Suicide can be prevented?Presented by: Hani HamedAssist. Prof. of PsychiatryActing Head, Psychiatry Department,Beni-Suef UniversitySupervisor of Psychiatry Department ,El-Fayoum UniversityMember of American Psychiatric AssociationAlex,May, 2013
World Suicide Prevention Day September 10 is World Suicide Prevention Day, aday not widely celebrated or even known about. According to WHO, every year approximately onemillion people worldwide commit suicide--almostone death every 40 seconds. Suicide rates are reported to be rising steadily indeveloping countries, primarily amongst thosebetween the ages of (15 – 44).
U.S. Suicide Statistics Average of 83 suicides per day* 8thleading cause of death for males, 19thleading cause for females 4 times more men than women die by suicide Highest suicide rates (73%) in the U.S. = white men over age 85 3 times more women than men report a history of attempted suicide Leading method of suicide = firearmsSource: National Institute of Mental Health*Suicide Prevention Resource Center – U.S. Suicide Prevention Fact Sheet
■ 850,000 suicides per year worldwide920,000 deaths caused by malaria■ The suicide risk in depressed patients is up to 30-times higher than in the general population■ 30 to 50 % of suicide attempts are due to depression■ Approximately 15% of severely depressed patientsdie by suicideSuicidesChallengesMajor lethal risk !WHO 2009
Angst et al, 2002Zurich Cohort, N=147 deaths1959 -1997Cardio-vascularvascularAccidents SuicideNeoplasmp <0.01Cerebro-vascularp <0.01Otherp <0.01All causesp <0.010510152025303540 p <0.01UntreatedTreated(%)Challenges
Suicide in Egypt As for Egypt, it is reported to have an annualsuicide rate of less than 6.5 per 100,000--orfewer than 5070 deaths by suicide each year. Exactly how many Egyptians do commit suicideeach year? Estimates are available, but thereare no definitive statistics.
Introduction About 90% of suicides occur in persons witha clinically diagnosable psychiatric disorder.
Introduction Evidence pertaining to potential anti-suicidaleffects of various psychotropic drugs onsuicide risk has been strikingly limited aswell as inconsistent and inconclusive. Particularly surprising, there is onlyinconsistent evidence that antidepressantsmay help prevent suicides.
Terminology and definitions insuicide research Suicide: the act of intentionally ending ones own life. Nonfatal suicidal thoughts and behaviors:– suicide ideation: thoughts of engaging in behaviorintended to end ones life– suicide plan: the formulation of a specific method throughwhich one intends to die– suicide attempt: engagement in potentially self-injuriousbehavior in which there is at least some intent to die.– Nonsuicidal self-injury : self-injury in which a person hasno intent to die
Suicide can be prevented While some suicides occur without any outwardwarning, most do not. The most effective way to prevent suicide amongloved ones is to learn how to recognize the signs ofsomeone at risk, take those signs seriously andknow how to respond to them. The emotional crises that usually precede suicideare most often both recognizable and treatable.
Demographic factors– Suicide: male, an adolescent or older adult, non-HispanicWhite or Native American (in the US)– Suicidal behaviors: female, younger, unmarried, havinglower educational attainment, unemployed Psychiatric factors– Mood, impulse-control, alcohol/substance use, psychotic,personality disorders Psychological factors– Hopelessness , anhedonia, impulsiveness .Risk Factors
Biologic factors– disruptions in the functioning of serotonin Stressful life events– Diathesis-stress model– family conflicts, legal problems, child maltreatment Other factors: access to lethal, chronic or terminal illness,…Risk Factors
Family history of abuse, violence, or other self-destructive behaviors place individuals at increasedrisk for suicidal behaviors (Moscicki 1997, van derKolk 1991). Histories of childhood physical abuse and sexual abuse,as well as parental neglect and separations, may becorrelated with a variety of self-destructive behaviorsin adulthood (van der Kolk 1991).FAMILY PSYCHOPATHOLOGY
PSYCHOSOCIAL SITUATION:LIFE STRESSORS Recent severe, stressful life events associated withsuicide in vulnerable individuals (Moscicki 1997). High risk stressor: humiliating events, e.g., financialcrisis, being arrested or being fired (Hirschfeld andDavidson 1988) – can lead to impulsive suicide. Identify stressor in context of personality strength,vulnerabilities, illness, and support system.
RISK FACTORS (Yellow= modifiable)Demographic male; widowed, divorced, single; increases with age; whitePsychosocial lack of social support; unemployment; drop in socio-economicstatus; firearm accessPsychiatric psychiatric diagnosis; comorbidityPhysical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease;hemodialysis; systemic lupus erthematosis; pain syndromes;functional impairment; diseases of nervous systemPsychologicalDimensionshopelessness; psychic pain/anxiety; psychological turmoil;decreased self-esteem; fragile narcissism & perfectionismBehavioralDimensionsimpulsivity; aggression; severe anxiety; panic attacks; agitation;intoxication; prior suicide attemptCognitiveDimensionsthought constriction; polarized thinkingChildhood Trauma sexual/physical abuse; neglect; parental lossGenetic & Familial family history of suicide, mental illness, or abuse
Protective Factors• Children in the home, except among those withpostpartum psychosis• Pregnancy• Religious beliefs, religious practice, and spirituality• Moral objections to suicide• Life satisfaction• Reality testing ability• Positive coping skills• Positive social support• Positive therapeutic relationship
SUICIDE: A MULTI-FACTORIAL EVENTNeurobiologySevere MedicalIllnessImpulsivenessAccess To WeaponsHopelessnessLife StressorsFamily HistorySuicidalBehaviorPersonalityDisorder/TraitsPsychiatric IllnessCo-morbidityPsychodynamics/Psychological VulnerabilitySubstanceUse/AbuseSuicide
Areas to Evaluate in SuicideAssessmentPsychiatricIllnessesComorbidity, Affective Disorders, Alcohol / Substance Abuse,Schizophrenia, Cluster B Personality disorders.History Prior suicide attempts, aborted attempts or self harm; Medicaldiagnoses, Family history of suicide / attempts / mental illnessIndividualstrengths /vulnerabilitiesCoping skills; personality traits; past responses to stress; capacityfor reality testing; tolerance of psychological painPsychosocialsituationAcute and chronic stressors; changes in status; quality of support;religious beliefsSuicidality andSymptomsPast and present suicidal ideation, plans, behaviors, intent;methods; hopelessness, anhedonia, anxiety symptoms; reasons forliving; associated substance use; homicidal ideationAdapted from APA guidelines, part A, p. 4
DETERMINATION OF RISKPsychiatric ExaminationRiskFactorsProtectiveFactorsSpecific SuicideInquiryModifiable RiskFactorsRisk Level:Low, Med., High
DIRECT QUESTIONING ABOUT SUICIDE:THE SPECIFIC SUICIDE INQUIRYAsk About: Suicidal ideation Suicide plansGive Added Consideration to: Suicide attempts (actual and aborted) First episode of suicidality (Kessler 1999) Hopelessness Ambivalence: a chance to intervene Psychological pain historyJacobs (1998)
COMPONENTS OF SUICIDAL IDEATION Intent:Subjective expectation and desire for a self-destructiveact to end in death. Lethality:Objective danger to life associated with a suicidemethod or action. 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 therapeuticrelationship, positive support system - including work)Beck et al. (1979)
WHAT TO DOCUMENTIN A SUICIDE ASSESSMENT Document:• The risk level• The basis for the risk level• The treatment plan for reducing the risk
Suicide Warning SignsDepression or ParanoiaExpresses guilt/shame over offenseStatements about suicide or deathSelf-harm attempts Each attempt should be taken seriously!
Suicide Warning Signs(continued) Severe agitation or aggression Agitation often precedes suicide Suicide can be a possible means to relieve agitation Hopeless/pessimistic about future Extreme concern or anxiety over what will happen tothem Appetite and sleep changes
Suicide Warning Signs(continued)Mood/behavior changes May refuse treatment Withdraws from others, may demand to be celled alone Neglects personal hygiene or appearancePreoccupied with past – doesn’t deal well withpresentPacking/giving away belongings
Suicide Warning Signs(continued) Writes a will Hallucinations and Delusions May hear voices or see visions that tell inmate to harm self
MYTH OR FACT?1. Myth: People who threaten suicide don’t go throughwith itFact: Most people who commit suicide have madedirect or indirect statements about their suicidalintentions2. Myth: Suicide happens suddenly and withoutwarningFact: Most suicidal acts represent a carefully thoughtout strategy for coping with their problems
MYTH OR FACT? (continued)3. Myth: People who attempt suicide have gotten itout of their systemFact: Any individual with one or more prior suicideattempts is at much greater risk than those whohave never attempted suicide4. Myth: Suicidal people are intent on dyingFact: Most suicidal people have mixed feelingsabout killing themselves; they are doubtful aboutliving, not intent on dying. MOST WANT TO BESAVED!
MYTH OR FACT? (continued)5. Myth: Asking offenders about suicidal thoughts oractions will cause them to kill themselvesFact: You cannot make someone suicidal when you arediscussing the possibilities of suicide Concerned, non-judgmental questions encouraging theperson to discuss his/her ideas may help relieve thepsychological pressure6. Myth: All suicidal individuals are mentally illFact: A suicidal person is extremely unhappy but notnecessarily mentally ill; a “normal” person can besuicidal.
Means-restriction programs: can decreasesuicide rates by 1.5–23%. Primary-care physician education and trainingprograms: show reductions of 22–73%. Although effective prevention programs existmany people engaging in suicidal behavior donot receive treatment of any kind.Prevention/intervention programs
Suicide Prevention Training Increase their awareness of suicide and seeprevention opportunities they may otherwise miss. Become more alert to clues and communicationsthat someone may be thinking of suicide. Ask about suicide and respond in ways that showunderstanding and assess risk. Work with persons at risk to increase their safety. Facilitate links with further help from family, friendsand professional helpers as needed.
Treating suicidal individuals• Need to assess suicidal risk and ensure adequatesupervision of attempter•Deal with life crisis swiftly•Therapy focused on building protective factors andreducing risk factors, through a variety of differentapproaches• Encourage open talk about suicidal ideation
Communicating With Suicidal Patients1. Listen Patiently Encourage the person to talk, including about suicide plan1. Trust Your Own Judgment If you believe patient is in danger of suicide, implementsuicide prevention protocols and keep the person in a safeplace
Is Suicide Screening Effective? Still noClear Answer Trying to separate out the large population at risk for suicidefrom those who go on to die by suicide is difficult. Preventive Services Task Force found, there is currently alimited evidence basis for suicide-specific screening. However, It is important to remember that for those primarycare practices that use collaborative care for depression-treatment models, screening for depression is supported bythe task force.Psychiatric News, 2013
Take Home Message…Suicide Prevention EffortsYOU form the bridge of communication with potentiallysuicidal persons by: Observing daily behaviors Interacting with and listening to him Reporting concerns to medical/mental health staffpromptly
Blood Test for Suicide Risk? Suicidal thoughts and behavior may be uniquelylinked to inflammatory markers in patients withmajor depressive disorder (MDD), new researchsuggests. A study of 122 adults in Ireland showed thatthose with MDD and high suicidal ideation hadsignificantly higher levels of inflammation (asshown through blood draws) than both thosewith MDD and low suicidal ideation and healthypeers without MDD.Depression Anxiety. 2013;30:307-314
Blood Test for Suicide Risk? A composite score comprising theproinflammatory cytokines interleukin-6 (IL-6)and tumor necrosis factor–alpha (TNF-α), theanti-inflammatory cytokine interleukin-10 (IL-10), and C-reactive protein (CRP) was used asan inflammatory index. Circulating levels of adrenocorticotropichormone (ACTH) and cortisol were alsomeasured to assess hypothalamic-pituitary-adrenal (HPA) axis abnormalities.Depression Anxiety. 2013;30:307-314
Blood Test for Suicide Risk? Results showed higher inflammatory indexscores for the group with MDD and high suicidalideation compared with the group with MDDand low suicidal ideation (P = .009) andcompared with the control group (P < .001). There were no significant differences betweenany of the groups on ACTH or cortisol levels.Depression Anxiety. 2013;30:307-314