathy• •Early maladjustment• •Personality disorder• •Prior supervision failure

Risk of violence

Clinical (Dynamic)

• •Lack of insight• •Negative attitudes• •Active symptoms of major mental illness• •Impulsivity• •Unresponsive to treatment

Risk of violence

Risk management (Future)

• •Plans lack feasibility

• •Exposure to destabilisers

• •Lack of personal support

• •Non-compliance with remediation attempts

• •Stress

Risk of violence

• •Severity• •Imminence• •Frequency• •Duration of risk• •Likelihood

• •Risk-enhancing factors• •Risk-protective factors• •Monitoring• •Treatment• •Supervision• •Victim safety planning

Many thanks

• Questions?

• Discussions?

• CASC practice?

References

• RCPsych. 2009. MRCPsych Paper 2. Available from: http://www.rcpsych.ac.uk/examinations/about/mrcpsychpaper2.aspx [Accessed 11.9.2012].

• Semple, D. Smyth, R. 2009. Oxford Handbook of Psychiatry (2 ed) Oxford: Oxford University Press.

• SPMM. 2010. MRCPsych Paper 2 Course Online. Available from: http://www.spmmpsychiatrycourse.co.uk/ [Accessed 10.9.2012].