DISCONTINUITY BETWEEN SUICIDE ATTEMPTS AND

COMPLETED SUICIDEImplications for Prediction

Angus H Thompson

Dept of Public Health, Flinders University

EVIDENCE FOR DISCONTINUITY

• Many Attempters do not wish to die

• Very few attempters take their own lives

• There are some differences between the two groups

SINGLE DIMENSION MODEL

Thoughts of Death

Suicidal Thoughts

Plans/Serious Ideation

Suicide Attempts

Completed Suicide

SINGLE DIMENSION MODEL

• Attempts signify higher risk

• Escalation in lethality if no resolution

• Observed differences between the two may

be due to differences in escalated intensity

PREDICTION OF SUICIDE

Too Rare to be Usefully Predicted?

• About 11 per 100,000 in Australia and Canada currently

(< 1 Ninetieth of one percent)

STUDY 1

Canadian University Students

N = 227

65% Female

STUDY 1Q1 Has there ever been a period when

you felt like you wanted to die?

Q2 Have you ever felt so low you thought of committing suicide?Q3 Have you ever made definite plans to

commit suicide (even though you did

not actually make an attempt)?Q4 Have you ever attempted suicide?

Persons at a particular level who also displayed a “lower” level of suicidal behaviour

“Preceded” by:

Index Level Plan Suic Tht Death Wish

Attempt 91% 100% 100%

Plan 100% 100%

Suic Thought 96%

RESULTS

The frequency of acknowledgement of each level of suicidal behaviour

NoneDeathWish

SuicideWish Plan Attempt

108(48%)

115(51%)

80(35%)

26(12%)

12(5%)

RESULTS

IMPROVING PREDICTION 1

• Annual Rate (then) 0.014%

• Lifetime Ideator rate 1.18%

• Lifetime (40 Yr) rate 0.56%

STUDY 2

COMMUNICATION OF INTENT/ATTEMPTS

• Review: Psychological Autopsy Studies

• Suicides with Prior Communication and Attempts

STUDY 2

Premise:

If an attempt is often a means of communication, then attempts should be considered along with other forms of expression of suicidal intent for the purposes of prediction and understanding.

COMMUNICATION INCLUDES:

• Direct Statements

• Dire Predictions, Allusions to Being Better off Dead, Expressing a Wish to be Dead

PSYCHOLOGICAL AUTOPSY STUDIES

N % Male Age AttemptCommIntent

Attempt &Comm‡

Robins et al. 134 77% Broad 22% - 69%

Wroblenski & McIntosh

112 76% Broad 92%

Rich et al. 283 82% <30/30+ 42/35% - 71/63 %†

Åsgård 104All

female Broad 63% 59% 97%

Runeson 58 72% 15-29 66% 78%

Heila et al. (Schizophrenia)

73 77% Broad 52% 84%

Heila et al. (No Schizophrenia)

1065 77% Broad 55% 70%

† This, assuming that attempts were included (underestimate?).‡ Median = 75%

Thus, on “average” 75% of suicides were preceded by a communication of intent (Range: 63%-97%)• Conservative? All key informants?

• Conservative? Drop low scores?

• Liberal? Retrospective bias?

• Not a predictive value (how many communicators complete?

Studies Lifetime Year 1Post Yr 1(per year)

Sakinofsky (2000) 28 1.61% .47%

Owens et al. (2002) 90 1.80% .47%

Maris (1992) 10-15%

PROPORTION OF ATTEMPTERS WHO COMPLETE

ESTIMATING THE PROPORTION OF COMMUNICATORS WHO COMPLETE

Assume the Ratio of Communicators (Including Attempters) to Attempters Only Among Completed Suicides (1.69) is the Same AmongAll Showing Parasuicidal Behaviour

We Have Estimates of the Interrelationships of:Death Wishes, Ideation, Attempts & Suicides – but Without Communication of Intent…

PREDICTION OF OUTCOMES

  PREDICTED VALUES

PREDICTORS Thoughts PlansCommun.

IntentDeath1st-Yr.

DeathLifetime

DEATH WISH 67.0% 22.8% 17.6% 0.32% 1.76%

 

 

 

PREDICTION OF OUTCOMES

  PREDICTED VALUES

PREDICTORS Thoughts PlansCommun.

IntentDeath1st-Yr.

DeathLifetime

DEATH WISH 67.0% 22.8% 17.6% 0.32% 1.76%

SUICIDALTHOUGHTS

  32.9% 25.4% 0.46% 2.54%

PREDICTION OF OUTCOMES

  PREDICTED VALUES

PREDICTORS Thoughts PlansCommun.

IntentDeath1st-Yr.

DeathLifetime

DEATH WISH 67.0% 22.8% 17.6% 0.32% 1.76%

SUICIDALTHOUGHTS

  32.9% 25.4% 0.46% 2.54%

PLANS   65.1% 1.17% 6.51%

PREDICTION OF OUTCOMES

  PREDICTED VALUES

PREDICTORS Thoughts PlansCommun.

IntentDeath1st-Yr.

DeathLifetime

DEATH WISH 67.0% 22.8% 17.6% 0.32% 1.76%

SUICIDALTHOUGHTS

  32.9% 25.4% 0.46% 2.54%

PLANS   65.1% 1.17% 6.51%

COMMUN.OF INTENT

      5.14% 28.56%

PREDICTION OF OUTCOMES

  PREDICTED VALUES

PREDICTORS Thoughts PlansCommun.

IntentDeath1st-Yr.

DeathLifetime

DEATH WISH 67.0% 22.8% 17.6% 0.32% 1.76%

SUICIDALTHOUGHTS

  32.9% 25.4% 0.46% 2.54%

PLANS   65.1% 1.17% 6.51%

COMMUN.OF INTENT

      5.14% 28.56%

MORTALITY DUE TO SUICIDE(% of All Deaths)

2000 2001 2002 2003

Canada 1.7 1.7 1.7 1.7

Australia 1.8 1.9 1.7 1.7

ARE THERE RISK FACTORS?

• Most cases are captured in Death Wishes

• We need to identify precursors of the first death wish

• We need to know what prevents movement to the next level of intensity

HONING PREDICTION

• Distal prediction is relatively low because of many false positives. Distal nature and absence of negatives make it ideal for population and health promotion approaches

• Proximal prediction is much higher, but late in the game. Lower false positives. Suited for clinical and individually-based services

IMPROVING PREDICTIONMatching Activity & Predictability

1. Primary Prevention

2.Early Detection/Intervention

3.Crisis Intervention / Rx

IMPROVING PREDICTIONMatching Activity & Predictability

1. Primary Prevention Population Focus 1.7%

2.Early Detection/Intervention

3.Crisis Intervention / Rx

IMPROVING PREDICTIONMatching Activity & Predictability

1. Primary Prevention Population Focus 1.7%

2.Early Detection/InterventionDeath Wish/ Ideation 1.7% - 2.5%

3.Crisis Intervention / Rx

IMPROVING PREDICTIONMatching Activity & Predictability

1. Primary Prevention Population Focus 1.7%

2.Early Detection/InterventionDeath Wish/ Ideation 1.7% - 2.5%

3.Crisis Intervention / RxPlans/Communication 6.5% - 29%

IMPROVING PREDICTIONProblem Synthesis

• Social problems are interrelated: Common base?

• Preventing one will prevent others

• Common Underlying Factors

Childhood Trauma Brain Development

Substance Abuse Secure Attachment

Neglect / Abuse

Heredity (Serotonin)

Optimism / Helplessness

IMPROVING PREDICTIONAdding Risk/Protective Factors

• Focus on PrecursorsChildhood Trauma Brain DevelopmentSecure Attachment Neglect / Abuse

Punishment as Suppressant

• Focus on Trajectory ModifiersCoping Strategies Social SupportGene Action TreatmentRandom Acts Transitions

WHEN I GET TO BE DICTATOR …

For More Information:

Angus H ThompsonDept of Public Health, Flinders University

angus.thompson@flinders.edu.au

www.socialproblemindex.com

Many Thanks

Serotonin Transporter GeneExperience in Early Life - Depression

Age 26

No Abuse Moderate Abuse Severe Abuse

.30

.50

.70

A. Caspi, Science, 18 July 2003, Vol 301.

Depression Risk

LL

SS

SL

S = Short Allele L = Long Allele

Founders Network

The frequency of acknowledgement of each level of suicidal behaviour

NoneDeathWish

Ideation Plan Attempt

Total 108 (48%) 115 (51%) 80 (35%) 26 (12%) 12 (5%)

MostSerious

108 (48%) 38 (17%) 52 (23%) 16 (7%) 12 (5%)

RESULTS