SUICIDAL BEHAVIOUR Dr Victor Makanjuola Dept. of psychiatry University of Ibadan Suicide: defined as the act of deliberately killing one self. Epidemiology Suicide is a major public health problem approximately 0.9 percent of all deaths are the result of suicide. About 1000 persons are estimated to commit suicide each day worldwide. In the United States suicide ranks as the eighth leading cause of death, and there are approximately 75 suicides per day, or one every 20 minutes, and more than 30,000 each year. The number one suicide site in the world is the Golden Gate Bridge in San Francisco. In general the suicide rate is low in less prosperous countries and higher in more affluent countries; it is high in all Eastern European nations. The United States has a rate in the middle range, around 12 per 100,000. Risk factors Age: Suicide rates increase with age. The elderly attempt suicide less often than do younger people but are successful more often. The elderly account for 25 percent of the suicides, although they make up only 10 percent of the total population. The rate of suicide for those 75 or older is more than three times the rate among the young. Sex: Males at all ages commit suicide more often than females and male-to-female suicide ratios range from 2 to 1 to 7 to 1. Race: Ethnic and minority groups tend to be more cohesive and have lower suicide rates. In the United States, blacks have lower suicide rates than whites. Suicide among immigrants is higher than in the native- born population. Marital Status: Married persons have the lowest suicide rates. The suicide rate for single persons is twice that of married persons and that of the divorced, separated, or widowed, four to five times higher. Social Integration: Neighbourhood and families ties and religious affiliations affect the risk of suicide. Suicide rates are lower among Jews and Catholics than among Protestants Employment: Work, in general, protects against suicide. The unemployed have higher suicide rates, probably owing to an interaction of socioeconomic circumstances, psychological vulnerability, and stressful life events. Causes of Suicide Social Factors Emile Durkheim Egoistic suicide is determined by a lack of meaningful family ties or social interactions. Such suicide occurs in individuals who had lost their sense of integration within their social group, hence no longer felt subject to its social, family and religious control. Anomic suicide occurs when the relationship between an individual and society is broken by social or economic adversity. It occurs in individuals living in a society that lacked “collective order”.e.g suicide rates rose during the Great Depression of the 1930s and fell in nearly all European countries during both world wars. Altruistic suicide results from excessive integration in society (e.g., harakiri, sati). Psychological Factors Freud: Freud stated that suicide represented aggression turned inward against an introjected, ambivalently cathected love object. Freud doubted that there would be a suicide without the earlier repressed desire to kill someone else. Menninger: Karl Menninger in “Man Against Himself” conceived of suicide as a retroflexed murder, an inverted homicide, as a result of the patient's anger toward another person, which is either turned inward or used as an excuse for punishment. He described three components of hostility in suicide: the wish to kill, the wish to be killed, and the wish to die. Recent Theories: Aaron Beck has demonstrated the importance of hopelessness while Edward Shneidman has observed cognitive constriction of choices among the suicidal. Biological Factors Diminished central serotonin plays a role in suicidal behavior. Low concentrations of CSF 5-HIAA also predicts future suicidal behaviour. Recent studies also report some changes in the noradrenergic system of suicide victims. Genetic Factors Suicidal behaviour, like other psychiatric disorders, tends to run in families. For example, Margaux Hemingway's 1997 suicide was the fifth suicide among four generations of Ernest Hemingway's family. In psychiatric patients a family history of suicide increases the risk both of attempted suicide and of completed suicide in most diagnostic groups. Medical factors Mental disorders Mental disorders are a most important cause of suicide. Depressive disorders: rates of suicide are increased among depressed patient. (paradoxical suicide) Alcohol Abuse: is the second most frequent psychiatric disorder among those who die by suicide being present in 25% of cases Other Drug Dependent: patients also have an increased suicide risk Personality disorders: is detected in a third to half of people who commit suicide Schizophrenia: account for only about 3% of suicides hence the risk must be borne in mind. Physical Disorder Post-mortem studies show that a physical illness is present in 25 to 75 percent of all suicide victims; a physical illness is estimated to be an important contributing factor in 11 to 51 percent of suicides. In each instance, the percentage increases with age. Rational suicide: suicide occasionally is the rational act of mentally healthy person Suicide pacts: two people agree that at the same time each will take his or her own life Assessing suicidal risk All general risk factors are to be enquired about Interview must be conducted in an unhurried and sympathetic manner that allows the patient to admit any despair or self destructive behaviour Current problems must be enquired about Mental state examination should be particularly thorough and cognitive functions must not be overlooked. The mood must also be examined and homicidal ideas should be enquired about. Management Management in the community Full assessment of patient and relatives including review of suicidal risk Organisation of adequate social support Regular review Full dosage of safe psychiatric treatment Choose less toxic drugs Small prescriptions Involve relatives in care of tablets Arrange immediate access to extra help for patient and relatives In the presence of significant suicidal risk, inpatient care is nearly always required Management in the hospital Safe ward environment Adequate well trained staff with good working relationship Clear policies for assessment, review, and observation On admission Asses risk Agree level of observation Remove objects which might be used as a means of suicide Discus plans with patient Agree policy for visitor During admission Regular review of risks and plans Clear plans for leave If patient leaves the ward without notice, take Immediate action Discharge Plan and agree in advance Prescribe adequate but non-dangerous amount of drugs Early follow up Suicide Prevention Primary Prevention Better and more available psychiatric services Restricting the means of suicide Educational programmes Restricting opportunities for imitations Secondary Prevention Better and more available psychiatric care Crisis centres and “hotlines” Deliberate Self Harm (attempted suicide or Parasuicide) Deliberate self poisoning: Accounts for about 90% of DSH and usually involve a drug overdose. Most commonly used drugs are non opiate analgesics such as paracetamol and salicylates Deliberate self injury: Accounts for about 5 – 15% of DSH. Methods include lacerations (usually of the fore arm or wrists). Others including jumping from heights or in front of a train or motor vehicle, shooting, and drowning Epidemiology In England and Wales, self-poisoning is the most common diagnosis of admitted patients under 50 years of age; among women it is the most common reason for emergency medical admission whereas among men it is second only to heart attacks Risk Factors Age: commoner among the young people with rates declining sharply in the middle ages Sex: commoner among females, about 1.3 to 1.5 times higher Socioeconomic class: Prevalence higher in the lower socioeconomic class Marital status: Highest rates are found among the divorced. High rates are also recorded among teenage wives, younger single men and women. Other social factors: high rates in areas with high unemployment, overcrowding, etc Causes of deliberate self harm Precipitating factors Stressful life events: compared with the general population, people with DSH experience 4 times as many stressful life problems in the six months before the act. Predisposing factors Marital difficulties Unemployment A background of poor physical health: epileptics are six times more likely to carry out DSH than the general population Early parental loss Poor skills in solving interpersonal problems and in planning for the future Psychiatric disorders: few have psychiatric disorders though affective symptoms are common. Depressive disorder and alcohol dependence are the two commonest disorders associated with DSH. NB: The risk of completed suicide is increased about 100 times over that of the general population Assessment of patients after DSH Circumstances suggesting high suicidal intent Planning in advance Precautions to avoid discovery No attempts to obtain help afterwards Dangerous methods „Final acts‟ Factors predicting suicide after deliberate self harm evidence of serious intent depressive disorder alcoholism or drug abuse antisocial personality disorder previous suicide attempts social isolation unemployment older age group ( female only) male sex Factors predicting the repetition of non fatal deliberate self poisoning Previous deliberate self harm Previous psychiatric treatment Antisocial personality disorder Alcohol or drug abuse Criminal records Low social class Unemployment Management About 5 – 10 % require immediate in patient treatment in psychiatric facility, about 25%require no special treatment because their self harm is a response to temporary difficulties and carried little risk of repetition. The rest may require some outpatient treatment. The treatment is mainly psychological and social. Drugs may be needed in a small minority to treat depression.