What works for suicide?

Transcription

1 What works for suicide? Michael R. Phillips Shanghai Mental Health Center, Shanghai Jiao Tong University WHO Collaborating Center for Research and Training in Suicide Prevention Beijing Hui Long Guan Hospital Departments of Psychiatry and Global Health, Emory University Shanghai Mental Health Center Emory University Collaborative Center for Global Mental Health 1

2 Outline 1.Different theoretical models of suicide 2.The Best Practice Registry 3.Status of research on suicide prevention 4.International perspective 5.Pesticides 6.Integrated approaches 2

3 1. Different theoretical models of suicide 3

4 Theories of suicide There are many theoretical models of suicide. Typically preventive and therapeutic activities are based on the relationship between variables suggested by a specific theoretical model. The majority of the models center on individual factors with only a peripheral acknowledgment of social and environmental factors Some take a longitudinal life-course approach to understanding suicidal behavior Still other models give equal importance to the individual factors and to the social contextual factors Current models do not capture the dynamic nature of the suicide phenomenon. The patterns of risk factors, the relative importance of risk factors, and the stakeholders involved in the process are constantly changing. 4

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6 Suicide has multiple contributing factors Biological Factors Predisposing Factors Proximal Factors Immediate Triggers Familial Risk Major Mental Disorders Hopelessness Public Humiliation Shame Serotonergic Function Substance Use/Abuse Intoxication Access To Weapons Neurochemical Regulators Personality Profile Impulsiveness Aggressiveness Severe Defeat Demographics Abuse Syndromes Negative Expectancy Major Loss Pathophysiology Severe Medical/ Neurological Illness Severe Chronic Pain Worsening Prognosis SUICIDE RISK ASSESSMENT WORKSHOP, University of Michigan David J. Knesper, M.D. Available at

7 Suicide Prevention for Men Years: A Developmental, Layered Model Peri-suicidal State RISK Depression, Hopelessness Symptoms, Resiliency, Family Turmoil, Work Problems Substance/Alcohol Abuse, Role Changes, Acute & Chronic Stresses TIME Personality Factors, Social Ecology, Cultural Values & Perceptions "Distal" RISK FACTORS "Proximal" Universal Selective Indicated PREVENTION STRATEGIES Caine & Conwell,

8 Targets of Suicide Preventive Interventions (Mann, et al., JAMA, 294(16),2064-, 2005) 8

9 2. The Best Practice Registry 10

10 The Best Practice Registry: 11

11 The Best Practice Registry: Section I Listings: Evidence-Based Programs Suicide-related interventions currently listed in National Registry of Evidence-Based Programs and Practices (NREPP) operated by Substance Abuse and Mental Health Services Administration (SAMHSA) Section II: Expert/Consensus Statements Lists statements that summarize the best knowledge in suicide prevention in the form of guidelines, protocols, or consensus statements that are reviewed by preeminent experts in the field. Section III: Adherence to Standards Lists programs, practices, policies, protocols, and informational materials focused on specific settings (e.g., schools, clinics etc.) whose content has been reviewed according to current program development standards and recommendations and that meet the recommendations of the United States National Strategy for Suicide Prevention. 12

12 EVIDENCE-BASED PROGRAMS LISTED ON BEST PRACTICE REGISTRY American Indian Life Skills Development/Zuni Life Skills Development Brief Psychological Intervention after Deliberate Self-Poisoning CARE (Care, Assess, Respond, Empower) CAST (Coping and Support Training) Dialectical Behavior Therapy Dynamic Deconstructive Psychotherapy (DDP) Emergency Department Means Restriction Education Emergency Room Intervention for Adolescent Females LEADS: For Youth (Linking Education and Awareness of Depression and Suicide) Lifelines Curriculum Model Adolescent Suicide Prevention Program (MASPP) Multisystemic Therapy With Psychiatric Supports (MST-Psychiatric) PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) Reconnecting Youth Reduced Analgesic Packaging SOS Signs of Suicide Sources of Strength United States Air Force Suicide Prevention Program 13

13 3. Status of research on suicide prevention 14

14 Clinical research Several training interventions are based on the presumption that mental health clinicians can accurately identify high-risk individuals, but this is not the case Most studies are too small and too short-term to show changes in suicides or attempted suicides so they assess proxy outcomes (such as suicidal ideation or depression) which have limited correlation with suicidal behavior Antidepressants for those with major depressive disorder are of uncertain effectiveness in preventing suicide and MAY increase risk in youth Lithium is definitely effective for persons with bipolar (manic-depressive) disorder and clozapine MAY be effective for persons with schizophrenia Only 4/10 persons who report suicide attempts in high-income countries and 2/10 in LAMIC countries receive mental health treatment so improving service may not have a substantial effect on community suicide levels The data about the role of improving and expanding mental health services as the core method of reducing suicides is equivocal 15

15 Psychological interventions for self harm summary odds ratios Emergency contact card vs TAU (N=1144) 0.79 (0.39 to 1.57) Intensive aftercare + outreach vs TAU (N=1395) 0.87 (0.83 to 1.14) Letter from GP vs TAU (N=1932) 1.12 (0.94 to 1.34) Specialised vs general services (N=2881) 0.97 (0.85 to 1.11) Problem-solving therapy vs TAU (N=1014) 0.87 (0.73 to 1.03) Group therapy vs TAU (N=63) 0.19 (0.05 to 0.81) Dialectical behaviour therapy vs. TAU (N=63) 0.81 (0.66 to 0.98) Psychological therapy vs TAU (N=1014) 0.88 (0.74 to 1.05) Nice guidelines, Self Harm, 2004

16 COMMUNITY-BASED INTERVENTIONS: Several interventions assume that screening methods can accurately identify high-risk individuals, which is not the case Nevertheless, brief interventions with high-risk groups appear moderately effective (SUPRE-MISS, telehelp-telecheck, etc.) School awareness programs, gate-keeper programs (QPR), telephone hotline services, are largely of unproven effectiveness Comprehensive community-wide initiatives aimed at increasing treatment-seeking for depression in Germany and the US Airforce program have shown decreased suicide rates. Means restriction methods (paracetamol packaging in UK, car exhaust controls, safety nets on bridges, pesticide lockboxes in China and Sri Lanka) are hopeful but need further evaluation Media-based interventions may decrease copy-cat suicides (i.e., Vienna subway suicides) 17

17 Institute of Medicine (2000) Reducing Suicide: A National Imperative much more needs to be learned about the processes leading to suicide detection case identification for those at risk for suicide is a serious problem. currently available tools are inadequate to determine acute suicide risk or to predict when a person will attempt or complete suicide. need for longitudinal, prospective studies

18 4. International Perspectives 21

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21 deaths per 100,000 population 30 Suicide Rate in China > 1 million less lives lost to suicide over the 20 years 10 5 >100,000 less suicides per year in 2006 than in year 24

22 PSYCHIATRIC DIAGNOSES IN 161 MALE AND 456 FEMALE ATTEMPTED SUICIDES NO DIAGNOSIS Affective Disorders 12 Alcohol Disorders 7 6 Organic Disorders Psychotic Disorders SEX male Other Disorders femal e 25

23 Pre-meditation in attempted suicide Time from FIRST considering suicide to making the suicide attempt in 451 individuals who made serious suicide attempts in China with pesticides 5 minutes or less 44% 10 minutes or less 51% 2 hours or less 64% 26

24 Data from LAMIC countries is challenging conventional wisdom about suicide Rapid urbanization does not, necessarily, lead to increased rates The heavy predominance of male suicides (3:1 in most Western countries) is not seen in China and other Asian countries Mental illness is NOT a precondition for suicidal behavior The valence of risk and protective factors such as divorce and religious affiliation are context and time dependent The role of specific life events which can change over time is less important that the cumulative stress of all life events Chronic and acute stress are independent risk factors for suicide that may work on different pathways Risk factors are largely additive Pesticide ingestion is, by far, the most common method of suicide in the world 27

25 TOUGH QUESTIONS FOR SUICIDE PREVENTION ADVOCATES IN LAMICs Given the very limited access to mental health services and the reluctance of community members to use mental health services, is focusing on expansion of mental health services the best way to reduce suicides? Given the lack of country-specific evidence about the relative value of different interventions, how much should we depend on results from high income countries to determine our intervention priorities? How much of the effort should be placed on improving the quality of the monitoring systems for suicides and attempted suicides? Given the disconnect between level of intent and case-fatality, do we need to change our paradigms for identifying high-risk individuals? What should the relative balance of resource allocation be on universal (i.e., community based), selective (i.e., at high-risk groups) and indicated (i.e., on persons who have attempted suicide) preventive measures? What role should means restriction play in the overall intervention package? 28

26 Pesticides 29

27 Worldwide intentional pesticide-ingestion is the most common method of suicide accounting for over 300,000 suicides annually. In China pesticides are used in 58% of all suicides. The estimated 166,000 suicides by pesticide ingestion each year in China account for one-fifth of all suicides in the world. 75% use pesticides stored in the home 58% use category I organophosphates 62% receive medical resuscitation that fails Pesticides are also used in 574,000 of the medically treated attempted suicides in China each year, 28.7% of all attempts. 84% use pesticides stored in the home 82% use category I organophosphates Given the public health importance of this problem, we know surprisingly little about the characteristics and prevention of pesticide-ingestion suicides 30

28 The characteristics of pesticide-ingestion suicides in China point to the need for four types of interventions that need to be integrated into the overall suicide prevention effort 1. Banning of the most toxic compounds; 2. Decreasing access to pesticides in the home 3. Community education about the lethality of these chemicals and about appropriate storage 4. Improved training and increased access to necessary drugs and equipment for rural primary care health providers. 32

29 Gunnell et al, Int J Epidemiology doi: /ije/dym164 33

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34 rural % rural REGION suicide households that rate often store pesticides East % West % Inner Mongolia Shaanxi Shanxi Henan Hubei Heilongjiang Central % Jilin Liaoning Beijing Tianjin Hebei Xinjiang Shandong Gansu Jiangsu Qinghai Shanghai Ningxia Anhui Tibet Zhejiang Sichuan Jiangxi Fujian Yunnan Chongqing Guizhou Guangxi Hainan Hunan Guangdong 39

35 2 adjacent townships where lockboxes were installed with combined population of 51,441 in 11,923 households Heng Qu Township MEI COUNTY Huai Ya Township 40

36 Estimated benefits from sequential application of three separate pesticide-related strategies* assuming 195,643 suicides a year in China, that 62% of suicides are pesticide-ingestions and that each intervention decreases pesticide-ingestion suicide deaths by 20%. single intervention two sequential interventions three sequential interventions proportional reduction in total suicides 12.4% 22.3% 30.3% lives saved 24,260 43,668 59,194 Potentially Productive Years Life Lost (PPYLL) saved economic benefit based on $1,740 per saved PPYLL ($US) 398, , ,275 $693,343,465 $1,248,018,238 $1,691,758,056 *restricting access in homes, banning most toxic pesticides, and improving access to and quality of medical management 41

37 Integrated Approaches 42

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40 Beijing Suicide Research and Prevention Center World Health Organization Collaborating Center for Research and Training in Suicide Prevention Beijing Huilongguan Hospital

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42 Proposed national suicide prevention plan for China GOAL 1: Promote psychological well-being, resilience and community connectedness GOAL 2: Promote broad-based support for suicide prevention GOAL 3: Decrease access to and lethality of means for suicide, particularly pesticides GOAL 4: Enhance social support networks for high-risk groups GOAL 5: Promote community-based screening programs to identify high-risk individuals GOAL 6: Increase awareness and change attitudes about mental health problems and suicide GOAL 7: Improve availability and quality of mental health services GOAL 8: Develop specific services for high-risk individuals and others affected by suicide GOAL 9: Expand scientific evidence base for the prevention and management of suicide GOAL 10: Improve and expand surveillance of suicidal behavior GOAL 11: Develop sources of sustained funding for suicide-related services and research 47

43 Thank you for listening 48