The health burden, cost and prev vention of su icide Michael R. Phillips Shanghai Mental Health Center, Shanghai Jiaotong University WHO Collaborating Center for Re esearch and Training in Suicide Prevention Beijing Hui Long Guan Hospital Departments of Psychiatry and Global Health, Emory University
2 The global burden of suicide
Global leading causes of death all ages, 2004 3
WHO estimate of global injury deaths, both genders, all ages, 2004 Cause number of % all % all % all deaths deaths injuries violent deaths All injury deaths 5,784,000 9.8% 100.0% Unintentional injury deaths 3,906,000 6.6% 67.5% road traffic accidents 1,275,000 2.2% 22.0% poisonings 346,000 0.6% 6.0% falls 42 24,000 07% 0.7% 73% 7.3% fires 310,000 0.5% 5.4% drownings 388,000 0.7% 6.7% other unintentional injuries 1,163,000 2.0% 20.1% Intentional (violent) injury deaths 1,642,000 2.8% 28.4% 100.0% suicide 84 44,000 1.4% 14.6% 51.4% homicide 600,000 1.0% 10.4% 36.5% war and conflict 184,000 0.3% 3.2% 11.2% 4
Contribution of different types of injury to overall injury deaths by age in Chin na, mean values for 2002-20062006 1.00 Prop ortion of all injur ry deaths 0.80 0.60 0.40 0.20 traffic / transport suicide drowning falls all other injury 0.00 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 Age 5
6 Global leading causes of burden of disease (DALYs) all ages, 2004
WHO estimate of burden of disease (DALYs) from injuries, both ge enders, all ages, 2004 cause All injuries 187,614,000 12.3% 100.0% Unintentional injuries 138,564,000 9.1% 73.9% road traffic accidents poisonings falls fires drownings other unintentional injuries Intentional (violent) injuries self inflicted injuries inter personal violence war and conflict number of DALYs % of all DALYs % of all injury DALYs % of all violent injury DALYs 41,223,000 2.7% 22.0% 7,447,000 0.5% 4.0% 17,157,000 1.1% 9.1% 11,271,000 0.7% 6.0% 10,728,000 0.7% 5.7% 50,738,000 3.3% 27.0% 49,050,000 3.2% 26.1% 100.0% 19,566,000, 1.3% 10.4% 39.9% 21,701,000 1.4% 11.6% 44.2% 7,373,000 0.5% 3.9% 15.0% 7
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9 How can the cost of suicide be measured?
Components of the cost of suicide Direct costs (medical, funeral, legal, etc.) Indirect costs ( human capital approach) lost tmarket ktoutput t lost non market output Non economic, quality of life cost to individual ( willingness to pay ) py) Cost to family and associatess decreased productivity decreased quality of life Increased risk of health problems and suicide Societal costs lost productive capacity perceptions of family and community cohesiveness suicide contagion costs to prevent suicidal behavior 10
11 WISQA ARS (US CDC) Web based based Injury Stati stics Query and Reporting System http://wisqars s.cdc.gov:8080/costt
Estimated cost of Em mergency Room Care for non fatal violent injuries, USA, 2005 Self harm is 2% of total 12
Estimated cost of ho ospitalization for non USA, fatal violent injuries, 2005 Self harm is 36% of total 13
Estimated cost of fatal violent injuries, USA, 2005 Suicide is 57% of total 14
Cost of suicide in Ireland, 2002 From: Kennelly B. (2007) The economic cost of suicide in Ireland. Crisis 28:89 94 15
Cost of suicide in New Zealand From: O Dea D and Tucker S. 2005. The Cost of Suicide to Society. Wellington: Ministry of Health. 2005 16
17 Effects of suicide on the family [Diversity of methods and target subjec cts makes it difficult to draw clear conclusions] Response of family members to suicide varies highly based on relationships of deceased within the family, the underlying psychological health of surviving family members, and type of response from external support networks Common issues that need to be dealt with are blame, shame, secrecy, stigma Decreased family cohesion and adaptability following suicide can lead to separation, mental health problem ms, problems with the law, and suicide Social ostracism and self isolation of family members is common Estimated 7,000 12,000 children lose a parent to suicide each year in US Cross sectional studies find increased substance abuse, violence, suicide attempts Unclear if response to suicide is fundamentally different from other types of bereavement in children Very few studies on effect on family members following attempted suicide Very few studies on family effect of suicide in low and middle income (LAMIC) countries ti but we do know from stu udies of HIV/AIDS that t children from LAMIC who lose a parent have poor educational, health and social outcomes
18 Number of children suicide each year in who lose a parent to China (1995 1999) 1999) (based on projecting national study results to estimated number of all suicides) Age of child Rural children Urban children mother father parent mother father parent All children under 2 8,261 2,226 10 2-4 14,948 5,407 20,355 618 136 754 21,109 5-9 37,764 14,311 52,075 1,545 1,086 2,631 54,706 10-1414 28,323 17,492 45,487 155 0 155 10,642,815 1,854 1,222 3,076 48,891891 15-17 15,735 10,177 25,912 773 543 1,316 27,228 under 18 105,031 49,613 154 4,644 4,945 2,987 7,932 162,576
19 Serious methodolog gical problems in assessing the costs associated with suicide The human capital approach yields low or negative values for certain groups and implies life is worth more in richer countries How do you value lost non market output? Willingness to pay methods assess the human value of life as the amount a person would be willing to pay to avoid death, butdifferent assumptions when using the method lead to widely variant results about the value of life ($0.1 million to $29.4 million), and it has never be assessed for suicide Is the quality of the life of someon e who dies of suicide the same as that of someone who dies of some other cause? Should the fact that most persons who die of suicide have mental illness and, thus, are less productive and have highermedicalcosts costs infuture beconsidered? The lost output and decreased quality of life of family members and associates or suicide decedents and the negative utilities on society more generally are not considered in any of the costing mo odels How should the social costs of suicide prevention activities be factored in?
20 What shou uld be done to prevent suicides?
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22 Suicide Preventi ion Resource Center http://www.sprc.org/about_sprc/index.asp Best practices re egistry http://www2.sprc.org/bpr/ /section i evidence based programs i evidence
The Nuremberg Alli iance Against Depression 2 year multi facetted program inclu uding 1) training of family doctors and support through different methods; 2) a pub blic relations campaign informing about depression; 3) cooperation with com mmunity facilitators (teachers, priests, local media, etc.) ; and 4) support for self help activities as well as for high risk groups. From: Heg erl U et al. (2006) Psychological Medicine 36:1225 1233 23
Relative importance of different classes of causes of suicide in China as asses ssed by interviewers and researchers after detaile ed evaluation of each case SER RIOUS SUICIDE COMPLETED ATTEMPTS SUICIDE TYPE OF CAUSE N=632 N=895 Psychological problems: Mood disorder Alcohol disorders 30.4% 20.6% 2.8% 47.5% 29.3% 4.0% Other mental disorderss 7.0% 14.2% Social problems: Family conflict Economic difficulties Physical illness Other social problems 69.6% 54.7% 2.7% 2.4% 9.8% 52.5% 26.3% 8.4% 11.3% 6.5%
Premeditation in attempted suicide Time from FIRST considering suicide to making thesuicide attempt in 590 individuals in China who made serious suicide attempts: 5 minutes or less 37% 10 minutes or less 46% 2 hours or lesss 60%
MULTI FACTOR MODEL OF SUICIDE NATIONAL AND GLOBAL FACTORS EXTERNAL INFLUENCES globalization of Western values regional and global economic integration MACRO ENVIRONMENT OF THE COMMUNITY CULTURAL FACTORS beliefs about suicide and the afterlife traditional norms of interpersonal relationships, of defining status SOCIOPOLITICAL FACTORS means of production, distribution of wealth political structure, influence of the media community level suicide prevention campaigns LOCAL WORLD OF THE INDIVIDUAL INTERPERSONAL NETWORKS relationships with family, friends, associates beliefs about suicide of intimate associates SOCIOECONOMIC ENVIRONMENT access to social resources such as education, work, housing, health care, social welfare, etc. access to and effectiveness of suicide prevention and treatment services availability and lethality of means of suicide INDIVIDUAL CHARACTERISTICS SOCIAL IDENTITY negotiated social status and social roles intersubjective legitimation/delegitimation ATTEMPTED AND COMPLETED SUICIDE PERSONAL RESOURCES AND STRESSORS educational level, economic status life events, coping skills BIOLOGICAL AND PSYCHOLOGICAL STATUS genetic factors, gender, age personality, level of life satisfaction physical and mental illness 26
27 The pesticidee story Worldwide intentional pesticide ingestion is the most common method of suicide accounting for over 300,000 suicides annually. In China pesticides are used in 62% 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 pesticid des stored in the home 82% use category I organophosphates
WHO Pesticides and Health Initiative
MODELING POTENTIAL EFFECT OF PESTICIDE- RELATED SUICIDE PREV VENTION ACTIVITIES: Proportion of pesticide-ingestion suicide d eaths reduced by a single intervention 01 0.1 02 0.2 03 0.3 04 0.4 Proportion of all suicide deaths from pesticide ingestion 0.4 4.0% 0.5 5.0% 0.6 6.0% 0.7 7.0% 8.0% 12.0% 16.0% 10.0% 15.0% 20.0% 12.0% 18.0% 24.0% 14.0% 21.0% 28.0%
Estimated benefits from sequential application of three separate pesticide-related strategies assuming 287,000 suicides a year in China, that 62% of suicides are pe esticide-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% 3% lives saved 35,588588 64,058 86,835835 Year productive lives (YPL) saved 719,200 1,294,560 1,754,848 Economic benefit of intervention based on $1,740 per saved YPL ($US) $1,251,408,000 $2,252,534,400 $3,053,435,520
From: Gunnell et al, Int J Epidemiology 2007. doi:10.1093/ije/dym164 32
Promoting the suicide prevention effort in LAMICs Develop model research and service delivery centers around the country (centers of excellence) Develop, implement and monitor local and national suicide prevention plan Conduct periodically national psychological autopsy studies to monitor the changing pattern of suicide iid and attempted t suicide iid Conduct high quality research to assess the cost effectiveness of proposed prevention measures
Promote national and local suicide prevention plans with the follow wing goals: 1. Promote psychological well being, resilience and community connectedness 2. Promote broad based support for suicide prevention 3. Decrease access to and lethality of means for suicide, particularly pesticides 4. Enhance social supportnetw works for high riskgroups groups 5. Promote community based screening programs to identify high risk individuals 6. Change attitudes about me ental health problems and suicide 7. Improve availability and quality of mental health services 8. Develop specific services for high risk individuals and others affected by suicide iid 9. Expand scientific evidence base for the prevention and management of suicide 10. Improve and expand surveillance of suicidal behavior 11. Develop sources of sustained funding for suicide related services and research 34
Prevention measu res that need to be tested as part of lo ocal and national suicide prevention n plans 1) different methods for restricting access to means 2) methods for increasing psychological resilience in youth 3) methods to increase social support networks for high risk groups 4) promotion campaigns about mental health and suicide 5) improve health providers ability to recognize and manage the psychiatric problems associated with suicide 6) institutescreening screening program ms to identify high riskindividuals individuals 7) expand crisis support services and targeted mental health services for high risk individuals 8) increase the ability of primary care facilities to manage the medical complications of suicide attempts
Thank you for listening 36
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