Suicide

Back to Basics

April 2, 2013

Clare Gray MD FRCPC

Epidemiology Canadian Data average rate of suicide in Canada has been

13/100,000 translates to 3500 deaths/year by suicide

Epidemiology 4 males:1 female Males -- firearms, hanging, gasses, jumping

from high places Females -- drug ingestion, firearms, gasses,

hanging

Epidemiology Suicide rates for males steadily increase with

age and peak >75 years old suicide rate for white males >85 years old is

in the order of 65/100,000 for females, the suicide rate peaks in the late

40’s early 50’s

Epidemiology

Higher suicide rates in single, widowed and divorced individuals vs. married

Marital Status Widowed 24/100,000 Divorced 40/100,000 Divorced men 69/100,000 Divorced women 18/100,000

Epidemiology 1952 to 1992 the rate of suicides in

adolescents and young adults tripled (4 to 13.2/100,000)

1992 to 2002 rates decreased (13.1 to 9.9/100,000)

But more recently we have seen a rise in suicide rates in this age group

Etiology Biochemical Factors Genetics and Family variables Psychiatric diagnosis Personality traits and disorders Psychosocial and environmental factors Chronic medical illness

Etiology- Biochemical Factors 5HT (serotonin) dysregulation

association between aggression, impulsivity and 5HT dysregulation

relative deficiency of 5HT has been found in CNS of suicide completers

5HIAA (metabolite of 5HT) is decreased in the CSF of depressed patients and even more decreased in suicide attempters and completers (especially violent suicides)

Genetics

Roy and colleagues (1991) Reviewed the world literature of case reports

of twin suicides Found a much higher concordance for

suicide among monozygotic than dizygotic twins (11.3 percent vs. 1.8 percent)

Etiology - Genetic and Family Variables Family history of suicide is a significant risk

factor for suicide identification with/imitation of family member family stress/contagion effect transmission of genetic factors for suicide transmission of genetic factors for psychiatric

illness

Psychiatric Illness and Suicide 90% of suicide completers have a major

psychiatric illness 50% to 80% are clinically depressed 25-50% are substance abusers

BUT it is a small percentage of patients with psychiatric illness who commit suicide

Mood Disorder Schizophrenia Alcohol Dependence Borderline PD

2 – 8% commit suicide 4 – 5% 5 – 7% 5 – 10%

Bostwick, JM. Pankratz VS. 2000; Hor, K, Taylor, M. 2010; Palmer BA, Pankratz VS, Bostwick JM. 2005; Inskip HM, Harris EC, Barraclough B, 1998 ; Oumaya M, Friedman S, Pham A, et al. 2008;

Psychiatric Illness and Suicide Psychiatric diagnosis in completers tends to

vary with age suicide completers <30 years old

substance abuse disorders or antisocial PD Stressors: separation, rejection, unemployment,

legal troubles suicide completers >30 years old

mood disorders and cognitive disorders Stressors: illness

Personality Traits and Disorders Important contributory risk factors antisocial and borderline personality

disorders are particularly associated with suicidal behaviour in adults

conduct disorder and borderline traits in adolescent suicides

add depression to any of these -- lethal combination

Decreased social supports Bereavement Separation/divorce Humiliation

interpersonal discord, job loss, impending disciplinary crisis, threat of incarceration

Retirement Stressful life events

Chronic Medical Illness About 5% of suicide completers have serious

physical illness elevated suicide rates in patients with

brain trauma, epilepsy MS, Huntington’s, Parkinson’s AIDS, cancer Cushings, Klinefelter’s syndrome, porphyria Peptic ulcer, cirrhosis (likely related to Etoh) Prostatectomy, hemodialysis

Elevated rates of suicide have been found in patients with diagnoses of Neurological disorders

Seizures, MS, Huntington’s chorea, Brain injury Cancer Asthma, bronchitis CHF End stage renal disease HIVDruss, B., Pincus, H.  2000; Jurrlink, DN, Herrmann N, Szalai JP, et al. 2004; Kurella, M, Kimmel PL,

Young BS, et al. 2005 ;Carrico, A, Johnson, M, Morin, et al., 2007; Berger, D. 1995;

The first week after a patient's discharge from a psychiatric hospital is of particularly high risk for a suicide (Hunt IM, Kapur N, Webb R, et al. 2009)

43% of suicides occurred within a month of discharge

47% of these patients died before their first follow-up appointment

40% of those who die by suicide have made a previous attempt (Cavanagh J, Carson A. Sharpe M, et al. 2003)

Of those who make an attempt 7% go on to die by suicide 23% go on to make further attempts 70% make no further attempts (Owens D, Horrocks J,

House A. 2002)

In children and youth who make a suicide attempt 25 to 66% will make another attempt (Stewart SE, Manion IG,

Davidson S, et al. 2001; Rosewater KM, Burr BH.1998)

Increases risk for suicide Study of adolescent suicide completers

Were twice as likely to have firearms in the home (Brent DA, Perper JA, Allman CJ, et al, 1991)

Overall, 50.7% of suicide completers use firearms (Karch DL, Dhalberg LL, Patel N, 2007)

Highlights importance of removing access to firearms in the homes of suicidal patients

Attempters vs. Completers

Difficult to know exactly how many people attempt suicide don’t seek help, not reported

estimates are 8 to 10 attempters for each completer

up to 40% or more of attempters have personality disorders

Suicide Attempters Female Younger Depression, Alcoholism, Personality D/O Impulsive Low lethality (overdose) High availability of help

Suicide Completers Male Older Depression, Alcoholism, Schizophrenia Careful planning High lethality (firearms) Low availability of help, socially isolated 30% have history of suicide attempts

Suicide completers Approximately 1 in 6 completers leave a

suicide note 50% of people who commit suicide have

been seen by a primary care MD within one month prior to their deaths

with older suicide victims, this rises to 70%

Risk Factors for Suicide-- SADPERSONS scale Sex (Male) Age (very young or very old) Depression Previous attempt Ethanol abuse Rational thinking loss (psychosis) Social supports lacking Organized plan No spouse Sickness (chronic illness)

SADPERSONS Scale 1 point for each if present 7-10 points then hospitalize or commit 5-6 points strongly consider hospitalization,

depending on confidence in follow up arrangement

3-4 points then close follow up, consider hospitalization

0-2 points send home with follow up

Risk Factors BUT people don’t kill themselves because

statistics suggest they should people kill themselves because of

unbearable psychological pain statistics are good for large populations, but

not so good when applied to an individual patients can have very few risk factors and

still decide to kill themselves

Introducing the topic in a sensitive manner Sometimes when people are feeling down, it can

be hard to get up and greet the day – do you ever feel this way?

Do you ever feel like you don’t want to go on living?

Have you ever had thoughts of wanting to end your life?

Can you tell me about these thoughts? Have you ever thought of a plan to kill yourself?

Degree of hopelessness is more predictive of future suicidal behaviour than severe depression

Do you have hope that things will get better?

Passive “I wish I could disappear” “I’d like to go to sleep and not wake up” “It would be okay with me if I were to be hit by a

bus” Active

“I want to die” I am going to go and kill myself”

Patient felt their attempt would kill them Low chance of being found following attempt Concrete suicidal plans, with access to means A wish to be reunited with a dead loved one Putting affairs in order “Things would be better for everyone if I were

dead” Reluctant to communicate and/or accept help Lack of social support

When to send suicidal patients to the Emergency Department Acute suicidal ideation

With plan and intent With poor social supports With lack of future orientation Use of scales from 1-10 Hopelessness Contracts

Safety Safety Safety If at all unsure about patient’s ability to

control his/her suicidal behaviour, then admit patient to hospital

Can admit voluntarily or involuntarily Can order a sitter for 1:1 observation on the

ward

When to refer suicidal patients to a mental health professional Patients not at imminent risk Use of contracts Always ensure patient knows they can use

the ED if situation changes Ensure close follow up or bridging until

appointment

No evidence to support “contracting for safety” Having suicidal patient agree to no longer be

suicidal

Safety planning makes much more sense Developed in collaboration with the patient List of things patient agrees to try when feeling

suicidal

Potential triggers for suicidal thinking Potential coping strategies Social supports Phone numbers for crisis lines Instructions on when to return to ED How to make environment safe (removing

firearms)

Suicide is a major public health issue BUT there is hope!

< 1% of people who have had suicidal ideation go on to kill themselves

suicidal ideation is transient for most people SO, if we an detect the acutely suicidal

patient and provide an alternative that delays the act, there is a reasonable chance the patient will change their mind

In the 15 – 24 year old age group, what percentage of all deaths were due to suicide?

a) 5%

b) 15%

c) 25%

d) 35%

C) 25% (actually 23.8%)

What percent of patients who commit suicide have been seen by their family physician within one month of their suicide?

20% 35% 50% 75%

50%

Antares is the 15th brightest star in the sky and it’s more than 1000 light years away!

So just remember to keep everything in perspective – Good Luck with your exams!

gray_c@cheo.on.ca