Dr Chong Yew Siong BSc, MD, MMed (Psych) Lecturer & Psychiatrist Faculty of Medicine & Health Sciences USIM
Introduction Recent Updates & Statistics Suicide Risk Assessment Management Q & A
Suicide is a legal term Definition : The human act of self inflicting one s own life s cessation Suicide is a tragedy not only for the individual, but also for the family and society. Akin to seeking a permanent solution to what are usually temporary problems. Suicide & attempted suicide major public health problems.
10 million people commit suicide annually 1 suicide case every 40 seconds; 60% in Asia. 20-50 million attempted suicide annually. In male : suicide rate = 20 cases per 100,000 populations; female : 8 cases per 100,000. 1/3 of all suicide cases involved insecticide. (WHO, 2009)
Malaysia : 10-13 per 100,000 populations (1990 2000). Data paucity : due to misclassifying suicides as undetermined deaths (> 90%). Attempted suicide rate : 10x higher than suicide rate. 2 % all suicides influence of media reporting
Why inaccurate suicide data & reporting??? Stigma!!! Legality : suicide is a crime/an offence Religious principle Death registry mishap Suicide statistics in Malaysia do not reflect reality!
Suicidal ideation Suicidal plan Deliberate self harm Suicide attempt Completed suicide (Chiles & Strosahl 2005; Meltzer & Dev 2000)
Suicidal Ideation Suicidal Intent Suicidal Plans Higher risk Frequent, intensed, prolonged Higher risk High Higher risk Well-planned, highly lethal means, access to means Lower risk Infrequent, transient Lower risk Low Lower risk No plans, choice of low lethality, no access to means
Absence of mental illness Employment Children at home Sense of responsibility to family Pregnancy Strong religious beliefs Intact reality testing Positive coping skills Positive problem-solving skills Good social support Positive therapeutic & confiding relationship High life satisfaction
Assessment of suicidality Identifying targets for intervention Suicide risk assessment Evaluation of suicide risk factors Identifying what s going on
Active? Passive? Ideation Intent Hidden intent Hidden motivation Plans Access to means Clinical intuitive impression Access to means
High lethality Low frequency Past suicide behaviour assessment High frequency Low lethality
Age & gender Past & current suicidality Psychiatric symptoms/mental illness Personality Individual history : Medical History, Family History, Psychosocial History, Neurobiology
Suicide rates generally increase with increasing age. Rise sharply in late adolescence & early adulthood, levelling off in midlife, rise again after age 70. Suicidal behaviours & attempts more common in the younger age group. Completed suicides higher in the elderly.
Higher suicide rates in men than women Less likely to seek help for emotional / psychological problems than women Less willing to accept help for emotional / psychological problems than women More impulsive than women Less socially embedded than women May choose more lethal suicide methods
Past suicidal behaviours associated with increased suicide risk Higher risk Lower risk Detected suicide attempts Multiple attempts First attempt Undetected suicide attempts Planned Impulsive Aborted suicide attempts Low likelihood of rescue High likelihood of rescue Self-harming behaviour High intent Use of highly lethal method Availability of lethal means Serious medical consequences Low intent Low lethal method Ambivalence
Psychiatric Symptoms Panic attacks Hopelessness Hallucinations Dysphoria Agitation Insomnia Impulsivity Decreased self-esteem Mental Illness Mood disorders Psychotic disorders Anxiety disorders Alcohol & other substance use disorders Personality disorders
Medical history Higher risk Lower risk Neurological disorder Chronic illness Healthy HIV/AIDS Associated pain Feels physically well Peptic ulcer disease Functional impairment Pregnancy Systemic lupus erythematosus (SLE) Chronic renal failure (with hemodialysis treatment) Heart disease Chronic obstructive pulmonary disease (COPD) Prostate disease Loss of sight or hearing Disfigurement Increased dependence on others Malignancies
Higher risk Suicide in first degree relative Lower risk No family history of suicide Mental illness in first degree relative No family history of mental illness
Higher risk : Sexual orientation : homosexuality Unemployment & Type of employment (healthcare professional) Marital status * Financial & legal difficulties Past history of sexual/physical abuse
BDNF Neurotrophin (NT) Nerve Growth Factor (NGF) Increased suicide risk Neurotransmitter imbalance (Serotonin)
Combination of factors Why? Why now? What s going on?
Psychiatric symptoms & diagnoses Treat disorder & alleviate symptoms Distressing psychosocial situation Address modifiable triggers / stressors Characterological difficulties Address maladaptive traits & coping skills
Emotion response Cognitive response Behaviour response Anger Hatred Anxiety This person is weak/ disgusting This person is a waste of time/trying to get attention/manipulating me Avoidance Rejection Frustration Helplessness Incompetence This person makes me feel useless/inadequate If this person kills himself it will be my fault Overinvolvement Overprotection
DO NOT : Rush / ask leading questions You don t have any ideas about suicide, do you? Interrogate / force patient to defend his / her action Why would you do such a thing? Why would you even consider suicide? What is wrong with you? What is so bad in your life? What is your problem?
DO NOT : Minimize / disregard the patient s distress Oh, you are fine. My problems are bigger. It s not such a big thing, is it? Many people go through these kind of things & they are fine! You will feel better after a good night s rest. If you really wanted to die you would be dead by now. Get over it.. you are OK!
DO : Be empathic Make gentle inquiry Be proximal vs distal Be non-judgemental / non-critical Be non-prescriptive (e.g. Do this, Do that ) Offer other ways / options of solving problems Be there for them Refer if high risk
Significant changes in home, school, work & social function Significant changes in behaviour & personality Withdrawal from friends, families & social activities Neglect of personal appearance Significant sleep problems & changes in weight Increased irritability, anger/ aggression Increased impulsivity & difficulty controlling emotion Preoccupation with death & people who have died by suicide Hopelessness as theme of conversations & work Giving away valued possessions
Support Safety & security Targeted intervention Basic Principles
Henderson J.P, Mellin C., Patel F. Suicide A statistical analysis by age, sex and method. J Clin Forensic Med 2005;12:309 307 Maniam, T. (1988). "Suicide and parasuicide in a hill resort in Malaysia." British Journal of Psychiatry 153: 222 225. National Center for Injury Prevention and Control (2002). Preventing Suicidal Behaviour. CDC Injury Research Agenda. Atlanta (GA), Centers for Disease Control and Prevention:61 72. Pouliot, L. and D. D. Leo (2006). "Critical issues in psychological autopsy studies." Suicide and Life Threatening Behaviour 36(5): 491 510. Reiget, M. S. (2001, 15 Jan 2007). "Saying the Right Thing: Death in the Field and Grief Support Guidelines Curriculum Workbook."
Appleby L, Cooper J, Amos T, Faragher B. Psychological autopsy of suicides by people under 35. Br J Psychiatry 1999; 175:168]174. Cheng, A.; Chen, T; Chen, Chwen]chen; Jenkins, R: Psychosocial and psychiatric risk factors for suicide: Case control psychological autopsy study. British Journal of Psychiatry. 177:360]365, October 2000 Cooper, J, RMN Ethical issues and their practical application in a psychological autopsy study of suicide. Journal of Clinical Nursing. 8(4):467]475, July 1999. Foster, T; Gillespie, K; McClelland, R; Patterson, C: Risk factors for suicide independent of DSM]III]R Axis I disorder: Case control psychological autopsy study in Northern Ireland. British Journal of Psychiatry. 175(8):175]179, August 1999. WHO (2008) Suicide rates per 100,000 by country, year and sex for the year 2007.http://www.who.int/mental_health/prevention/suicide_rates/en/ index.html