Dr Carmelo Aquilina Senior Staff Specialist & Service Director Sydney West Area Health Service Clinical Senior Lecturer, University of Sydney A suicide
Outline Part 1: understanding suicide Part 2: What are risk factors? Part 3: How to assess suicidal behaviour? Part 4: How to manage suicidal behaviour Part 5: Prevention of suicide
1: Understanding suicide 1 million people die each year from suicide More people than killed in conflicts X10 x 20 attempt suicide Numbers vary widely from country to country e.g. Greece 3.4 vs. Slovenia 28.1 (per 100,000) Methods vary from country to country E.g. firearms in US, poisoning in India Rates highest in older men but younger men catching up quickly 1: Understanding suicide
1: Understanding suicide Risk increases with age peak in over 75s Attempted suicide 61.4 per 100,000 Completed suicide 29.3 per 100,000 Highest in men Ratio of attempted to completed suicide decreases significantly in older people (200:1 to 4:1) all attempts are to therefore be taken seriously 1: Understanding suicide Completed suicide: a selfinflicted act resulting in death Suicidal intent Variable, usually high Lethality Absolute Attempted suicide: self-injurious behaviour with variable intent that does not result in death Variable, usually high Variable Suicidal ideation: thought of selfinjurious behaviour Variable, usually low if fleeting but higher as gets more intense or delusional No Self-harm: deliberate self-injury without suicidal intent Nil Variable, usually low
1: Understanding suicide 1: Understanding suicide Suicidal behaviour can be Intentional Sub-intentional Unintentional Ambivalent Suicidal motivation can be : Interruption Manipulation Retribution Russian roulette Better off dead
Quick check What was George Eastman s motivation?
2; Suicide risk factors Demographic: Male Old Poor Unemployed Single/divorced Socially isolated Personal history Difficult upbringing Family history of suicide Medical illnesses Chronic Painful Functional impairment multiple 2; Suicide risk factors Psychiatric History Recent contact with services Past history of self harm Personality disorder Depression Schizophrenia Bipolar Alcohol dependence Situational Anniversaries Holidays Adverse life events e.g. financial, legal, family, relationship problems Access to lethal means
2:suicide risk factors
2: Suicide risk factors Quick check What were George Eastman s risk factors? Biological Predisposing Proximal Precipitating (trigger)
3: Suicide assessment Situation What are you trying to find out? Suicidal ideation Is intent serious? What is the risk of it happening? Suicidal attempt Was intent serious? What is the risk of it being tried again? 3: Suicide assessment SCREEN do you still get pleasure out of life? do you feel hopeful from day to day? / do you think things will turn out well? are you able to face each day? /do you ever wish you would not wake up tomorrow? do you feel life is a burden? / do you wish it would all end? have you ever thought of ending your life or harming yourself? / is there anything to live for?
3: Suicide assessment ASSESS IDEATION What are you thinking? How frequent are these thoughts? When are they most likely to occur? How strong are these thoughts or feelings? How are you able to resist the thoughts? Is there a plan? Are there specific methods, date or place in mind? Have specific preparations been made? 3: Suicide assessment ASSESS IDEATION Has there been a practice or real attempt? What is the outcome wanted? (motivation) Are the means for suicide available? Are the means lethal (objectively) and what is the patient s understanding of lethality (subjectively)? What is the strength of intent? How likely are you to kill yourself? How impulsive is the patient (including use of alcohol)? What would happen if you died? Who would miss you?
3: Suicide assessment ASSESS ATTEMPT A useful question to start is the 24 hour question i.e. to ask the person to describe the events of the last 24 hours before the attempt itself. 3: Suicide assessment ASSESS ATTEMPT Assess how the person got to where he or she is Start from event and work backwards Life events, stressors, past history, family history
3: Suicide assessment ASSESS INTENT Attempt premeditated and actively planned Precautions taken to avoid intervention Impulsivity increased by taking alcohol or other drugs attempt carried out when alone attempt timed to minimise risk of discovery suicidal attempt communicated prior to attempt 'final acts' in anticipation of death (e.g. suicide note or will) violent, active methods or drugs patient knows to be lethal 3: Suicide assessment ASSESS INTENT person believed act would be final and irreversible (expectation of lethality) person states aim was to kill oneself person regrets surviving the attempt no actions to get help or to let people know after the attempt previous attempts Stressors triggering the attempt likely to happen again
3: Suicide assessment SCREEN FOR DEPRESSION Most important and treatable risk factor Use BASDEC or GDS- 15 Jenike s mnemonic is SIGE CAPS Beware hidden depression in elderly Sleep disturbed Interest decreased Guilt Energy decreased Concentration is poor Appetite disturbed Psychomotor changes Suicidal ideation 3: Suicide assessment HIGH RISK MENTAL STATE Despair Guilt Humiliation Hopelessness Helplessness Anhedonia Abandonment Agitation Poor concentration
3: Suicide assessment AAS WARNING SIGNS MENMONIC IS PATH WARM? Ideation Substance use Purposelessness Anxiety / agitation Trapped Hopeless/ helpless Withdrawal Anger Recklessness Mood changes 3: Suicide assessment PITFALLS IN ASSESSMENT OR RISK Deliberate denial Variability in distress and intent Ambivalence False improvement Malignant alienation Not asking an informant Not recording assessment Not communicating risk
3: Suicide assessment PITFALLS IN ASSESSMENT open admissions are not manipulative Asking increases risk Fleeting ideation does not pose any risk A suicide prevention contract absolves you of any responsibility A low score on a standardised assessment tool means a low risk Respecting confidentiality at all times 3: Suicide assessment ASSESSING OLDER PEOPLE Older people are less likely to agree that they have or have had suicidal ideation than younger people but confess this more often to family or friends All attempted suicide should be taken seriously by health professionals Severe depression increases risk by 23 times Diagnosis of dementia a risk factor Higher burden of physical illness
3: Suicide assessment ASSESSING OLDER PEOPLE Frailty (increased vulnerability) Living alone and having poor supportive networks Greater intent and planning than in younger people (less impulsive) Intent is often communicated to more than one person and by different means Adverse live events common Quick check What would you have been asking George Eastman to be able to assess immediate risk?
4: managing suicide risk Assess risk severity and imminence Treat underlying mental illness Minimize weaknesses /aggravating factors e.g. pain, stop alcohol use, remove alcohol, etc. Enhance strengths e.g. encourage family support, hope-based therapy Collaborative plan Include patient, carers, colleagues, GP Regular review Contemporaneous documentation 4:manging suicidal risk
4: managing suicide risk Risk Assessment answers the questions How likely How soon How severe? Absolute predictions impossible Reasonable foreseeability is standard Be open about uncertainties Document a thorough assessment of all factors considered
4:managing suicide risk Beneficial Likely to be beneficial Unknown effectiveness Antidepressants Non-directive counselling Befriending Cognitive Behavioural Therapy Problem solving therapy Bibliotherapy (use of books and poetry as therapeutic aid) ECT Combining antidepressants with interpersonal therapy Exercise Interpersonal therapy ST John s wort Psychological therapies 4:managing suicide risk
Quick check What would have been a management strategy for George Eastman?
5:Preventing suicide Primary prevention Managing economic poverty Retirement planning Media reporting responsibly Addressing social isolation ( anomie ) and stigmatization in society e.g. volunteer or trade visitors Reduce access to means Role retention voluntary work or consultancy from older people 5: preventing suicide Secondary prevention Suicide awareness training for professionals (Gotland study) Access to mental health services and prompt treatment especially of depression Prompt and effective pain relief Help lines
Quick check What are things that could be implemented in a suicide prevention strategy in Malta? Conclusion Suicide is common cause of death Suicide is commonly preventable Needs awareness of risk Open and honest discussion Collaborative management Prompt management of underlying difficulties