McLean–Stanford

Webinar on Suicide20 October, 2021

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Suicide:Basic Facts

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Ross J. Baldessarini, M.D.Professor of Psychiatry & Neuroscience

Harvard Medical School, Boston[No conflicts to disclose]

0 10 20 30 40 50 60Proportion of Excess Deaths (%)

Endocrine

Accidents+Other Violence

Pulmonary

Suicide

Cardiovascular

All Medical

All Violence

Causes of Excess Mortality: Bipolar Disorder Patients

[From Osby et al. Arch Gen Psychiatry 2001; 58: 844–850]

General population suicidal risks (US)

Measure Value Ideation 3000/100k/year Attempts 500/100k/year Suicides 14/100k/year

Ideation/Attempts 6 Attempts/Suicides 36 Ideation/Suicides 214 From Kessler et al. JAMA 2005; 293:2487–2495.

US Suicide Rates/100k/year by County, 2015

[From Rossen et al. Am J Prevent Med 2018]

Factors associated with state suicide rates (2001)

Factors in US Correlation

(r) p-value Population density –0.735 <0.001

Male sex +0.576 <0.001

Annual income/capita –0.550 <0.001

Psychiatrists/100,000 –0.544 <0.001

Native-American (%) +0.543 <0.001

Physicians/100,000 –0.528 <0.001

Federal MH aid –0.443 0.001

African-American (%) –0.430 0.002

Uninsured residents (%) +0.391 0.005 From Tondo et al.: J Clin Psychiatry 2006; 67: 517–523 (for 51 states+DC).

Risk factors for suicide ——————————————————————————————————————

n Previous suicide attempts

n Major depression or bipolar disorders n Abuse of alcohol or drugs n Losses, deaths, shame, poverty n Social isolation, unmarried n Lack of access to clinical care n Access to firearms, toxins, medicines n Soon post-hospital discharge ——————————————————————————————————————

0

5

10

15

20

25

30

35

40

45

50

55

60

65%

of L

ong-

term

Fol

low

-up

(±CI

)

BD-I BD-II All-BD UP

Total MorbidityDepression [Hypo]mania

[23 studies; n=3936]

[15 studies; n=2479]

[12 studies; n=2760]

[8 studies; n=822]

Long-Term Morbidity in Clinically Treated Mood-Disorder Patients

[From Forte et al. 2015]

[Depression = 86.4% of the 45.3% of time ill in 9.4 yrs]

% time ill

Forest plots of random-effects meta-analyses of studies of effects of A. modern drugs for psychosis otherthan clozapine (n=28 studies) or B. clozapine (CLZ; n=7) vs. suicidal acts (attempts or suicides), comparedto indicated alternative treatments. Effects of CLZ are highly significant (pooled OR = 0.229 [CI: 0.110–0.476]; z-score = 3.94. p<0.0001), but not drugs other than CLZ (OR = 0.941 [0.790–1.12]; z=0.680,p=0.497).

Antisuicidal Effects of Antipsychotic Drugs: Clozapine vs. Others

[From Forte et al. J Psychopharmacol 2021]

B. Clozapine

A. Other SGAs

0.0 0.1 1.0 10.0 100.0 1000.0Rate Ratio [RR; 95%CI]

Pooled RR

Yervanaian et al. 2007bYerevanian et al. 2007a

Collins & McFarland 2007Gonzalez-Pinto et al. 2006

Angst et al. 2005Yerevanian et al. 2003

Goodwin et al. 2003Calabrese et al. 2003

Bowden et al. 2003Rucci et al. 2002

Coryell et al. 2001Kallner et al. 2000

Brodersen et al. 2000Bauer et al. 2000

Tondo et al. 1998Coppen & Farmer 1998

Bocchetta et al. 1998Greil et al. 1996

Nilsson et al. 1995Kouopoulos et al. 1995

Sharma & Markar 1994Lenz et al. 1994

Felber & Kyber 1994Rihmer et al. 1993

Müller-Oerlinghausen et al. 1992Modestin & Schwarzenbach 1992

Nilsson &Alexsson 1990Lepifker et al. 1985

Hanus & Zapletalek 1984Vankoba-Rao et al. 1982

Ahlfors et al. 1981Poole et al. 1978

Kay & Petterson 1977Prien et al. 1974

Pooled RR [CI] 4.14 [3.02–5.67] (p<0.0001)

10 100 1000

Effects of Lithium:Suicides &Attempts

[From Baldessarini & TondoBipolar Disord 2008; 10:114–115]

[n=34 studies; N=3200 subjects]

Summary & Conclusions——————————————————————————————————————l Major mental illnesses can be fatal: suicide in younger,

with medical illnesses in older patients. l Suicide risks rising in US (declining in many other countries),

with all locales & ages.l Suicide risk: higher with BD than MDD; also high with

substance abuse. l Lethality ratio (attempt/suicides) ca. 30 in general pop.;

<10 in mood disorders. l Risk factors: prior attempt, substance abuse, mood disorder,

unresolved depression, social isolation, losses, post-hospital. l Medical treatments vs. suicide: clozapine (schizophrenia),

lithium (mood disorders). ——————————————————————————————————————