Suicide, Para suicide and Risk Assessment LPT Gondar Mental Health Group www.le.ac.uk
Objectives: Definition of suicide, Para suicide/dsh Changing trends of methods used Epidemiology Clinical Variables Risks factors and assessment Case Scenarios
Suicide Definition. Suicide is not a diagnosis. It is a verdict / category of death in which the death was unnatural and result of the victim s own actions with the intention to kill him/herself.
Para suicide Definition An act with non-fatal outcome, in which an individual deliberately initiates a non habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage
Deliberate Self Harm The behaviour is self-initiated harm is intended (intention to kill is low) results in injury or harm Two main types: self-poisoning self-injury
SUICIDE
Methods used are subject to trend and availability Violent methods more common in males more common in those with a mental illness e.g. Hanging and strangulation, drowning, throwing self in front of moving vehicles, firearm use.
Non-violent methods drug overdose, CO poisoning
World wide statistics 1 million people commit suicide worldwide each year. Most countries count suicide as being 1 of the top ten causes of death Among 15-34 year olds suicide is reported as the 2nd or 3rd commonest cause of death.
Sex Distribution of Suicides In Britain suicides by hanging and by CO poisoning account for - 2 out of 3 male suicides - 1 out of 3 female suicides - Female suicide is more commonly via overdose male : female = 3:1 higher in young (15-24 yrs) and elderly males(>75) Main methods of suicide- hanging and poisoning by psychotropic drugs
Epidemiology Underestimated for a variety of reasons e.g. methods of reporting 4500-5000 general population suicides occur per year in England and Wales. Approximately 25% of these people have been in recent contact with mental health services. Accounts for 1% of death from all causes
Epidemiology ( U.K data) The period of highest risk after discharge from in-patient care is the first 14 days Identified risk factors- being male, living alone, unemployment, drug and alcohol misuse, mental illness. Co morbidity, including substance misuse, and previous self harm are common.
SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric Illness Co-morbidity Substance Use/Abuse Severe Medical Illness Personality Disorder/Traits Suicide Neurobiology Impulsiveness Hopelessness Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior
Clinical Variables for Suicide Depression Lifetime risk of suicide is 15% (+) Main correlates include greater severity of illness self neglect hopelessness alcohol abuse Impaired concentration history of suicidal behaviour
Schizophrenia Lifetime risk of suicide 10-15% Main correlates: young and male relapsing pattern of illness past hx of depression Recent discharge inpatient to outpatient social isolation good insight into illness
Alcohol Abuse Lifetime risk is 2-4% Main correlates Male sex Longer duration of problems Single/divorced/widowed Currently drinking Presence of Depressive symptoms
Personality Disorder Evidence suggests that suicides associated with PD are nearly always associated with a depressive syndrome or substance abuse Lifetime risk of suicide under 10% reported. (Lower than depression or Schizophrenia)
Chronic Physical Illness The relative risk of committing suicide among patients with cancer is 2.5 Increased risk in patients with chronic neurological, gastro-intestinal, cardiovascular disorders Severe chronic pain leads to increased risk Disfigurement, especially in women
Chronic Physical Illness( Cont.) Chronic physical illness can lead to limitations including loss of job, role, family, money, etc Strong relationship between physical ill health and depression.
Social variables of Suicide Lower socio-economic status Unemployed Overcrowded Inner city areas Social deprivation Social isolation / single In custody
DELIBERATE SELF HARM
Epidemiology Underestimated 150,000 new attendances at A+E per year in E+W Higher rates in females Peak age 15-44 yrs. 10-14% of those with DSH ultimately die by their own hand
Risk of dying from suicide following DSH is 100X that of the general population 90% of DSH referred to general hospital involves drug overdose, usually with paracetamol or aspirin.
Motives Underlying DSH Wish to die Trial by ordeal Time out Cry for help Communication with others Unbearable symptoms
Associations with repeated self-harm Previous self-harm/ psychiatric contact Alcohol / Drug misuse Unemployment/ Social class V Personality disorder label Criminal record/ history of violence Age 24-54 years Single / divorced / separated
Some psychological characteristics associated with self-harming behaviour: impulsivity dichotomous thinking cognitive rigidity problem-solving deficits autobiographical memory deficits hopelessness
Substance Abuse and DSH Alcohol use is reported in 50% of suicides Extensive use at time of DSH or just before DSH 40-75% males 12-50% females
Use of alcohol can add to the potential dangers of an OD Alcohol increases the toxicity of psychotropic drugs Alcohol alone can lead to unconsciousness and therefore delay time to treatment
Risk Factors - DSH and Suicide Demographic Age, gender, marital status, employment status Presentation Depression, schizophrenia, alcohol misuse, personality disorder
Risk Factors- continued Past psychiatric history previous history of DSH/ attempts of DSH Past medical illness- chronic illness Personal and social history- social variables, premorbid personality
Mental State Examination Depression Retardation Low mood Suicidal thoughts Negative cognition (hopelessness) Psychotic symptoms Lack of insight
Mental State Examination Schizophrenia - Positive psychotic symptoms, post psychotic depression, development of insight. Alcohol misuse Depression, psychosis and poor physical health.
DETERMINATION OF RISK Psychiatric Examination Risk Factors Modifiable Risk Factors Protective Factors Specific Suicide Inquiry Risk Level: Low, Med., High
HISTORY TAKING Detailed! When talking about the event remember to ask about INTENT Chronological - start with when did you first decide? Look at the preparation before the act - the sorting out of affairs, collecting of pills etc
HISTORY TAKING ( Cont.) Did anything happen to you that led to you wanting to kill yourself? Concealment of the act Was alcohol involved How were they found? How do they feel to be alive now? What would you do if you went home? Do you still want to kill yourself?
HISTORY TAKING ( Cont.) Have you done this before? Nothing predicts future behaviour as well as past behaviour Remember to ask about past psychiatric illness, comorbid substance abuse Current mental state - depression, psychosis etc Social support important if you are thinking of discharge
Case Scenario - 1 25 year old female was brought to A&E department following an overdose and self inflicted injuries. She took an overdose of 15 paracetamol tablets in front of her boy friend after having an argument with him. She is well known to psychiatric services and had several episodes of self harm in the last few years. Assess suicidal risk?
Case 2 A 67 year old widower was admitted to the acute psychiatric ward 3 days ago. He has been weepy and depressed for 4 months. He has significant weight loss and marked anhedonia. He lives on his own and has no family. He said he took alcohol occasionally. He expressed ideas of hopelessness and helplessness. He wanted to leave the hospital as he could not see any reason to be in hospital. You were asked to see the patient whether he could go home.
Case 3 A 21 year old young man had been diagnosed as suffering from schizophrenic illness a few months ago. He was admitted to hospital with acute psychotic symptoms, hallucinations and persecutory delusions, and also had problems of social withdrawal, impairment of self care and motivation. He responded well to treatment with olanzapine and was discharged from hospital 2 weeks ago. Now he presented with feeling depressed, withdrawn and also felt hopeless and helpless.he has insight into his illness. He expressed feeling demoralised. What will you do?
Case 4 A 55 year old lady is brought into A+E. She has MS and is wheelchair bound. Her husband who works away came home early to find that she had taken 120 paracetamol tablets that she receives from her GP for chronic pain. She has written letters to her family and states that she wants to be allowed to die. She refuses blood tests and parvolex. What will you do?
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