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					suicide prevention of the rich
            versus
   rich suicide prevention
                      or
             suicidology in vitro
                   versus
             suicidology in vivo



                   andrej marušič
                university of primorska,
                    koper, slovenia
three remarks to
remember
 1.   suicide    between      ideation    and
      behaviour - huge differences in
      defining suicide intention and risk

 2.   suicide between a moment and a
      process - remarkable differences in
      understanding the biopsychological
      background of both

 3.   suicide between being considered as
      rare or freqeuent event - depending
      where do we take a look
1. classical
definitions tend to …
      the completed suicide consists of
       intent, act and death:
           intent of self-destructiveness and
           act that is self-directed and life-
            threatening and
           that will be fatal


      in the absence of the             third
       component: suicide attempt

      in the absence of the second and
       the third component: suicide
       intent
          2. suicide: a process
          rather than a moment
                      negative thinking

                             

                       suicide ideation

                             

                        suicide plan

                             

 impulsivity            suicide intent        aggression

                                       

suicide attempt       completed suicide
3. suicide: is it really
rare?
   in general it is, but not in high risk
    groups
       in depression, schizophrenia, ...: 15%
       in suicide attempters even higher: 100
        times higher in a year after the attempt


   similarly, miocardial infarction is quite
    rare in general, but not so in
       male smokers, 40 years old
       angina pectoris patients
      suicide prevention
1.   who can prevent?

2.   how (with whom, where, when and what)
     to prevent?

3.   can it be effective?
who? public health
response needed
                           experts
       suicide risk related to
    complicated mental disorders
                   mental health

        suicide risk linked to
                  primary
          mental disorders       care

      NGOs, volunteers
      suicide risk associated to
           mental distress
    media, users, relatives
      how? via various
         networks

after suicide attempt risk                legislation (as part of ...):
                               what exactly should be done after every attempt


                                   responsive health and social care network
risk in mental disorders in connections with all other potential improvement provider
                               education, process-or-quality-related-innovations

                                    national programme for mental health:
 risk in mental distress                          stigma-less
                                     promotion of positive mental health
                                                   assertive
can prevention be effective?
populational-based
strategies
     reducing access to means
         guns
         north sea gas
         catalytic convertors
         paracetamol boxes
         fencing off railway lines & bridges
         perspex covers & doors at the
          underground station
     public education
     work & unemployment policy
     school based programme
     media reporting
     attention to desinhibiting drugs
     PRIMARY PREVENTION
high risk strategies
    detection & treatment
        depression & primary care - Gotland study,
         ...
        attempted suicide & ER
        schizophrenia & mental health services -
         CPA
    crisis intervention
    enhanced access to mental health
     services

    training of health professionals
    training of prison staff & prisoners
    SECONDARY PREVENTION
 bertolote &
fleischmann,
     2003
suicide &
depression
   15% eventually commit suicide
    (30 times risk in general)
   early part of course of illness
   male, single, alone
   previous attempts
   insomnia, self-neglect,
    retardation, hopelessness

   GPs need to be educated
suicide in alcohol-
related diagnoses
    15% eventually commit suicide
    later stage of course
    also depressed
    poor physical health
    poor work record
    previous attempts
    recent end of a close relationship

    SWs and others need to be
     mobilised
suicide in
schizophrenia
   10% will commit suicide
   in earlier stages of course of illness
   male, young, high expectations and high
    level of educational status – fears of
    mental disintegration
   chronic relapsing
   affective symptoms with suicide threats
    and hopelessness
   just after discharge
   akathisia

   long term community support and
    careful aftercare planning needed
suicide in previous
attempts
    risk following an attempt, for one
     year: 100 times that in general
     population
    15-25% repeat within 6 months
     remains high for some years
    1/3 of those who repeat report
     previous attempt
high degree of risk
    planned and prepared act

    dangerous method involved
        medical dangerousness
        also knowledge of dangerousness

    precaution were taken to avoid
     discovery

    patient did not seek help or stated
     his/her intention beforehand

    final acts such as will or leaving
     suicidal note
other risk factors
   unemployment - more in males

   social isolation - divorced or widowed

   vulnerable intervals - monday, spring

   criminality – prisons

   physical ilness – HIV, epilepsy (TLE),
    chronic ilness and pain
        assessment of risk
     (tuckman & youngman)
    One point for each
      2-5: subsequent suicide rate 7/1000;
      above 10: 60/1000)
                                         6.    Poor physical
1.   Age above 45                              health
2.   Male                                7.    Recent medical
                                               treatment
3.   Unemployed
                                         8.    Mental disorder
4.   Not married
                                         9.    Violent attempts
5.   Living alone
                                         10.   Previous
                                               attempts
                                         11.   Suicide note
suicide prevention in
many rich countries
     left to enthusiasm (leading to disappointment)

     globally disorganised
        no national programme or strategy


     lack of vision (if there is one, lack of strategy)
        “why?” has not been answered
        the following not even questionned
              “how, where, when, who, with whom?”

     lack of “bridging” between:
        sectors and disciplines
        “this is my garden!”


     no incentives for successfully solved problems
        not good for lions
        perfect for hienas
suicidology of the
rich?
      prevention of suicide only when in an
       institution (following stigma-based
       definition of safety)

      could be with the best possible
       pharmacological approach

      could also be providing some
       psychotherapeutical appprocahes (out of
       pitty), even if not evidence-based

      but there is lack of bridge between health
       and social care sector (hence, no continuity
       of prevention)

      “in vitro” suicidology
a rich suicidology?
   suicide prevention in the community provided
    by the community as a whole

   continously assessing suicide risk in the
    functionally and geographically defined
    population

   a dense health and social care network, which
    is providing continous prevention, an optimal
    social care and occupational (or educational)
    provision, so that one can remain outside
    dangerous levels of suicide risk

   “in vivo” suicidology
aims for a good suicide
prevention strategy
 1.   availability ob several management options with the
      least restrictive to be chosen

 2.   involvement of users (well informed, role of decision)

 3.   respecting users (no discrimination, no patronising)

 4.   protection (users, carers, experts) without prejudices

 5.   cooperation

 6.   locallity of
         a global, whole, integrated,
         continuous, flexible and
         human mental health care

 7.   lowering general and specific suicide rates at the
      same time
key elements of
richness of suicidology
 1.   integrated

 2.   continuous

 3.   global

 4.   local

 5.   wholistic
      -   an overall well-being is more than absence of risk

 1.   flexible
      -   person-centred and not suicidologist-centred

 2.   human
      -   always level out his or her right for freedom and
          right for be safe and mentally healthy
4-level intervention
     approach
cooperation with
   primary care      public relations,
  (e.g. advanced      information for
 training for GPs    the broad public
    and nurses)




  help offers for      cooperation
   patients and            with
  relatives (self-     community
    help, high         facili-tators
   risk groups)
e-suicide prevention
           e-health technologies can
            contribute in improving
            the standard care of
            depression and prevention
            of suicide by adding new
            ways of following-up
            persons with depression,
            effectively allocating the
            usually scarce resources
            and by empowering
            patients
              e-suicidology -
            a rich suicidology
            can be even richer
   e-health technologies can contribute in
    improving the standard care of depression
    and prevention of suicide
     by adding new ways of following-up persons
      with depression,
     effectively allocating the usually scarce
      resources and
     by empowering patients

				
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posted:7/8/2011
language:English
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