Suicidal Behaviour

Dr E CassidyCUH

January 2011

Terminology

SuicideDeathby individual who died“intentional”act or omission“completed” rather than “successful”

Self-HarmAttempted SuicideDeliberate Self-HarmParasuicideSelf-Poisoning or Self-InjurySelf-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 o

f dea

ths

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 o

f dea

ths

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 24124120042004 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

70010

-14y

rs

15-1

9yrs

20-2

4yrs

25-2

9yrs

30-3

4yrs

35-3

9yrs

40-4

4yrs

45-4

9yrs

50-5

4yrs

55-5

9yrs

60-6

4yrs

65-6

9yrs

70-7

4yrs

75-7

9yrs

80-8

4yrs

85yr

s+

Rat

e pe

r 100

,000

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-MutilationPunishment, 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)

Kap 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)

Kap 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 PresentationsPresentationsNumberNumber (%)(%) 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 CSFReduced frontal 5-HT2A receptor biding5HT is involved in impulsivity5-HTTLP predicts self-harm following life stress

HPA axis Hyperactivity predicts self-harm / completion in depressives

CholesterolLow cholesterol predicts

Prefrontal CortexFailed response inhibition

Repetition

Risk of RepetitionThink of risk as immediate and long term

Characteristics of attemptCharacteristics of personUnderlying psychiatric or physical disorder

Repetition and Suicide

15% repeat by 1 year10%% 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 ManagementTreat 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 WalesAnnual 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