suicide by dr. hisham afaneh
TRANSCRIPT
Suicide AssessmentNajran Armed forces Hospital programme
Continues medical education Programme
Psychiatric department
March 28, 2010
Hisham Afaneh, MD
Jordanian Board of Psychiatry ,
Definition of suicide
Suicide is a verdict or a category of death which is broadly defined by the following requirements:
the death was unnatural It was the result of the victim`s own
actionThe victim intended of kill him self suicide (beck)A willful self- inflicted life threatening act
which has resulted in death.
Definition of self-harm
``Deliberate self-injury`` substituted for `` attempted suicide`` because many patients performed their acts in the belief that they were comparatively safe.(kessel)
Parasuicide refers to a behavior analogue of suicide but without considering a psychological orientation towards death being in anyway essential to the condition(kreitman)
Types of suicide Euthanasia and assisted suicide Murder-suicide Suicide attack Mass suicide Suicide pact Metaphorical suicide
Suicide-More Background10th leading cause of death worldwide with
about a million people dying by suicide annually
11th leading cause of death in 2000 (28,322) 2005 suicides in the U.S. outnumber homicides
by nearly 2 to 1,China, India and Japan may account for 40%
of all world suicides3rd leading cause of death for 15-24 year olds,
5th leading for 5-14 years old.1.3% of all deaths are from suicide (double the
rate of AIDS).Males 4x more likely to commit suicide.Estimates suggest that between 8-25
unsuccessful attempts for every successful.
Epidemiology of suicide (1)
Lithuania (42 suicides per 100,000)
Japan (23.8) China (13.9), 13 (per 100,000) and that
for women 14.8
Spain (8.2), UK (6.9)Islamic & Arab countries Iran (2),Libanon (1)
Kuwait, (2) Egypt (0)
Jordan (0) (0.23)
Epidemiology of suicide (2)
Age :- incidence increased e age 47% of male suicide over 45 years 21% Increased in suicide over 65 y 20% increased in suicide ~ 15-19 y Sex :- Male <female for all age groups suicidal attempt more common than female Marital status :- highest ( Divorced &widowed) Urban < rural area Seasonal highest in spring& lowest in winter Social class : 1, V Religion : catholic > protestants and Jews Occupation :- doctors , lawyer and musicians unemployed
Profile of the Suicide
30,000 suicides per year in the US
0.01% annual incidence rate (11.4/100,000)
80% suicides are in males (4:1 m/f ratio)
Third leading cause of death in the 15-24 age
group representing 20% of suicides
Associated with severe depression
Majority not in mental health treatment
75% have seen a physician in previous six months
No one factor predictive of suicide
60% suicide on first attempt
No medication has ever been proven to cause suicide
Accutane FDA (PRI 006 Jacobs) 10
Definitional Issues - Suicidal BehaviorSuicidal Ideation:
– A) nonspecific -- thoughts of death
– B) specific -- the thought of death includes an intent to die with a plan of action
Prevalence of suicidal ideation = 2.6%
Thoughts of death = 28.2%
Suicidal ideation (definition B) is associated with a psychiatric disorder, primarily depression
Suicide Attempts: – A) (U.S.) Potential or actual self-
injurious behavior accompanied by intent to die
– B) (Europe) Parasuicide -- a self-harmful act with nonfatal outcome -- intent not included in definition
(U.S.) Current prevalence estimates: 0.3 to 0.8%– Male/Female ratio 1:3 (inverse
of suicides)– Attempts/completion 18/1
Higher incidence of attempts in 15-24 age population: 100/1 (parasuicide)
Serious suicide attempts indicative of severe psychiatric illness
Methods of suicide Non-violent (drugs and poison) Violent which are more commonly by men and mentally ill. In U.k suicide by hanging and by poisoning with vehicle exhaust
fume account for 2 in 3 male suicide but only 1 in 3 women IN USA Firearms account for 55-60% of suicides (Baker 1984, Sloan 1990). Firearms at home increase risk for adolescents: Guns are twice as likely to be found in the homes of suicide
victims as in the homes of attempters (Brent et al 1991) Type of gun (handgun, rifle, etc.) was not statistically correlated
with increased risk for suicide
Risk management point: Inquire about firearms when indicated and document instructions and response
SUICIDE PREDICTION vs .SUICIDE ASSESSMENT
• Suicide Prediction refers to the foretelling of whether suicide will or will not occur at some future time, based on the presence or absence of a specific number of defined factors, within definable limits of statistical probability
• Suicide (risk) Assessment refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail. Risk assessment carried out in a systematic, disciplined way is more than a guess or intuition – it is a reasoned, inductive process, and a necessary exercise in estimating probability over short periods.
SUICIDE: A MULTI-FACTORIAL EVENT
Neurobiology
Severe MedicalIllness
Impulsiveness
Access To Weapons
Hopelessness
Life Stressors
Family History
SuicidalBehavior
Personality Disorder/Traits
Psychiatric IllnessCo-morbidity
Psychodynamics/Psychological Vulnerability
Substance Use/Abuse
Suicide
Areas to Evaluate in Suicide Assessment
Psychiatric Illnesses
Comorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders.
History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness
Individual strengths / vulnerabilities
Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain
Psychosocial situation
Acute and chronic stressors; changes in status; quality of support; religious beliefs
Suicidality and Symptoms
Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation
Adapted from APA guidelines, part A, p. 4
PROTECTIVE FACTORS
Children in the home, except among those with postpartum psychosis
Pregnancy
Deterrent religious beliefs
Life satisfaction
Reality testing ability
Positive coping skills
Positive social support
Positive therapeutic relationship
DETERMINATION OF RISK
Psychiatric Examination
Risk Factors Protective
Factors Specific Suicide
Inquiry Modifiable Risk
Factors
Risk Level: Low, Med., High
RISK FACTORS (blue = modifiable)
Demographic male; widowed, divorced, single; increases with age; white
Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access
Psychiatric psychiatric diagnosis; comorbidity
Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system
Psychological Dimensions
hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism
Behavioral Dimensions
impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt
Cognitive Dimensions
thought constriction; polarized thinking
Childhood Trauma sexual/physical abuse; neglect; parental loss
Genetic & Familial family history of suicide, mental illness, or abuse
COMPONENTS OF SUICIDE ASSESSMENTAppreciate the complexity of suicide /
multiple contributing factorsConduct a thorough psychiatric
examination, identifying risk factors and protective factors and
distinguishing risk factors which can be modified from those which cannot
Ask directly about suicide; The Specific Suicide Inquiry
Determine level of suicide risk: low, moderate, high
Determine treatment setting and planDocument assessments
SUICIDE RISKS IN SPECIFIC DISORDERS
Prior suicide attempt 38.4 0.549 27.5Eating disorders 23.1Bipolar disorder 21.7 0.310 15.5Major depression 20.4 0.292 14.6Mixed drug abuse 19.2 0.275 14.7Dysthymia 12.1 0.173 8.6Obsessive-compulsive 11.5 0.143 8.2Panic disorder 10.0 0.160 7.2Schizophrenia 8.45 0.121 6.0Personality disorders 7.08 0.101 5.1Alcohol abuse 5.86 0.084 4.2Cancer 1.80 0.026 1.3
General population 1.00 0.014 0.72
Condition RR %/y %-Lifetime
Adapted from A.P.A. Guidelines, part A, p. 16
COMORBIDITY
In general, the more diagnoses present, the higher the risk of suicide.
Psychological Autopsy of 229 Suicides44% had 2 or more Axis I diagnoses31% had Axis I and Axis II diagnoses50% had Axis I and at least one Axis III
diagnosisOnly 12 % had an Axis I diagnosis with no
comorbidityHenriksson et al, 1993
AFFECTIVE DISORDERS AND SUICIDE
High-Risk Profile: ( 15%)• Suicide occurs early in the course of illness• Psychic anxiety or panic symptoms• Moderate alcohol abuse• First episode of suicidality • Hospitalized for affective disorder secondary
to suicidality• Risk for men is four times as high as for
women except in bipolar disorder where women are equally at risk
SCHIZOPHRENIA AND SUICIDE
High-Risk Profile: Previous suicide attempt(s) Significant depressive symptoms - hopelessness Young ,Male gender, single First decade of illness – (however, rate remains
elevated throughout lifetime 6-10%) high previous premorbid functioning or educational attainment
Current substance abuse Poor current work and social functioning Recent hospital discharge
15% of alcoholics kill themselves
Suicide occurs later in the course of the illness with communications of suicidal intent lasting several years
In completed suicides, men have higher rates of alcohol abuse, women have higher rates of drug abuse
Increased number of substances used, rather than the type of substance appears to be important
Most have comorbid psychiatric disorders, females have Borderline Personality Disorder
High Risk Profile: Recent or impending interpersonal loss Comorbid depression
ALCOHOL / SUBSTANCE ABUSE AND SUICIDE
PERSONALITY DISORDERS AND SUICIDE
Borderline Personality Disorder Lifetime rate of suicide - 8.5% With alcohol problems -19% With alcohol problems and major affective disorder -38%
(Stone 1993). A comorbid condition in over 30% of the suicides. Nearly 75% of patients with borderline personality disorder
have made at least one suicide attempt in their lives.
Antisocial Personality disorder 5% Suicide associated impulsivity. 3x risk of suicide than G.P
Family history of abuse, violence, or other self-destructive behaviors place individuals at increased risk for suicidal behaviors (Moscicki 1997, van der Kolk 1991).
Histories of childhood physical abuse and sexual abuse, as well as parental neglect and separations, may be correlated with a variety of self-destructive behaviors in adulthood (van der Kolk 1991).
FAMILY PSYCHOPATHOLOGY
FAMILY HISTORY/GENETICS
Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal
subjects.
Twin studies indicate a higher concordance of suicidal behavior between identical rather than
fraternal twins.
Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives .
Suicide appears to be an independent, inheritable risk factor.
(Baldessarini, to be published)
PSYCHOSOCIAL SITUATION:LIFE STRESSORS
Recent severe, stressful life events associated with suicide in vulnerable individuals (Moscicki 1997).
Stressors include interpersonal loss or conflict, economic problems, legal problems, and moving (Brent et al 1993b, Lesage et al 1994, Rich et al 1998a, Moscicki 1997).
High risk stressor: humiliating events, e.g., financial ruin associated with scandal, being arrested or being fired (Hirschfeld and Davidson 1988) – can lead to impulsive suicide.
Identify stressor in context of personality strength, vulnerabilities, illness, and support system.
All studies are reviews
Social variable
Emile Durkheim states that we must understand the relationship between
individual and society.Egoistic suicide: suicide of isolated
individual.(single)Altruistic: over involvement with society.
Suicide undertaken on behalf of the group.Anomic: when society fails to regulate its
members (adolescent rejected by peer group, farmer ruined by economic structure)
Fatalistic: excessive regulation (e.g., prisoners, slaves)
Biochemical variable
Dysfunction of monoaminergic neurotransmission ( serotonergic and noradrenergic systems)
low 5 HIAA Concentration IN C.S.F ( most consistent finding in patient with completed suicides)
Post mortem ligand binding – increased nr. Of 5 HT receptors in prefrontal cortex
and hippocampus Abnormalities of opoid receptors
( increased destroy ) and abnormalities of N/A ( decreased alpha 1 cortical N/A
density)
Firearms account for 55-60% of suicides (Baker 1984, Sloan 1990).
Firearms at home increase risk for adolescents:• Guns are twice as likely to be found in the homes of suicide
victims as in the homes of attempters (OR 2.1) or in the homes of control group (OR 2.2) (Brent et al 1991)
• Type of gun (handgun, rifle, etc.) was not statistically correlated with increased risk for suicide
Risk management point: Inquire about firearms when indicated and document instructions and response.
PSYCHOSOCIAL SITUATION:FIREARMS AND SUICIDE
Explanations for Suicide
PsychologicalFreud: Suicide is murder turned around
180 degrees. Person identifies themselves with a lost person or object.
They become angry at loss and turn their anger inward.
INDIVIDUAL STRENGTHS/ VULNERABILITIES:PSYCHODYNAMICS FROM MENNINGER
Menninger KA. “Psychoanalytic Aspects of Suicide” International Journal of Psychoanalysis. 14 (1933) 376-390.
Believed that suicide could be understood through the interplay of three internal wishes:
• Wish to kill• Wish to be killed• Wish to die
DIRECT QUESTIONING ABOUT SUICIDE:THE SPECIFIC SUICIDE INQUIRY
Ask About:Suicidal ideationSuicide plans
Give Added Consideration to:Suicide attempts (actual and aborted)First episode of suicidality (Kessler
1999)HopelessnessAmbivalence: a chance to intervenePsychological pain history
Jacobs (1998)
COMPONENTS OF SUICIDAL IDEATION
Intent:Subjective expectation and desire for a self-destructive act to
end in death.Lethality:
Objective danger to life associated with a suicide method or action. Lethality is distinct from and may not always
coincide with an individual’s expectation of what is medically dangerous.
Degree of ambivalence - wish to live, wish to die
Intensity, frequency
Rehearsal/availability of method
Presence/absence of suicide note
Deterrents (e.g. family, religion, positive therapeutic relationship, positive support system - including work)
Beck et al. (1979)
Circumstances suggesting high suicidal risk
Planning in advance - telling other about their intent
Giving away beloved objects.Changes in eating or sleeping habits.Displaying a sense of calmness after a
period of agitation.Precaution to avoid discoveryCarried out alone No attempts to obtain help of othersViolent methodsFinal act (suicide
PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SUICIDE
HopelessnessImpulsivity / AggressionAnxietyCommand hallucinations
PSYCHIATRIC SYMPTOMATOLOGY:IMPULSIVITY / AGGRESSION
May contribute to suicidal behaviorIt is important to assess level of
impulsiveness when assessing for suicidality (Sher 2001, Fawcett et al,
in press)Suicide attempters may be more likely
to present traits of impulsiveness / aggression regardless of psychiatric
diagnosis (Mann et al 1999).Important in assessing risk of murder-
suicide
PSYCHIATRIC SYMPTOMATOLOGY:
ANXIETY Anxiety symptoms (independent of an anxiety
disorder) associated with suicide risk: Panic Attacks Severe Psychic Anxiety (subjective anxiety) Anxious Ruminations Agitation
In a review of inpatient suicides 79% met criteria for severe or extreme anxiety or agitation
PSYCHIATRIC SYMPTOMATOLOGY:COMMAND HALLUCINATIONS
Existing studies are too small to draw conclusions, patients with command hallucinations may not be at greater risk, per se, than other severely psychotic patients.
However, the majority of patients with suicidal command hallucinations should be considered seriously suicidal
Management of patients with chronic command hallucinations requires consultation and documentation
Adapted from A.P.A. Guidelines, Part A, p. 20-21
DETERMINATION OF THE LEVEL OF RISK
Clinical judgment based upon consideration of relevant risk factors, present episode of illness, symptoms,
and the specific suicide inquiry.
Seek consultation / supervision as needed
Suicide risk will need to be reassessed at various points
throughout treatment, as a patient’s risk level will wax and wane.
DETERMINE TREATMENT SETTING AND PLAN
Attend to issue of patient’s safety.
Assess treatment plan/setting/alliance.
Somatic treatment modalities:ECT – used to treat acute suicidal behaviorBenzodiazepines – may reduce risk by treating anxietyAntidepressantsLithium, AnticonvulsantsAntipsychotics, recent study on Clozapine
Psychotherapeutic intervention – widely viewed as helpful for suicidal patients, evidence is limited
Provide education to patient and family.
Monitor psychiatric status and response to treatment.
Reassess for safety and suicide risk frequently.
SOMATIC TREATMENTS
ECT Evidence for short-term reduction of suicide, but not long-term.
Benzodiazepines May reduce risk by treating anxiety
Antidepressants A mainstay treatment of suicidal patients with depressive illness / symptoms. No conclusive evidence of suicide reduction
Lithium and Anti-convulsants
Lithium has a demonstrated anti-suicide effect; anticonvulsants do not
Antipsychotics Evidence for Clozapine reducing suicidality in schizophrenia and schizo-affective disorders
Psychotherapy Regardless of theoretical basis, key
element is a positive and sustaining therapeutic relationship
Recommended (primarily from clinical consensus)
To target issuesDenial of symptomsLack of insight
To manage high risk symptomsHopelessnessAnxiety
Effective treatment in high risk diagnosesDepressionPersonality disorders (use of D.B.T.)
Adapted from APA Guidelines, Part A, p. 40
SUICIDE CONTRACTS
Problems:•Commonly used, but no studies
demonstrating ability to reduce suicide.•Not a legal document, whether signed or
not.•Used pro-forma, without evaluation by
psychiatrist.
Possibilities:•Useful when there is positive therapeutic
relationship (do not use when covering for colleague).
•If employed, outline terms in patient’s record.
•Useful when they emphasize availability of clinician.
•Rejection of contracts have significance.
Bottom line – still considered within standard of care but usage should be
“shrinking”
At first psychiatric assessment or admission.
With occurrence of any suicidal behavior or ideation.
Whenever there is any noteworthy clinical change.
For inpatients:• Before increasing privileges/giving passes• Before discharge
The issue of firearms:• If present - document instructions• If absent - document as pertinent negative
WHEN TO DOCUMENT SUICIDE RISK ASSESSMENTS
WHEN A SUICIDE OCCURS
Despite best efforts at suicide assessment and treatment, suicides can and do occur in
clinical practice
Approximately, 12,000-14,000 suicides per year occur while in treatment.
To facilitate the aftercare process:Ensure that the patient’s records are
complete
Be available to assist grieving family members
Remember the medical record is still official and confidentiality still exists
Seek support from colleagues / supervisors
Consult risk managers
WHAT TO DOCUMENT IN A SUICIDE ASSESSMENT
Document:• The risk level• The basis for the risk level• The treatment plan for reducing the risk
Example: This 62 y.o., recently separated man is experiencing his first
episode of major depressive disorder. In spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of his serious suicide attempt and his continued anxiety and hopelessness. The plan is to hospitalize with suicide precautions and medications, consider ECT w/u. Reassess tomorrow.
References
Jacobs DG, ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA. Jossey-Bass Publisher, 1998.
Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. American Journal of Psychiatry (Suppl.) Vol. 160, No. 11,
November 2003