Suicide Prediction and Prevention: A Practical Synthesis of the Evidence

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1 Montgomery. Alabama April 21, 2017 Suicide Prediction and Prevention: A Practical Synthesis of the Evidence. Professor Emeritus of Psychiatry DISCLAIMER Dr. Rich does not have any industry relationships. Alabama Psychiatric Association April 8, 1995 Fairhope, Alabama 1

2 Arch Gen Psychiatry 1986; 43: Arch Gen Psychiatry 1986; 43: Clinical Investigation + Toxicology Age Range < n Drug Use 59% 29% p <.001 CONCLUSIONS 1. Suicide is the fatal outcome of a small number of mental disorders (maybe only one) 2. The Last Straws in suicide are largely a) unpredictable and b) unpreventable ERGO: The best way to prevent (or delay?) suicide is to effectively treat the potentially fatal illness(es) That means: a) close monitoring and b) long-term follow-up 2

3 Fluoxetine introduced in 1986 Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, NCHS data brief, no 241. Hyattsville, MD: National Center for Health Statistics Suicide Prediction and Prevention: A Practical Synthesis of the Evidence The Plan 1. Review Prediction Situation (briefly) 2. Develop an Accurate Suicide Model 3. Apply the Model to Prevention 3

4 Some Factors Correlated with Suicide Correlations Predictions 1958 patients evaluated from scored >9 on 20 point hopelessness scale Included 16 of 17 suicides (high sensitivity) 1145/1161 = 98% False Positive (low/no specificity) Some Factors Correlated with Suicide All of these correlates include too many false positives. 4

5 Suicide Prediction Conclusion No single correlate or combination can be used to predict an individual suicide with any degree of clinical (or legal) utility. Some Factors Correlated with Suicide Maybe we can put all of these together in a way that explains suicide and allows us to successfully intervene. Suicide Prevention GOAL To devise a Profile (MODEL) That is the most FACTUALLY COMPREHENSIVE And CLINICALLY APPLICABLE 5

6 Durkheim Osgood Garfinkel Heikkinen et al Shaffer et al 1959 Consecutive Cases Systematic Database Valid Diagnostic Criteria Eli Robins, M.D

7 80% LIE LIFE LIE LIFE 7

8 Annals of Clinical Psychiatry 1989; 1:79-85 LIE LIFE LIFE EXISTENTIAL PRESSURES STRESSORS 8

9 The relative effect of particular stressors in a population can be estimated, but any individual s response to a particular stressor at any given time is pretty much unpredictable. LIFE EXISTENTIAL PRESSURES STRESSORS PRECIPITANT(S) Precipitants: Why Now? 1.Can t always tell (<50% in SDSS) 2.Tend to be recurrent 3.Tend to be mundane 4.Tend to be precipitous 5.Always determined after the fact Therefore, not of much clinical utility 9

10 LIFE EXISTENTIAL PRESSURES STRESSORS PRECIPITANT(S) + Intoxication * *IAS = Intoxicating Abusable Substance LIFE EXISTENTIAL PRESSURES STRESSORS PRECIPITANT(S) + Antidepressants? 10

11 Mainly short term studies Subjects excluded for suicidality So, any provocative effect should be seen right? P > 0.05 NS Mainly short term studies Subjects excluded for suicidality So, any provocative effect should be seen right? 11

12 LIFE EXISTENTIAL PRESSURES STRESSORS 5% Lifetime PRECIPITANT(S) LIFE EXISTENTIAL PRESSURES STRESSORS * Suicide Allowing Defect(s) Demographics Genetics Brain Chemistry Traits Hopelessness etc. PRECIPITANT(S) LIFE EXISTENTIAL PRESSURES STRESSORS Suicide Allowing Defect(s) Demographics Genetics Brain Chemistry Traits Hopelessness etc. Suicide Protection Factor(s) Demographics Partner Children etc. PRECIPITANT(S) * 12

13 LIFE EXISTENTIAL PRESSURES STRESSORS Suicide Allowing Defect(s) Demographics Genetics Brain Chemistry Traits Hopelessness etc. Suicide Protection Factor(s) Demographics Partner Children etc. Time PRECIPITANT(S) Place Method * J Clin Psychiatry 2003; 64: Hong Kong 2. 21,921 discharged patients >15 yo suicides in first year after discharge (38%) occurred in first 28 days Psychiatry Grand Rounds MCG 9/22/2016 UK General Practice Research Database 159,810 Users of Antidepressants We think the most likely explanation for this finding is that antidepressant treatment may not be immediately effective. It is also possible that patients [start] to take an antidepressant when their depression is at its worst..or maybe? 13

14 2/3 of people prescribed AD s had negative toxicology Utah Youth Suicide Study: Psychological Autopsy Michelle Moskos, Ph.D., M.P.H. Lenora Olson, M.A., Ph.D. Sarah Halbern, B.S. Trisha Keller, R.N., M.P.H. Doug Gray, M.D. Suicide and Life Threatening Behavior 2005; 35: Phase suicides age Phase 2-49 investigated thoroughly 32 had been seen and diagnosed 14 were prescribed medication 0 positive on post mortem toxicology LIFE EXISTENTIAL PRESSURES STRESSORS Suicide Allowing Defect(s) Demographics Genetics Brain Chemistry Traits Hopelessness etc. Suicide Protection Factor(s) Demographics Partner Children etc. Time PRECIPITANT(S) Place Method * 14

15 Weapons Act 1990 Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, NCHS data brief, no 241. Hyattsville, MD: National Center for Health Statistics Our major clinical point, however, was and remains that suicidal individuals be they old or young, urban or rural cannot be considered out of harm s way simply because they do not have access to a gun. Rich C, Amer J Psychiatry, Jan

16 LIFE EXISTENTIAL PRESSURES STRESSORS Suicide Allowing Defect(s) Demographics Genetics Brain Chemistry Traits Hopelessness etc. Suicide Protection Factor(s) Demographics Partner Children etc. Time PRECIPITANT(S) Place Method Suicide Prediction and Prevention: A Practical Synthesis of the Evidence The Plan 1. Review Prediction Situation (briefly) 2. Develop an Accurate Suicide Model 3. Apply the Model to Prevention 16

17 SSRI Introduction Suicides and Antidepressant Sales Summary of Pharmacoepidemiologic Studies Positive Neutral Negative Isacsson - Sweden (2000) all Rihmer - Hungary (2001) + Joyce - New Zealand (2001) age Kelly - Northern Ireland (2003) older younger Oravecz - Slovenia (2003) females males Hall - Australia (2003) older Younger* Olfson - USA (2003) males females Lodhi - England/Wales (2004) older males Helgason - Iceland (2004) + Grunebaum - USA (2004) females? Barbui - Italy (2005) > age 45 Barak - Israel (2006) males Korkeila - Finland (2007) all Nakagawa - Japan (2007) males > females Bramness - Norway (2007) + Castelpietra - FVG Italy (2008) all 17

18 7 studies (10 reports) (Texas, Japan, Austria, England, Greece) 5 Positive (higher lithium, lower suicides rates) 1 Neutral 1 ± Females Lots of sampling and statistical issues Known nephro- and thyrotoxic effects?teratogenicity Are you ready to have lithium put in your drinking water? Call me old fashioned, but it s not like flouride, is it? Am J Psychiatry 1990; 1457: NIMH Collaborative Study on the Psychobiology of Depression depressed patients 10 years 32 suicides (3%) 13 (41%) in 1 st year Year 1 Years

19 Annals of Clinical Psychiatry 2008; 20: No studies Ann Clin confirm Psychiatry that 2008; treatment 20: with sedatives/hypnotics reduces suicide risk Acute Intoxication Disinhibition (frequently) Persistent Intoxicaction Depression (infrequently) April 1, 1999 September 30, ,859 Depressed veterans (92% males) 1,892 Suicides The odds of completed suicide were greater among patients who received any anxiety medication, and were further increased among those who received high dose treatment. 100 consecutive suicides age 65+ We found a four-fold increased suicide risk among elderly using sedatives and/or hypnotics. 19

20 alternatives to sedatives/hypnotics should be used if early adjunctive treatment for anxiety is thought to be indicated. Hydroxyzine More sedating antidepressant? Low dose second generation antipsychotic? (see Roberts et al, Asia Pac Psychiatry May 12. doi: /appy PubMed PMID: ) No data on actual suicide rates Emergent suicidality is a common occurrence [12%] in psychosocial treatment of adolescent depression, with rates similar to those reported in recent antidepressant trials. 20

21 Suicide Prediction and Prevention Clinical Conclusion Growing evidence strongly supports the suicide preventive effect of antidepressant treatment. October 15, 2004 Curious coincidence? or.. 21

22 Göran Isacsson and Johan Ahlner Suicides Ages vs After the warning, suicide in this age group increased for 5 consecutive years (60.5%). The increase occurred among individuals not treated with antidepressants. Thus, a treatment only approach to prevention has limited impact on national rates of suicide. Gotland, Sweden The program was successful in reducing suicide rates by 60%. Prevention was successful for as long as the program was instituted. 22

23 I would therefore argue that the FDA should consider removing the warning entirely..and I agree completely!! A Public Health Approach Prevention of Disease Healthy Living Healthy Environment Vaccination Detection and Treatment of Disease Public Awareness of Diagnosis Accessibility to Treatment Encouragement of Treatment Three Decades of Digging CONCLUSIONS 1. Suicide is the fatal outcome of a small number of mental disorders (maybe only one) 2. The Last Straws in suicide are largely a) unpredictable and b) unpreventable ERGO: The best way to prevent (or delay?) suicide is to effectively treat the potentially fatal illness(es) That means: a) close monitoring and b) long-term follow-up 23

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