Author: Michael Jibson, M.D., Ph.D., 2009License: Unless otherwise noted, this material is made available under the terms ...
Citation Key                              for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share +...
Suicide         M2 Psychiatry SequenceMichael JibsonFall 2008
“The moment one inquires about the sense of  value of life, one is sick.”                                 Sigmund Freud
EpidemiologyUS Suicide Data (2004)•  Annual rate is 11.1 suicides per 100,000•  >32,000 deaths annually•  15th leading cau...
US Suicide Statistics (2004)                                                                               RateGroup      ...
US Suicide Statistics                                                                               RateGroup             ...
National Institute of Mental Health
Prevalence Rates for Subpopulations•  Age: Highest rates among elderly•  Gender: Men complete suicide 3-4x more often   th...
Prevalence Rates for SubpopulationsProfession•  Highest rates for professions that deal with death   and violence, and tha...
Methods for SubpopulationsCompleted Suicides•  Firearms most common method for men and   women in the U.S. (57%)•  Hanging...
Lethality of Means            Most Lethal 90%    Firearms                        70%    Falls                        50%  ...
Recent Trends and their           Public Health Implications•  Increases among young and women•  Increases in suicide by f...
Suicide Rates for Various Nations•  U.S. has a moderate suicide rate relative to other   nations•  Hungary has the highest...
Previous Attempt and Help Seeking Histories•  30-40% of completers have attempted suicide   before•  Nearly two-thirds of ...
Clinical Risk FactorsMental/Psychiatric Disorders•  Depression•  Alcohol/Drug Abuse•  Schizophrenia•  Other Psychiatric Di...
Depression•  >50% clinically depressed at time of suicide•  Nearly 15% of persons with significant mood   disorders will c...
Alcoholism/Drug Abuse•  Nearly one-third of suicides occur in persons with   chronic alcoholism•  2-4% of chronic alcoholi...
Schizophrenia•  5-10% of schizophrenic patients commit suicide•  In general population studies, schizophrenia   accounts f...
Other Disorders•  Other mental disorders increase risk to   5-10%•  Serious physical illness increases risk
Social Isolation/        Interpersonal Loss or Conflict•  Among alcoholics who commit suicide, 50% have   a history of int...
Social Isolation/           Interpersonal Loss or Conflict•  Among adolescents & young adults, interpersonal   conflict an...
Suicidal IndicesSuicidal Ideation•  Passive – no plan or intent   •  I wish I were dead   •  I wish I could just go to sle...
Suicide Indices•  History of attempts (esp if highly lethal)    •  Highest predictive value in past 2 months    •  Suicide...
Suicide Indices•  Final arrangements   •  Will   •  Suicide note   •  Giving away possessions
Current Mental Status•  Hopelessness•  Acute agitation•  Intoxication•  Psychosis (especially with command   hallucination...
Summary of Risk FactorsDemographic      Psychiatric         Mental Status       OtherOlder            Depression          ...
Clinical Assessments/InterventionsGeneral Principles of Intervention•  Recognize the "cry for help" or the expressed   sui...
Clinical Assessments/InterventionsGeneral Principles of Intervention•  Do not alienate the patient with sarcasm, ridicule,...
Clinical Assessments/InterventionsGeneral Principles of Intervention•  Always seek corroborative information  •  Family an...
Clinical Assessments/InterventionsClinical Decision Making•  Gather as much information as possible•  Carefully assess the...
Clinical Assessments/InterventionsClinical Decision Making•  Assess and discuss reasons for living•  Involve family or fri...
Clinical Assessments/Interventions•  Hospitalize if:  •  An attempt is clinically serious  •  Risk factors suggest high ri...
Clinical Assessments/Interventions•  Consider outpatient care if:  •  Risk is relatively low  •  Stressors can be immediat...
Myths•  People who talk about suicide wont commit suicide•  People who want to commit suicide won’t tell you•  Suicide hap...
Additional Source Information                                   for more information see: http://open.umich.edu/wiki/Citat...
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10.30.08(c): Suicide

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10.30.08(c): Suicide

  1. 1. Author: Michael Jibson, M.D., Ph.D., 2009License: Unless otherwise noted, this material is made available under the terms of theCreative Commons Attribution–Share Alike 3.0 License:http://creativecommons.org/licenses/by-sa/3.0/We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adaptit. The citation key on the following slide provides information about how you may share and adapt this material.Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, orclarification regarding the use of content.For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use.Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medicalevaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about yourmedical condition.Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  2. 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation LicenseMake Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Suicide M2 Psychiatry SequenceMichael JibsonFall 2008
  4. 4. “The moment one inquires about the sense of value of life, one is sick.” Sigmund Freud
  5. 5. EpidemiologyUS Suicide Data (2004)•  Annual rate is 11.1 suicides per 100,000•  >32,000 deaths annually•  15th leading cause of death overall•  3rd leading cause of death at ages 10-24
  6. 6. US Suicide Statistics (2004) RateGroup Number (per 100,000) % of DeathsUS Population 32,439 11.1 1.4Male 25,566 17.7 2.2Female 6,873 4.6 0.6White 29,251 12.3 1.4Black 2,019 5.2 0.7Nonwhite 3,188 5.8 0.9Elderly (>65 yrs) 5,198 14.3 0.3Young (15-24 yrs) 4,316 10.4 12.9 State of Connecticut Department of Mental Health and Addiction Services
  7. 7. US Suicide Statistics RateGroup Number (per 100,000)White Male 23,081 19.6White Female 6,170 5.1Black Male 1,655 9.0Black Female 364 1.8Nonwhite Male 2,485 9.3Nonwhite Female 703 2.4State of Connecticut Department of Mental Health and Addiction Services
  8. 8. National Institute of Mental Health
  9. 9. Prevalence Rates for Subpopulations•  Age: Highest rates among elderly•  Gender: Men complete suicide 3-4x more often than women; however, women attempt suicide 3x more often than men•  Race: Whites have highest rate; African Americans the lowest•  Region: Highest rates in Mountain States (inc Alaska)
  10. 10. Prevalence Rates for SubpopulationsProfession•  Highest rates for professions that deal with death and violence, and that have access to lethal means •  Physicians (men & women: 38/100,000) •  Police officers •  Military personnel
  11. 11. Methods for SubpopulationsCompleted Suicides•  Firearms most common method for men and women in the U.S. (57%)•  Hanging second most common for men•  Toxic ingestion (poison, drug overdose) second most common for women
  12. 12. Lethality of Means Most Lethal 90% Firearms 70% Falls 50% Hanging 10% Ingestion Least Lethal <1% CuttingM. Jibson
  13. 13. Recent Trends and their Public Health Implications•  Increases among young and women•  Increases in suicide by firearms
  14. 14. Suicide Rates for Various Nations•  U.S. has a moderate suicide rate relative to other nations•  Hungary has the highest rate; Finland, Denmark, Austria, Switzerland, France, Japan, Norway, among others, also have higher rates than the U.S.•  Italy, Ireland, England, Portugal, Spain, Israel, Greece, Venezuela, among others, have lower rates than the U.S.
  15. 15. Previous Attempt and Help Seeking Histories•  30-40% of completers have attempted suicide before•  Nearly two-thirds of suicide completers communicated their suicidal intentions to others (including to health-care providers)•  Most suicide attempters are able to experience a reduction in suicidality and a return to full function
  16. 16. Clinical Risk FactorsMental/Psychiatric Disorders•  Depression•  Alcohol/Drug Abuse•  Schizophrenia•  Other Psychiatric Disorder
  17. 17. Depression•  >50% clinically depressed at time of suicide•  Nearly 15% of persons with significant mood disorders will commit suicide•  Depression is genetically predisposed, and there is a strong link between depression and suicide•  Suicide can occur in all phases of depressive episode•  Risk may be highest during early recovery phase
  18. 18. Alcoholism/Drug Abuse•  Nearly one-third of suicides occur in persons with chronic alcoholism•  2-4% of chronic alcoholic patients commit suicide•  Positive blood alcohol levels are found in 30-40% of suicides
  19. 19. Schizophrenia•  5-10% of schizophrenic patients commit suicide•  In general population studies, schizophrenia accounts for 5% of suicides
  20. 20. Other Disorders•  Other mental disorders increase risk to 5-10%•  Serious physical illness increases risk
  21. 21. Social Isolation/ Interpersonal Loss or Conflict•  Among alcoholics who commit suicide, 50% have a history of interpersonal loss within previous year•  Suicide more common among divorced, widowed, and single/never married than among married
  22. 22. Social Isolation/ Interpersonal Loss or Conflict•  Among adolescents & young adults, interpersonal conflict and disciplinary or legal problems often precipitate suicide •  Break-up with boyfriend or girlfriend•  Hopelessness regarding a dilemma, especially with the prospect of public humiliation •  Failing class but don’t dare drop out •  Sexual impropriety about to come to light
  23. 23. Suicidal IndicesSuicidal Ideation•  Passive – no plan or intent •  I wish I were dead •  I wish I could just go to sleep and not wake up•  Active –specific plan and intent to act •  Intrusive and obsessional vs •  Researched and thought out
  24. 24. Suicide Indices•  History of attempts (esp if highly lethal) •  Highest predictive value in past 2 months •  Suicide rehearsals or preparation •  Counting pills •  Holding gun •  Checking out high places
  25. 25. Suicide Indices•  Final arrangements •  Will •  Suicide note •  Giving away possessions
  26. 26. Current Mental Status•  Hopelessness•  Acute agitation•  Intoxication•  Psychosis (especially with command hallucinations or delusions)
  27. 27. Summary of Risk FactorsDemographic Psychiatric Mental Status OtherOlder Depression Suicidal ideation Medical IllnessWhite Substance abuse Hopeless Recent lossesMale Psychosis Agitated IntractableLiving alone Other psychiatric Command dilemmaNot working disorders hallucinations or Prospect of public delusions humiliationAvailability andLethality of the Means Firearms>Falls>Hanging>Ingestion>Cutting M. Jibson
  28. 28. Clinical Assessments/InterventionsGeneral Principles of Intervention•  Recognize the "cry for help" or the expressed suicidal ideation/intent•  Ask questions in an objective, straightforward, nonjudgmental manner•  Assess depression, substance abuse, impulsivity, and psychosis•  Ask specifically about availability of firearms
  29. 29. Clinical Assessments/InterventionsGeneral Principles of Intervention•  Do not alienate the patient with sarcasm, ridicule, or disbelief•  Do not minimize their perceived problems•  Talk calmly and openly about problems•  Convey a sense of hope; counteract hopelessness
  30. 30. Clinical Assessments/InterventionsGeneral Principles of Intervention•  Always seek corroborative information •  Family and friends •  Outpatient mental health providers•  Ask the tough questions that need to be asked •  What will keep this from happening again? •  What is be different now?
  31. 31. Clinical Assessments/InterventionsClinical Decision Making•  Gather as much information as possible•  Carefully assess the risk and protective factors•  Discuss the case with another clinician•  Establish limit-setting on self-destructive behavior
  32. 32. Clinical Assessments/InterventionsClinical Decision Making•  Assess and discuss reasons for living•  Involve family or friends whenever possible•  Convey knowledge that depression (or other treatable condition that is present) is treatable
  33. 33. Clinical Assessments/Interventions•  Hospitalize if: •  An attempt is clinically serious •  Risk factors suggest high risk •  There is no established outpatient care •  There is a discrepancy between the patient’s story and other information
  34. 34. Clinical Assessments/Interventions•  Consider outpatient care if: •  Risk is relatively low •  Stressors can be immediately addressed •  The patient already has a mental health provider •  Other safeguards can be implemented (eg, family support) •  Suicide threats or attempts are repeatedly used to communicate distress or manipulate others
  35. 35. Myths•  People who talk about suicide wont commit suicide•  People who want to commit suicide won’t tell you•  Suicide happens without any warning•  All suicidal persons are "insane"•  Suicide stems from a single mental disorder•  Asking about suicide "plants" the idea in the patients mind
  36. 36. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicySlide 6: State of Connecticut Department of Mental Health and Addiction Services, http://www.ct.gov/dmhas/lib/dmhas/prevention/cyspi/AAS2004data.pdfSlide 7: State of Connecticut Department of Mental Health and Addiction Services, http://www.ct.gov/dmhas/lib/dmhas/prevention/cyspi/AAS2004data.pdfSlide 8: National Institute of Mental Health, http://www.nimh.nih.gov/index.shtmlSlide 12: Michael JibsonSlide 27: Michael Jibson
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