SUICIDERISK FACTORS ASSESSMENT

METHODOLOGICAL PROBLEMS

AMIT CHOUGULEPG REGISTRARDEPARTMENT OF PSYCHIATRYCMC, VELLORE, INDIA

OVERVIEW

DEFINITION EPIDEMIOLOGY RISK FACTORS ASSESSMENT OF SUICIDE METHODOLOGICAL ISSUES CONCLUSION

DEFINITION Suicidal ideation is the occurrence of passive thoughts

about wanting to be dead or active thoughts about killing oneself

A suicide attempt is defined as a potentially self injurious behavior with at least some intent to die as a consequence of the act

Suicidal intent is necessary for a self injurious behavior to be labeled an attempt and the ideation must be connected to the act

(O’Carroll et al., 1996; Posner et al., 2007)

WHEN TO CALL IT A SUICIDE?

Self-injurious behavior without suicidal intent is engaged in for purposes other than death:1. Communicating distress to others or to oneself2. Stimulating or coping with strong emotions

Self-harming behavior without intent to die is not classified as suicidal

Suicide is a self injurious behavior that has the consequence of death and is accompanied by at least some intent to die as result of the behavior

(Posner et al., 2007)

GLOBAL EPIDEMIOLOGY

WHO 2011 data: One suicidal death every 40 seconds and one attempt

every 3 seconds Global mortality rate of 16 per 100,000 India ranks 43rd in descending order of rates of suicide

with a rate of 10.6/100,000 Suicide rates increased by 60% worldwide from 1950 to

1995

GLOBAL EPIDEMIOLOGY

The rate of suicide is highest in Eastern European countries

Low rates are found mainly in Latin America 86% of all suicides occurred in the low and middle-

income countries At least six close relatives or friends are bereaved by

every suicide These people also have an increased risk of depression

and suicide For every death from suicide 30 people attempt suicide

EPIDEMIOLOGY-INDIAN SCENARIO

More than one lakh lives are lost every year due to suicide In the last three decades the suicide rate increased by 43% The southern states have a suicide rate of >15 Northern States the suicide rate is <3 This variable pattern has been stable for the last 20 years Higher literacy, a better reporting system, lower external

aggression, higher socioeconomic status and higher expectations are the possible explanations for the higher suicide rates in the southern states

(Vijayakumar L, 2008)

EPIDEMIOLOGY-INDIAN SCENARIO

Majority of the suicides (37.8%) in India are by those below the age of 30 years

71% of suicides in India are by persons below the age of 44 years

More Indian women die by suicide than their Western counterparts

Poisoning (34.8%), hanging (31.7%) and self immolation (8.5%) were the common methods used to commit suicide

Two large epidemiological verbal autopsy studies in rural Tamil Nadu reveal that the annual suicide rate is six to nine times the official rates

RISK FACTORS Trait dependent/ Distal

factors:1. Genetic loading2. Personality characteristic3. Perinatal circumstances4. Early traumatic life events5. Neurobiological disturbances State dependent/ proximal:1. Psychiatric disorder2. Physical disorder3. Psychosocial crisis4. Availability of means5. Exposure to models

Risk Factors:1. Demographic2. Clinical3. Diagnostic4. Miscellaneous

SOCIO-DEMOGRAPHIC FACTORSGENDER: Males are almost four times as likely to die by suicide as

females (CDC, 2012) Females are two to three times more likely to think about

suicide and twice as likely to attempt suicide Females:1. Use less lethal means when attempting2. Are less likely to experience substance abuse or impulse

control disorders Male: female suicide ratio was 1.78 in India in 2008 and 2009

(Kessler et al., 1999; Weissman et al., 1999) (Hawton, 2000) (NCRB, 2009)

AGE Indian scenario: In females the suicide

rate decreases after 24 years and reaches lowest at 54 years

It rises again and peaks in women aged 75 or above

In males, the rate continues to rise steadily up to 74 years, showing a decline after 75 years

Early adolescence (10–14 years, 1.29/100,00)

Mid to late adolescence(15–19 years, 7.53/100,000)

Early adulthood (20–24 years, 13.62/100,000)

• Global scenario

AGE The rate continues to incline gradually to the early 50s

(19.85/100,000) before peaking again in the 80s 28% increase in suicide during middle age (34–65

years) between 1999 and 2010 (CDC, 2013) Suicidal ideation and attempts have been noted to

decline with age (Kuo et al., 2001; DeLeo et al., 2005; Kessler et al., 2005)

MARRIAGE

In West marriage is generally protective against suicide Divorced, separated, widowed, and single people are

more likely to commit suicide Having children appears to attenuate risk of suicide Marriage is not a strong protective factor for suicide

attempts in developing countries

RELIGIOSITY Religious belief or affiliation is associated with a reduced

risk of suicide The protective effect of religion may be due to the:1. Deterrent effect of religious beliefs such as that suicide

is a sin or is morally wrong2. Social support from family or a religious group

EDUCATION Low intelligence results in a 2-3-fold increased risk of

suicide In one study of attempted suicide in India 55.5% were

uneducated Women attempting suicide tended to have a lower

educational status compared to men

EMPLOYMENT Unemployment increases suicide risk through factors such

as poverty, social deprivation, domestic difficulties, and hopelessness

Persons with psychiatric disorders are at higher risk of suicide and are also more likely to be unemployed

Recent loss of employment is associated with greater risk vs long-term unemployment

FAMILY SUPPORT

Risk factors related to the family include:1. Parenting style: “Affectionless control” is associated with a

three-fold increase in the risk of suicidal behavior2. Family history of mental illness and suicide

CLINICAL RISK FACTORS

Past Suicidal Ideation, Suicidal Behavior and Nonsuicidal Self-Injury(NSSI):

Suicidal ideation and attempt prospectively predicts suicide and suicide attempt

Ideation with a plan was found to be a stronger predictor of suicide attempt than ideation without a plan

NSSI has also been found to increase risk of later suicidal thoughts and behavior

PSYCHIATRIC DISORDER Prevalence of psychiatric diagnosis is as high as 90% as

determined by psychological autopsy Comorbidity has been associated with increasing risk of

suicide attempt Kessler et al. (1999) found that those with more disorders,

regardless of type of disorder, were more likely to attempt suicide

Psychological autopsy studies from India, China and other eastern countries have reported considerably lower rates of diagnoses among suicides than those reported in western countries (Yang et al., 2005)

MOOD DISORDER A 20-fold increased risk for major depressive disorder 12-fold increased risk for dysthymic disorder 15-fold increased risk of suicide for bipolar disorder Clinical predictors of suicide in MDD:

1. Male gender 2. History of attempted suicide3. High levels of hopelessness4. Most likely to occur during the first episode 5. Alcohol misuse6. Impulsive- aggressive personality traits

SCHIZOPHRENIA

Lifetime suicide risk in schizophrenia is 4–5% Younger age and the initial years after onset of illness

have greatest risk In those with chronic schizophrenia greater risk is

associated with:1. Hopelessness

2. Insight into illness3. Higher cognitive function

ANXIETY DISORDERS

Most anxiety disorders independently and significantly elevate risk of future suicidal ideation and behavior

Panic disorder independently increases the risk of suicide attempts

Increased risk is only evident when comorbid disorders are present

PTSD

(PTSD) has been associated with eight times greater risk of suicide attempt than that in non-PTSD populations

PTSD and suicidal behavior is mediated by the presence of comorbid borderline personality disorder

SUBSTANCE USE Psychological autopsy studies have detected alcohol use

disorder in ∼50% of suicides Alcohol use disorders are highly associated with suicide

attempts in females than males Comorbidity raises the risk of suicide Significant risk of an unplanned attempt Risk of suicide associated with opiate and mixed substance

abuse has greater risk of suicide than alcohol Number rather than type of substances is more

important for predicting suicide attempts (Borges et al., 2000)

BORDERLINE PERSONALITY DISORDER 10% of those with BPD die by suicide and ∼75% attempt

suicide The presence of comorbidities increase the risk of suicide:

1. Depressive disorder 3.Drug and alcohol disorders

2. Hopelessness 4.Childhood sexual and physical abuse It is important to distinguish between self-injury with suicidal

intent from self-injury without suicidal intent Self-harm with low lethality remains an important risk factor

not to be ignored Patient may underestimate the lethality of self-injury made

without suicidal intent

HOPELESSNESS Hopelessness is considered a risk factor for suicidal

ideation, attempt and suicide Improvement in hopelessness and depression

precedes reduction in suicidal ideation Hopelessness elevates risk of suicidal behavior

independent of psychiatric illness

IMPULSIVITY AND AGGRESSION Impulsivity relates to behavioral disinhibition Impulsive suicide attempts might be less lethal than

those that are carefully and deliberately planned Aggressive behavior comorbid with a mood disorder

has been found to be associated with greater risk of suicide attempt

CHILDHOOD HISTORY OF ABUSE AND NEGLECT

Childhood neglect, psychological abuse, and physical abuse are independently associated with greater risk of suicidal ideation and attempts during adulthood

Physically abused children were found to be more likely to exhibit suicidal behavior

Childhood sexual abuse significantly elevates risk of suicide attempt in females and even more so in males

Sexually abused children were likely to experience an earlier suicide attempt

OTHER PSYCHIATRIC ILLNESS

Suicide is a common cause of death in people with eating disorders in particular anorexia nervosa

ADHD: increases the risk of suicide in males via increasing severity of comorbidities, in particular conduct disorder and depression

PHYSICAL ILLNESS:

Suicide is also associated with several physical disorders:

Cancer (head and neck cancers in particular) HIV/AIDS Huntington’s disease Multiple sclerosis Epilepsy Peptic ulcer Renal disease Spinal-cord injury SLE Chronic pain

SUICIDE RESEARCH FROM CMC VELLORE- DISPROVING WESTERN STATISTICS

37% of those who died by suicide had a DSM–III–R psychiatric diagnosis:

1. Alcohol dependence 16%2. Adjustment disorders 15%3. Schizophrenia, major depressive episode and dysthymia were 2%

each On-going stress and chronic pain heightened the risk of suicide Living alone and a break in a steady relationship within the past

year were significantly associated with suicide Psychosocial stress and social isolation, rather than

psychiatric morbidity, are risk factors for suicide in rural south India

PERCEPTIONS ABOUT SUICIDE: A QUALITATIVE STUDY FROM SOUTHERN INDIA

Focus group discussions were conducted with community health workers (1 group) and members of the public (6 groups) and 5 people who had attempted suicide and survived

The most common causes for suicide were interpersonal and family problems and financial difficulties

Mental illness was also reported as causal All 5 subjects who had attempted suicide mentioned

marital and family discord as the cause

ASSESSMENT OF SUICIDE RISK To evaluate current suicidal risk by determining

psychiatric diagnosis and also demographic and clinical risk factors and protective factors

No definitive empirically based approaches to predicting suicide risk

Suicide risk is known to fluctuate The limits of confidentiality best discussed at the first

interview

INTERVIEW

Ask direct questions about suicidal thoughts and behaviors in a sensitive manner

Begin with querying passive thoughts of suicide followed by enquiring about active thoughts of killing oneself

Determine whether patient has a plan with a method to implement it

Whether there is intent to act upon the plan

INTERVIEW Valuable details about suicidal ideation and behavior

include:1. Time of onset2. Course (e.g., episodic, escalating)3. Levels of suicidal intent associated with attempts4. Precipitants (e.g., conflict with spouse, isolation,

unemployment, command hallucinations)5. Probability of rescue from attempt6. Medical seriousness/need for medical attention7. Actual lethality of the attempt and the patient’s

understanding of lethality

SUICIDE NOTECONTENT %

1. Apology, shame, guilt 2. Love for those left behind 3. Instructions regarding practical affairs 4. Life too much to bear 5. Hopelessness 6. Advice for those left behind

905523141414

Important component to be incorporated into assessment, therapeutic and preventive strategies

TOOLS FOR MEASURING SUICIDAL INTENT

1. Beck Depression Inventory (BDI)2. Beck Hopelessness Scale (BHS)3. Suicidal Ideas Questionnaire (SIQ)4. Suicidal Behaviour Questionnaire (SBQ)

TOOLS FOR ASSESSMENT OF SUICIDE RISK

Beck et al. found that only the Hopelessness Scale and pessimism items on the Beck Depressive Inventory predicted suicides

A score of 10 or more on the Hopelessness Scale correctly identified 91% of eventual suicides

Hopelessness has been found to have a positive correlation with degree of suicidal intent

SADPERSONS SCALEOriginally described by Patterson et al reviewed by Juhnke 1. S: Sex2. A: Age3. D: Depression4. P: Prior History5. E: Alcohol (Ethanol) use6. R: Rational thinking loss,

i.e., psychosis7. S: Support system loss8. O: Organised plan9. N: No significant other10. S: Sickness

GOALS OF RISK ASSESSMENT Upon the completion of a risk assessment a clinician :1. Is not expected to be able to predict the future2. Will develop a judgment about a patient’s current level of

risk3. Respond accordingly in the interest of the patient’s safety This may include:1. Referral for inpatient treatment2. Increased monitoring as an outpatient3. Engagement of the support group4. Plan regarding procedures to be implemented if the patient

becomes more suicidal

METHODOLOGICAL ISSUES WITH RISK ASSESSMENT

The concept of suicide risk assessment is controversial and much debated

There is no widely accepted standard of care/guideline Risk assessment is often synonymous with risk

assessment tools or scales It represents a clinical encounter where a patient is

asked about suicidal thoughts and plans

DEFINITIONS AND PARAMETERS OF STATISTICAL TESTS IN RELATION TO SUICIDE PREDICTION

Sensitivity: 1. The proportion of people who later die by suicide

who are identified by an assessment tool as being at risk of suicide

2. Sensitivity is inversely related to the false negative rate Specificity: 1. The proportion of people who do not die by suicide

who are identified as not being at risk of suicide

2. Specificity is inversely related to the false positive rate

Positive predictive value (PPV):

1. The PPV statistic measures “true positives”

2. The proportion of people who later die by suicide compared with people who are both correctly and falsely identified by a test as a positive risk for suicide

3. High false positive rates or a low incidence of suicide (or both) will lower the PPV

Negative predictive value (NPV):

1. The NPV statistic measures “true negatives”

2. The proportion of people who do not die by suicide compared with people who are both correctly and falsely identified by a test as a negative risk for suicide

3. High false negative rates will lower the NPV

4. NPV tends to be high given the low incidence of suicide

METHODOLOGICAL ISSUES WITH RISK ASSESSMENT A fundamental challenge is determining which people

determined to be “high risk” will later die by suicide (“true positives”)

(PPV) of any risk tool that assesses an event with a low base rate in the population, such as suicide is likely to be low even when sensitivity and specificity values are high

Many people are inappropriately labeled “high risk” and provided with resources that they may not have needed

METHODOLOGICAL ISSUES WITH RISK ASSESSMENT

Reliance on subjectively reported information which can be misleading

One study found that almost 80% of people who eventually died by suicide denied suicidal thoughts in their last verbal communication

This has prompted the search for alternative measures of assessment

SHIFTS IN THE SCIENCE OF RISK ASSESSMENT SCALES

Traditional suicide risk scales were not developed using empirical evidence

Few are tested statistically Scales have never been tested on their predictive

ability for suicidal behavior Important shift in the science underlying risk

assessment scales has been the move from interview dependent tools to interview independent tools

CONVENTIONAL RISK ASSESSMENT SCALESScale Sensitivity Specificity PPV

Beck hopelessness scale (BHS)

78-80% 42% 1%

Beck depression inventory (BDI)

2%

Beck scale forsuicide ideation (BSS)

3%

Suicide intent scale (SIS) 59% 77% 10%

SAD PERSONS scale 23% 89%

Suicide assessment scale (SUAS)

75% 86% 19%

Karolinska interpersonal violence scale (KIVS)

88% 60% 14%

NEWER SUICIDE RISK SCALES

1. The Columbia-suicide severity rating scale (C-SSRS)2. Suicide trigger scale (STS)3. Suicide probability scale (SPS)

EMPIRICALLY DERIVED TOOLS

Manchester self-harm rule: Sensitivity (97%) for self harm or suicide within six

months Variables have the advantage of being interview

independent : 1. History of self harm2. Previous psychiatric treatment3. Presentation with a benzodiazepine overdose4. Current psychiatric treatment Specificity was low (26%) PPV (22%)

REACT SELF-HARM RULE

UK study group Statistical based selection of predictor variables

identified four variables:1. Recent self harm2. Living alone or homeless3. Cutting as a method of self harm4. Treatment for a current psychiatric disorder Predicted suicide within six months with:1. High sensitivity (88%) and NPV (almost 100%)2. Low specificity (24%) and PPV (0.5%)

REPEATED EPISODES OF SELF-HARM (RESH) SCORE Developed in Australia Four variables:1. Number of previous self harm episodes2. Time between episodes3. Diagnosis of a mental disorder in the past year4. Psychiatric admission in the past year Sensitivity was lower than that seen for the UK tools At higher scores (>16) it showed high specificity

(98%) and PPV (82%)

NOVEL METHODS OF RISK ASSESSMENT

Advances in suicide risk assessment include use of:1. Implicit thoughts2. Neurocognitive functioning Implicit thoughts of suicide represent an appealing

substrate for risk modeling They overcome the inherent challenge of patients

denying or even being unaware of their true suicide intent The Implicit association test (IAT) measures a

person’s unconscious beliefs on a subject or motivations towards a specific behavior

IAT is a computer based test

NOVEL METHODS OF RISK ASSESSMENT

A cohort study of 157 patients in a psychiatric emergency department showed that a specific death-life IAT test predicted future suicidal behavior within six months, independently of the person’s voiced intention and the clinician’s belief of future suicidal behavior

(sensitivity 50%, specificity 81%, PPV 32%, NPV 90%)

NOVEL METHODS OF RISK ASSESSMENT Several neurocognitive tests have been examined for

their ability to detect suicidal behavior Only three tests significantly correlate with a history of

suicidal behavior:1. Stroop test: suicidal people tend to fixate on

suicidal thoughts (deficits in attentional shifting)2. Verbal fluency test: difficulty communicating a

need for help3. Iowa gambling task: prone to impulsive and risky

behavior (poor decision making)

IS SUICIDE RISK ASSESSMENT WORTH WHILE?

WHO recommends that all people over the age of 10 years with a mental disorder or other risk factor should be asked about thoughts or plans of self harm within the past month

The use of scales or tools is more controversial NICE guidelines encourage risk assessment but oppose

the use of risk assessment tools A review for the US Preventative Services Task Force

found insufficient evidence to support screening tools in primary care

OPPOSITION TO USE OF STANDARD TOOLS

Opponents of tools argue that assessment tools have:1. Low precision2. Low specificity and PPV3. Predictive utility is limited 4. Results in the inappropriate allocation of sparse

resources One of the most consistent predictive variables for

future self harm is a history of previous self harm This subgroup may already be in treatment

METHODOLOGICAL ISSUES IN SUICIDE RESEARCH Suicide is a philosophical aspect of human life No established animal model for such behavior We cannot use or define any animal models to advance

our knowledge regarding suicide It is difficult to conduct any kind of clinical trials:

1. Low rate of suicide in general population2. Ethical issues3. Problem of sourcing the right control group

METHODOLOGICAL ISSUES IN SUICIDE RESEARCH Researchers focus more on deliberate self harm (DSH) DSH seems to be etiologically different compared to

suicide Different pattern of people commit DSH in comparison

with suicide Young people and women are more prone to DSH There are usually 10 to 20 times higher incidence of

DSH compared to suicide

METHODOLOGICAL ISSUES IN SUICIDE RESEARCH Suicidal cases ultimately terminate their life It is almost impossible to have reliable information

about:1. Underlying mechanism of suicide 2. Most important risk factors involved

Evidence suggests there are under reporting of any existing data in all societies and countries

Mostly related to stigma associated with suicide Some developing countries do not report their suicide

data to international organizations

METHODOLOGICAL ISSUES WITH SUICIDE RESEARCH

Difficulties in assessment of underlying motivations or causes of suicidal behaviour

Two major approaches to research in this area have been used:

1. Explore relationships between different sets of data National or regional statistics on suicide may be compared

with figures for the same area for marital breakdown, unemployment, indicators of poverty, or female labour force participation.

Such research may suggest relationships, but cannot prove causal relationships

METHODOLOGICAL ISSUES WITH SUICIDE RESEARCH

2. The second major approach - ‘Psychological autopsy’

Impact of unemployment or divorce, as well as questions of mental health are largely reported retrospectively

People reporting the death by suicide of a family member are likely to have a number of conflicting and very difficult emotions

They may wish to put less emphasis on factors such as relationships which may be blameworthy for the survivor

METHODOLOGICAL ISSUES WITH SUICIDE RESEARCH

Developing conservative countries have other perceived important problems

Attention of authorities shifted from suicide to other perceived public health problems

Different case fatality rates of diverse methods 1. Hanging as one the most prominent methods might have a case

fatality rate up to 90%2. Drug ingestion might have a case fatality rate less than 1

percent3. Fatal methods are more correctly recorded as suicide4. Less fatal methods might be recorded as undetermined or

unintentional injuries

SUMMARY/EVALUATION OF SUICIDE RISKVariable High risk Low risk

Demographic and Social ProfileAge Over 45 years Below 45 yearsSex Male Female Marital status Divorced/widowed Married Employment Unemployed Employed Interpersonal relationship Conflictual Stable Family background Conflictual Stable Health Physical Chronic illness Good health

Hypochondriasis Feels good Mental Severe depression Mild depression Psychosis Neurosis

Personality disorder

Normal personality

Hopelessness Optimism

EVALUATION OF SUICIDE RISKVARIABLES HIGH RISK LOW RISK

SUICIDAL ACTIVITYSuicidal ideation Frequent, intense,

prolongedInfrequent, low intensity, transient

Suicide attempt Multiple attempts First attemptPlanned ImpulsiveRescue unlikely Rescue inevitableUnambiguous wish to die Primary wish for change

Communication internalized (self-blame)

Communication externalized (anger)

Method lethal and available

Method of low lethality or not readily available

EVALUATION OF SUICIDE RISKVARIABLES HIGH RISK LOW RISK

RESOURCES

Personal Poor achievement Good achievement

Poor insight Insightful

Affect unavailable or poorly controlled

Affect available and appropriately controlled

Social Poor rapport Good rapport

Socially isolated Socially integrated

Unresponsive family Concerned family

CONCLUSIONS Risk assessment tools to date are limited in their

predictive ability Efforts on developing effective low resource intensity

interventions that acknowledge a high false positive rate Being complex, not having an established animal model

and culturally not acceptable in most countries, grants suicide a unique status among other public health problems

More well-planned and cross-cultural studies are needed to shed light on this odd phenomenon

FUTURE RESEARCH QUESTIONS What constitutes a reasonable standard of care in

suicide risk assessment given the challenges in behavior prediction?

Can large scale, longitudinal studies testing multiple assessment methods over short term intervals improve the prediction of suicide?

How will neurocognitive tests be incorporated into clinical practice ?

Can effective assessment and treatment practices be adequately scaled up given the constraints on psychiatric resources?

REFERENCES1. Kaplan and Sadock’s Comprehensive Textbook of Psychatry, 9th ed.2. PSYCHIATRY by Allan Tasman 4th edition3. Suicide risk assessment and intervention in people with mental

illness, James M Bolton, David Gunnell, Gustavo Turecki. BMJ 2015;351:h4978

4. Suicide: An Indian perspective, Radhakrishnan R, Andrade C; Indian J Psychiatry. 2012 Oct-Dec; 54(4)

5. Suicide in South India: A community-based study in Kerala. C. R. Soman, S. Safraj, V. Raman Kutty, K. Vijayakumar, K. Ajayan. Indian J Psychiatry 51(4), Oct-Dec 2009

6. Risk factors for suicide in rural south India: S. D. Manoranjitham, A. P. Rajkumar, P. Thangadurai, J. Prasad, R. Jayakaran, K. S. Jacob. The British Journal of Psychiatry (2010) 196, 26–30.

7. Researching suicidal behaviour: Sarah Payne and Rachel Lart8. Methodological issues and their impacts on suicide studies,

Mohsen Rezaeian. MIDDLE EAST JOURNAL OF BUSINESS - VOLUME 7, ISSUE 2

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