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This is an academic educational presentation given for those studying for MRCPsych (Royal College of Psychiatrists) Part I. It is from 2007, Leicester Partnership Trust. Apologies if this is difficult to follow when read in isolation.
Citation preview
Suicide andSuicide and
Part I - MRC
Alex MConsultant in Liaison
d Self Harm:d Self-Harm:
Psych April 2007
Mitchelln Psychiatry, Leicester.
NHS Statistics
• 13 million first outpatient appointments
• 15 million A&E episodes15 million A&E episodes
• (4 million emergency admissions)
• (5.5 million planned admissions)
• ? Suicides
• ? DSH Episodes
s in secondary care
I: Self-Harm
Tree (nomenclature) of Har
Suicide Attempt
Intent to die
Completed Near Miss Life-Thr
Violent Self-Poisoning
Hanging Paracetamol / Aspirin C
Jumping/RTA Psychotropic/ Trq
AntidepressantAntidepressant
Physical Meds Alc
rmful Behaviours
Self-Harm Attempt Thoughts Alone
No intent to die
reatening Physically Minor
Self-injuryToxic
Cuttingarbon Monoxide g
OtherGas
ohol / Illicit Drugs
Deliberate Self-Harm - EpidDSH Rates in Oxfo
500
600
400
500
300
200
100,
000)
100
e D
SH (p
er
01974 1976 1978 1980 1982 1984 1986
Rat
e
demiologyrd City (1976-1998)
Males
Females
6 1988 1990 1992 1994 1996 1998 2000
Rates of DSH for the Leices
600
400
500
300
400Rate per100 000
100
200
015-24 25-34 35-44 45-5
Age
ster (1997/98)
malefemale
4 55-64 65-74 75-84 85+e group
Data from Leicester (Dennis)
Self-Harm by Time of Day
Data from Leeds
Deliberate Self-Harm - ComC om position of DC om position o f D
30%
15%
25%
mpositionD SH
Borde rlineP e rsona lityD SH P e rsona lity
Alcohol Disinh ition
P sychia tric
5%
P sychia tric
Accide nta l
Fa ile d S uicide
25%
Deliberate Self-Harm - CateDSH and Pa
90
100
70
80
50
60
30
40
10
20
0Single Employed Psychiatric Alco
Abu
egoriesatient Types
Single
Employed
Psychiatric
Alcohol Abuse
PersonalityDisorder
Alcoholic
Drug Abuse
holuse
PersonalityDisorder
Alcoholic Drug Abuse
Deliberate Self-Harm – ReaProblems Repo
90
100
70
80
4350
60
3529
2530
40
20
10
20
0Partner Family Alcohol Employment Finances Isolat
asons Givenorted upon DSH
Partner
Family
AlcoholAlcohol
Employment
Finances
Isolation
Housing
BereavementBereavement
Friends
Physical Health
18 1712 11 9 9
Drugs
tion Housing Bereavement Friends PhysicalHealth
Drugs
Methods of Self-Harm (No.
Paracetamol overdose
Benzodiazepine overdose
Aspirin/non-steroid anti-inflammatory drug overdose
Tricyclic antidepressant overdose
Selective serotonin re-uptake inhibitor overdose
Other antidepressant overdose
Other psychotropic overdose
Other overdose
Deliberate illicit substance overdose
Wrist cutting
Other deliberate self-injury
Non-ingestibles
Carbon monoxide poisoning
Hangingg g
Other
Total no. of episodes of DSH = 934, 241 (26%) involved more than one meth
& % shown)
386 41
160 17
101 11
75 8
50 5
10 1
90 10
205 22
4 0.5
95 10
56 6
15 2
7 1
6 0.5
1 0
Data from Leedshod
Deliberate Self-Harm – RepTime to Repe
45
50
35
40
Aft i iti l t
20
25
30
g Pe
r Yea
r After initial presentwithin one year and
10
15
20
e R
epea
ting
0
5
10
Perc
enta
ge
0
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
petition Rateeat after DSH
CumulativeProportion Repeating
ti ith DSH 10% tation with DSH, 10% repeatd 30%+ within 10 years
r 7Yea
r 8Yea
r 9Yea
r 10
Year 1
1Yea
r 12
Year 1
3
Risk factors for repetition of
Risk factor StudPrevious episode 1-6pPrevious psychiatric care 1, 3, In current psychiatric care 1 Alcohol problems 1, 2, Drug dependence 1, 2, Antisocial personality 1, 2, Crim inal record 3, 6Showed lack of co-operation 2, 7Low social class 3, 6Separated from partner 1 3Separated from partner 1, 3Sex: male 2 female 8* Age: 25-34 years 1*
35-54 years 8* 35 54 years 8Separated from mother before age 15 3 Unemployed 6 Regrets about survival 3 Unprovoked index episode 3 Impulsive self-harm act 1
* factor reported but not statistically significant
f self-harm
ies Key:
1 Kessel & McC lloch 1966 n 511 97 (19%) repeated6
3, 63, 6
1. Kessel & McCulloch, 1966: n=511, 97 (19%) repeated; follow-up 1 year
2. Greer & Bagley, 1971: n=204, 53 (26%) repeated; follow-up 1-2 years
3. Morgan et al, 1976: n=215, 56 (26%) repeated; follow-up3, 6 3. Morgan et al, 1976: n 215, 56 (26%) repeated; follow up 1-2 years
4. Bancroft & Marsack, 1977: n=141, 36 (26%) repeated; follow-up 3 years
5. Wilkinson & Smeaton, 1987: n=1376, 259 (19%) repeated; follow-u 1-2 years
6. Buglass & Horton, 1974: n= 2809, 16% repeated; follow-up 1-2 years
7. Gardner et al, 1982: n=188, 50 (27%) repeated; follow-up 1 yearup 1 year
8. Kreitman, 1976: n=822; follow-up 1 year
Management of self-poisoning
Number of deliberateself-poisoning
PropodischargeHospital self poisoning
episodes in onemonth during 1996
dischargeaccidenemerg
Leeds 101 18%Leeds 101 18%
Leicester 111 55%
M h t 100 71%Manchester 100 71%
Nottingham 165 32%
All Centres 477 43%
From: Kapur N, House A, Creed F, Fe
in 4 teaching hospitals
ortioned from
Proportion dis-charged from A&E
Proportion of patientswho received psycho-ed from
nt andency
without receivingpsychosocialassessment
social assessment atany stage during their
hospital contact
% 15% 65%% 15% 65%
% 21% 68%
% 46% 36%% 46% 36%
% 25% 48%
% 26% 54%
eldman E, Friedman T, Guthrie E. BMJ 1998; 316: 831-2
Recent National Guidance
Hazardous Outcome after
• Suicide– 0.5-1% in 12 months
3% t 8– 3% at 8 years
• Repetition of DSHA 15% i 12 th– Approx. 15% in 12 months
– Most repeats during 3 months of fi
• General Mortality• General Mortality
• Use of psychiatric services– 5-10% admitted to psychiatric unit– 20% outpatients
S b t P hi t i Ill• Subsequent Psychiatric Illness
DSH
irst episode
Data from Leicester (Dennis)
II: Suicide
http://www.nimhe.csip.org.uk/our-work/suicide-prevvention/annual-report-on-progress-2006.html
Table 13.1 Life years lost for those dyspecific type of diseasep yp
Disease category (ICD codes)Heart disease (390-429)Lung cancer (162)Lung cancer (162)Motor vehicle (E180-E189) traffic accidentsBreast cancer (174, 175)Cerbrovascular (430-438) diseaseSuicide (E950) and self-inflicted injury (E959)Chronic obstructive pulmonary disease and alli
conditionsColorectal cancer (153-154)Cervical cancer (180)Pancreatic cancer (157)( )Due to alcohol (100%)*Diabetes mellitus (250)Bladder cancer (188)Diseases of the oesophagus, stomach and
duodenum (530-537)duodenum (530 537)Accidents caused by fire (E890-E899)Homicide and assault (E960-E969Accidental drowning (E910)Prostatic cancer (185)Accidental poisoning (E859 E858)Accidental poisoning (E859-E858)Laryngeal cancer (161)
ICD, International Classification of Diseases, 9* Includes ICD codes 291, 303, 305.0, 425.3, 5
ying before age 65 (1989) ranked by
Male Rank Female Rank450,979 1 165,248 1115 751 3 68 686 3115,751 3 68,686 3123,799 2 40,195 6
429 19 150,282 264,484 5 63,350 482,161 4 24,050 9
ied 47,398 6 42,058 5
44,516 7 38,981 729,651 8
16,619 9 15,284 11, ,23,025 8 15,461 1013,896 10 12,640 1210,156 13 4,816 16
9,242 15 6,254 13
8,845 16 5,700 146,390 17 4,636 17
10,624 12 2,239 1810,942 11
9 783 14 5 168 159,783 14 5,168 154,476 18 1,028 19
th Edition571.0, 571.1, 571.2, 571.3, 980
Suicide Statistics in the UK
• Annual number of Suicides in UK
• Annual number of Homicides in UKAnnual number of Homicides in UK
• Annual number of Suicides in USA
• Annual number of Homicides in USA
• Suicide (all ages) is the
• Suicide in adolescents is the
A l S i id t i• Annual Suicide rate is
5,000
1,0001,000
30,000
15,000
8th commonest cause of death
3rd commonest cause of death
10 100 000 l ti10 per 100,000 population
Suicide Risk FactorsII - DemSuicide and P
90
100
70
80
50
60
30
40
10
20
0Psychiatric Psychotropic GP Visit Depre
mographicsPatient Types
Psychiatric
P h t iPsychotropic
GP Visit
Depressed
Physical Illness
Alcoholic
Schizophrenia
ssed PhysicalIllness
Alcoholic Schizophrenia
Suicide EpidemiologyI - TotSuicide Rate (All Ages) En
140
160
120
on)
80
100
er m
illio
40
60
Rat
e (p
e
20
40
Suic
ide
MalesFemales
01955 1960 1965 1970 1975
S
The suicide rate is much higher men, largely due to the f
talngland & Wales 1960-1998
5 1980 1985 1990 1995 2000fall in the rate in women since 1987
Trend in suicide rate for youung men (aged 20-34)
Suicide EpidemiologyI – ByMale Suicide Rate by Age E450
400
300
350
llion
)
200
250
Rat
e (p
er m
i
150
200
Suic
ide
R
50
100
01955 1960 1965 1970 1975Suicide rates previously increased with age, but now are v
AgeEngland & Wales 1960-1998
65+45-6435-4425-3425-3415-24
1980 1985 1990 1995 2000very similar in men and woman across age groups
Death rates from Intentional seUndetermined Intent 1993-2005
lf-harm and injury of 5 and target for the year 2010,
DSH – Suicide OutcomeSuicide a
18
20
14
16
10
12
6
8
cide
s (%
)
2
4
mul
ativ
e Su
i
00 1 2 3 4 5 6 7 8 9
Years afte
Cu
DSH is an important risk factor for completed suicide, in
after DSH
9 10 11 12 13 14 15 16 17 18 19
er index Episodecreasing the risk about 100 fold
DSH & Suicide Overview
1%
DSH(150,000)
Sui(50
Depressed(30%)
30%
(30%)
GeneralPop’n
0.01%
Depressed
(5%)
icide000)
Depressed
70%
(5%)
d(80%)
Predictors of Poor Outcome
Risk Factor Suicid
History of Previous DSH ☯ ☯History of Previous DSH ☯ ☯
Psychiatric History ☯ ☯
Drug/Alcohol Abuse
Personality Disorder
Unemployment ☯
Lower Social Class / Stability ☯
Physical Illness ☯
Social Isolation ☯ ☯
High Suicidal Intent ☯
e after DSH
de Repeat DSH
☯ ☯ ☯☯ ☯ ☯
☯ ☯ ☯
☯
☯
☯
☯ ☯
☯
Recent warnings about (SSRI’s) in depre
• Committee on Safety of Medicines (y (SSRI’s for depressed children, exce
medicines.mhra.gov.uk/ourworkmonitorsafequalm
• FDA issues Public Health Advice onantidepressants in adults and childantidepressants in adults and childwww.fda.gov/bbs/topics/ANSWERS/2004/ANSO128
essed young people.
(December 2003) contra-indicated all ( )ept fluoxetine.
ed/safetymessages/ssrioverview_101203.pdf
n cautions for use for use of ren March 2004ren. March 2004
83.html
Antidepressants & Suicide
15%
Depression
ant
Suicide per 100,000 “depressed person years” - 141 on- 259 of
If all depressed persons were treated with antidepressan
Suicide
16% on70%
5%
antidepressants
20% ontidepressants
n antidepressantsff antidepressants [RR 1.8]p
nts, suicide rate could be reduced by 2000 deaths per year
risk
Agitation i th
uici
de increases then
decreases
Su
MoodMoodimproves1 2
w
Nutt 2003 Nutt 2003 –– Journal of PsychopharJournal of Psychophar
E i tiEnergization increases
Net effect onNet effect on suicide risk
dd s
3 4weeks
rmacology 17: 4, 355rmacology 17: 4, 355--364364
Antidepressants Prescriptioons & Suicide
What treatments are availab
Antidepressants• Antidepressants– Proven role where depression and/or
anxiety• Problem Solving
– Benefits for depression, anxiety & hopelessness but no effect on repetition
• Priority future treatmentPriority future treatment– ‘Green card studies’ showed no
benefit• Follow-up
S b fit ith d ti f– Some benefit with reduction of repetition
ble ?
• PsychotherapyPsychotherapy– Some suggestion that dialectical behaviour
therapy or IPT may reduce repetition
• Patient based self-helpp– MACT only moderately successful in
reducing repetition (confined to borderline personality disorder)
• GPs– GP guidelines of no significant benefit
Adapted from Original of Mick Dennis
III: Risk and Prediction
Predictive Scales after DSHRepetition after DSH (K
60
70
PercentageRepeating
NumberRepeating
50
on)
Repeating
30
40
s Pr
opor
tio
20
(Num
ber v
s
0
10
Rep
etiti
on
00 1 2 3 4 5
Positive Pr
R
Patients who score highly on the Kreitman & Foster scabut the majority who repeat do not score highly
H - Powerreitman & Foster Scale)
6 7 8 9 10 11 12
redictive itemsale are more likely to repeat,
Predictive Scales after DSH
• Kreitman & Foster DSH Outcome Scale
– Previous Para-suicide– Personality Disorder– Alcohol Abuse– Previous Psychiatric Treatment– Unemployment– Social Class V– Drug Abuse– Criminal Record– Violence– Age 25-54 yrs– Single, Divorced or Separated
∗ Br J Psychiatr (1991)
H - Factors
SAD PERSONS Scale
S SexA AgeD DepressionP Previous AttemptsE Ethanol AbuseR Rational Thinking LossS Social Support LackingO Organised PlanN No SpouseS Sickness
Suicide and depression: hig
• Lifetime risk is 2%– Bostwick J M Pankratz V S (2– Bostwick, J.M., Pankratz, V.S., (2
risk: a reexamination. Am. J. Psy
• Male, older [normal demographics]
• Persistent insomnia [severity]
• Previous act of deliberate self-harm [previou
• Self-neglect [severity]
• Severe Illness [severity]
• ?Impaired memory [severity]?Impaired memory [severity]
• Physical illness [co-morbidity]
• Agitation [co-morbidity]
P i k [ bidi ]• Panic attacks [co-morbidity]
gh risk factors
2000) Affective disorders and suicide2000). Affective disorders and suicide ychiatry 157 (12), 1925– 1932.
us]
Adapted from Original of Mick Dennis
Suicide and schizophrenia:
• Lifetime risk of suicide is 5% – Palmer et al (2005) AGP 62: 247( )
• Male [normal demographics]• Younger [normal demographics]• Unemployed [normal demographics]
• Previous act of deliberate self-harm [previous
• Depressive episodes [co-morbidity]• Anorexia/weight loss [co-morbidity]
• More serious illness [severity]• Recurrent relapse [severity]
• Recent diagnosis, recent discharge• Fear of deterioration, especially in those of hi
high risk factors
s]
gh intellectual ability
Adapted from Original of Mick Dennis
Suicide and alcohol addictio
• Lifetime risk of suicide is 3.4%%Murphy et al (1990) AGP
M l ( k 40 60 ) l d• Male (peak age 40 – 60 years ) normal demog
• High level of dependency [severity]
• Long history of drinking [severity]
• Disruption of major interpersonal relationsh
• Depressed mood [co-morbidity]
P h i l h lth [ bidit ]• Poor physical health [co-morbidity]
• Poor work record in previous four years [nor
• Past DSH history [previous]
on: high risk factors
% %
higraphics
ips [social]
rmal demographics]
Adapted from Original of Mick Dennis
Improving DSH Manageme
• Simple referral form
• Education for A&EEducation for A&E
• Satisfaction survey
• Quality of referral survey
• Prediction of DSH repetition study
ent in Leicester
10-Step Form Study
Frequency of Rep90
90
100 437
70
80
40
50
60
25
10
20
30
0
0 Rep
etitio
ns
1 Rep
etitio
n
2 Rep
etitio
ns
petitions of Self Harm
75 45 4
3 Rep
etitio
ns
4 Rep
etitio
ns
5+ R
epetiti
ons
5
10-Step Form Study
25
17
20
12
14
910
15
5
0
1 Day
2-7 D
ays
8-14 D
ays
15-28
Day
s
29-59
D
8 15 29
23 23
16
13
3Day
s
60-90
Day
s
0-180
Day
s
1-364
Day
s
365 D
ays+
60 90-1
181-3 3
Suicidal Plans or Conditional Threats?
Mood or Perceptions?
Previous Self-Harm?
Difficult Personal History?
Intended to die?
Housing problems?
Past Medical history?
Lack of social support?
Relationship problems?Relationship problems?
Work or Financial problems?
Admission required (if so where)?
Past Psychiatric history?
Psychosis (odd thinking or beliefs)?
Antidote, sutures required?
Dementia (memory, odd behaviour)?
Appearance or Behaviour?
Unusual or risky circumstances?
Cognition or Insight?
Believed method was dangerous/fatal?
Alcohol or Illicit Drug User?
Depression (low interest, self-esteem)?
ICU/ITU R it ti i d?ICU/ITU or Resuscitation required?
Medical Complications or detoxification?
Personality (self-destructive, impulsive)?
Current Suicidal Intent?
Refuses assessment?
Delirium (poor orientation or attention)?
Hopeless or Suicidal Thoughts?
Attempts at concealment or Final acts?
Speech or Thoughts?
4.345013258 1.65638E-05
4.109159234 4.57034E-05
3.441581787 0.000621875
3.116435435 0.001925556
2.642627391 0.008459658
1.583840408 0.113801724
1.369505014 0.171397338
1.276507103 0.202312118
1 189983947 0 2345633231.189983947 0.234563323
1.10905884 0.267886875
0.866449824 0.386619302
0.858214753 0.391145703
0.851262598 0.394990629
0.821525679 0.411700936
0.717845981 0.473154302
0.65807167 0.510764942
0.344064704 0.730928415
0.121893386 0.903027575
0.024546168 0.980425812
0.020860174 0.983364721
-0.044587427 0.964452202
0 11292289 0 910132669-0.11292289 0.910132669
-0.202967858 0.839234812
-0.311688368 0.755394419
-0.419258092 0.675189743
-0.669399303 0.503519167
-1.300189309 0.194075771
-1.658102832 0.097861755
-1.82325173 0.068804974
-1.871696803 0.061774313
Advanced Suicide Intent Sccales
IV: Extras
Mental State Examination
a. Consider whether the patient is of dejected app j p
b. Ask specifically whether the patient is depresday (i.e.. diurnal variation)
c. Does the patient have impaired sleep (difficulwaking?)
d. Is the patient experiencing feelings of guilt, u
e. Is the patient suffering impaired appetite with
f. Ask specifically about suicidal thoughts and
g. Is the patient pessimistic about his or her abi
h. Is another psychiatric syndrome present?
ppearance, agitated, restless or depressed.pp g p
ssed on waking and whether the mood lifts during the
lty in getting off to sleep, frequent or early morning
nworthiness or self-blame?
h weight loss?
intentions?
lity to resume and cope with normal life?
Adapted from Original of Mick Dennis
How to Take a DSH History
a. What were the precipitating events?
b. What were the motives for the act?
c. What were the circumstances of the act?
d. Were any precautions taken against discovery?y p g y
e. Were there any preparatory acts, e.g.. procuring meanote?
f. How violent was the method?
g. How lethal (potentially) were the drugs or poison use
h. Have there been symptoms of depression, such as li
i. Is there any sign of the use or abuse of alcohol (whic
y
ans, putting affairs in order, warning statements or suicide
ed?
istlessness or social withdrawal, preceding the act?
ch is a depressant and also a disinhibitor)?
Adapted from Original of Mick Dennis
Deliberate Self-Harm (DSH) in the e
• Usually failed serious suicide bids
• 90% self-poisoning– commonly analgesics & benzodiazepine
lderly
• Depression approx. 90%
• 2/3 physical illnesses • high suicide intent scores
• previous psychiatric history 30-55%
i lf h 30 40%• previous self-harm 30-40%
• high rates of subsequent suicide, especially those with persistent depression
Adapted from Original of Mick Dennis