Suicide and Self-Harm by zMqf080H

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									Suicidal Behaviour
    Dr E Cassidy
        CUH
    January 2011
Terminology
Suicide
  Death
  by individual who died
  “intentional”
  act or omission
  “completed” rather than “successful”
Self-Harm
 Attempted Suicide
 Deliberate Self-Harm
 Parasuicide
 Self-Poisoning or Self-Injury
 Self-Mutilitation


 Everything that doesn’t involve death – a behaviour not a
  diagnosis
Suicide
                            Deaths classified as suicide in Ireland
                                         (1996-2009)

                   500
                                                                      Men   Women
                   450
                   400
Number of deaths




                   350
                   300
                   250
                   200
                   150
                   100
                    50
                     0
                         1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
                         Year 2008 and 2009 figures are provisional
                            Trends in undetermined deaths in
                                         Ireland
                                       (1996-2009)
                   160

                   140                                            Men   Women

                   120
Number of deaths




                   100

                    80

                    60

                    40

                    20

                     0
                         1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


                     Year 2008 and 2009 figures are provisional
SUICIDE IN IRELAND
•500 per year
•Peak M 20-24yo (34/100,000)
•Peak F 45-54yo
•Males @ 80%
•Hanging, Poisoning, Drowning
Associations
  Unemployed and retired
  Divorced, never married
  Certain Professions
  Social class: I and V
  Country variation lower in LDCs than Western; China (females)
  Cultural variation
  Seasonal variation
          Highest April to June
Context
 1 in 6 leave notes

 1 in 2 have self harmed in the past

 Majority have told someone
  GP in previous month
Suicide and Psychiatry

 ?90% suffer from some mental disorder



 OCD may protect
Suicide and Schizophrenia
 10% mortality
 Risks with
                 Early in illness
                 Males, younger
                 Relapses
                 Akathisia
                 Recent discharge
                 Paranoid
                                     ( Roy, 1982 )
Suicide and Depression
 5-15% lifetime risk

 Melancholic depression

 Psychotic depression

 Family History
Self-Harm
 Incidence of deliberate self harm 2003-2009
     Total number of DSH episodes: 75,119
  Total number of individuals involved: 48,206


Year    Male rate*   % diff   Female rate*   % diff
2003       179                    241
2004       170       -5%          229        -5%
2005       165       -3%          227        -1%
2006       160       -3%          210        -8%
2007       162       +2%          216        +3%
2008       179       +10%         221        +2%
2009       197       +10%         221        +0.4%
                           Rate per 100,000




           0
               100
                     200
                              300
                                    400
                                          500
                                                         600
                                                                700
10-14yrs

15-19yrs

20-24yrs

25-29yrs

30-34yrs

35-39yrs

40-44yrs

45-49yrs

50-54yrs

55-59yrs

60-64yrs

65-69yrs
                                                         Male




70-74yrs
                                                                            Average rates 2003-2009


                                                Female




75-79yrs

80-84yrs
                                                                      Incidence of DSH by age and gender,




 85yrs+
              Main method of self harm
                (Average 2003-2009)
       Men                 Women           Overdose

                                2%         Alcohol
       4%                 17%
25%                 2%                     Poisoning
                    2%
                    1%                     Hanging
             60%    0%
 3%                                  76%   Drowning
6%
 2%                                        Cutting
  1%
                                           Other

 Alcohol was involved in 46% and 38%
 of male and female acts, respectively
Intentions

 Most neither want nor expect to die
    1/3 no thoughts
    Cry for help
    Escape

 Often impulsive
 20-40% alcohol on board
 Recent life stress
 20% repeats
 Self-Mutilation
        Punishment, Relieve tension
Associations

   Separated and divorced
   Low Socioeconomic status
   Urban > Rural
   Childhood disadvantage
   Lack of Social Support
   Lack of Religious affiliation
   Collective (Princess Di effect, clustering)
   Availability of means (paracetamol)
     Cumulative probability of repeated DSH
by DSH method and number of previous episodes
                       aaM e i e t m s
                       pn r l    u      t
                      K l - ei f ar esi ae                                  K l - ei f ar esi ae
                                                                             aaM e i e t m s
                                                                             pn r l    u      t




0.70                                                  0.70


0.60                                                  0.60


0.50                                                  0.50


0.40                                                  0.40


0.30                                                  0.30


0.20                                                  0.20


0.10                                                  0.10


0.00                                                  0.00

       0     3                6              9   12          0     3                6              9   12

              Time DSH (months)
           Time to to DSH (months)                               Time to DSH (months)
                 Self-cutting & overdose                               Four previous DSH presentations
                 Self-cutting only                                     Three previous DSH presentations
                 Other                                                 Two previous DSH presentations
                 Attempted drowning                                    One previous DSH presentation
                 Attempted hanging                                     No previous DSH presentation
                 Drug overdose only
              The burden of repeated
               deliberate self harm

Number of              Persons                    Presentations
DSH acts in   Number              (%)      Number                  (%)
2003-2009
One            37690             (78.2%)   37690              (50.2%)
Two            5874              (12.2%)   11748              (15.6%)
Three          2023              (4.2%)     6069                  (8.1%)
Four            881              (1.8%)     3524                  (4.7%)
Five            496              (1.0%)     2480                  (3.3%)
Six             345              (0.7%)     2070                  (2.8%)
Seven           203              (0.4%)     1421                  (1.9%)
Eight           132              (0.3%)     1056                  (1.4%)
Nine            109              (0.2%)     981                   (1.3%)
10 or more      453              (0.9%)     8080              (10.8%)
      Factors associated with repetition
      independent of previous repetition

   Women aged 35-44 years had the highest risk of
    repetition (+33%)

   Among women, those who engaged in self-cutting only
    (+57%) and those with self-cutting with drug overdose
    (+48%) had the highest risk of repetition

   Among men, those engaging in self-cutting in
    combination with drug overdose had the highest risk
    (+49%)
Aetiology of Suicidal Behaviour
Vulnerability – Stress
 Vulnerability
      Family history
      Impulsive/aggressive personality traits
      Childhood adversity/abuse
      Hopelessness
      Over generalised autobiographical recall
 Stress
    Life and esp interpersonal stress
    Physical illness
 Failed Inhibition
    Alcohol and Drugs
    Head Injury/ cognitive impairment
 Lack of Adaptive Coping
    social support, problem solving ability
 Maladaptive coping
    with alcohol, drugs (disinhibition)
Neurobiology

 Serotonin:
        Low 5-HIAA in CSF
        Reduced frontal 5-HT2A receptor biding
        5HT is involved in impulsivity
        5-HTTLP predicts self-harm following life stress
 HPA axis
        Hyperactivity predicts self-harm / completion in depressives
 Cholesterol
        Low cholesterol predicts
 Prefrontal Cortex
        Failed response inhibition
Repetition
Risk of Repetition
Think of risk as immediate and long term

Characteristics of attempt
Characteristics of person
Underlying psychiatric or physical disorder
Repetition and Suicide
 15% repeat by 1 year
 10%% suicide at long-term outome
    Lethal prior method
    Psychiatric disorder
    Older males
    Social isolation
    Repeated self-harm
    Avoiding discovery at time of self-harm
    Strong suicidal intent
    Substance misuse (especially in young people)
    Hopelessness
    Poor physical health
Enquiring about suicide
Asking about suicide

Asking about it does NOT increase the risk

It may decrease it!

But do it sensitively
Ask sensitively
 Many people…
 After what you’ve told me…
 How do you think things will turn out ?

 Do you ever wish you would never wake up ?
 Have you thought about ending it all ?
 What would you do ?
Assess suicidal risk

 Current plans and intent
   Availability
   How far down the path have they gone
   Why not yet
   Current mental state

 Previous attempts
   Planning, precautions
   Dangerousness (real and perceived)
   What happened
 Supports and ability to access them
Initial Management
Treat mental disorder
Address needs
  Alcohol
  Finance
  Relationships
Give crisis contact details
Prevention
 Complex public health initiatives
 ? Reduce alcohol
 Identify and treat more Depression
 Lithium in Bipolar disorder
 Clozapine in Schizophrenia
 DBT in Borderline PD
   NATIONAL CONFIDENTIAL
                    INQUIRY
INTO SUICIDE AND HOMICIDE
   BY PEOPLE WITH MENTAL
                    ILLNESS
         England and Wales
              Annual report
                      2009
Patient Suicide
 26% suicides had contact with mental health services in the 12 months prior

 Suicides less common following non-compliance/loss of contact with
   services

 14% of all suicides are Psychiatric Inpatients

 70% of these occurred off the ward

 Inpatient suicides falling

     Fallen by 1/3 (50% less hanging/strangulation)

     Belts, shoelaces, sheets, towels

     Removal of non-collapsible curtain rails 2002
Psychiatric diagnosis

Affective disorder (534)
Schizophrenia (198 - stable)
Personality disorder 104 - (fallen)
Alcohol Dependence (83 - fallen)
Drug Dependence (24 - fallen)
Other (176)
Method

Hanging, OD, Jumping

Hanging, jumping increased
Overdose, CO poisoning decreased
Drowning, firearms and burning stable
Reach Out National Suicide Strategy
 2005-2014

								
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