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Dr Ashley Baldwin Dr Ashley Baldwin Presentation Transcript

  • Suicide in later lifeDr A BaldwinDr A BaldwinConsultant in Later Life PsychiatryConsultant in Later Life PsychiatryAssociate Medical DirectorAssociate Medical Director5 Boroughs Partnership NHS FT5 Boroughs Partnership NHS FTHonorary LecturerHonorary LecturerAshley.Baldwin@5bp.nhs.ukAshley.Baldwin@5bp.nhs.uk
  • Global suicide rates by gender and age 199533.341.066.924.918.90.914.227.6 29.722.116.412.411.612.612.00.50102030405060705-14 15-24 25-34 35-44 45-54 55-64 65-74 75 oraboveSuiciderateper100,000populationMale Female
  • Suicide rates of selected countries18.619.622.726.015.913.911.713.417.811.,000populationMale FemaleUS(1998)Canada(1997)Australia(1997)UK(1998) China(1998)Singapore(1998)Korea(1997)Japan(1997)HK(1996)
  • Suicide:Age and Sex20%4%7%26%7%21%14%7%6%10%15%22%23%17%05001000150020002500Under 25 25-34 35-44 45-54 55-64 65-74 75+Age-groupFrequencyMale Female
  • Risk factors & suicide (2000-2004)Hunt et alHanging ( n =2288): 43% of totalMale<25Short illness durationAffective DisorderSelf poisoning ( n =1720): 32 %Female>25Social isolation/adversity (unmarried,unemployed,living alone)Self harm, alcohol misusePrimary drug dependenceCo-morbidityCarbon monoxide poisoning (n =281): 5%MaleAge 25-44Short illness durationAffective disorder and personality disorder
  • Risk factors & suicide (cont’d)Jumping (n = 901): 17% of total<25Ethnic minoritySchizophreniaNon compliance with treatmentCPARecent contact with mental health servicesDrowning (n =402):FemaleOlder Age (>45)Ethnic minoritySchizophreniaMultiple previous inpatient admissionsCurrent psychiatric inpatientBurning (n =119):Ethnic minorityMultiple previous inpatient admission/ recent ward discharge
  • Suicide in males according to agegroup(1978-2010)75+All males25-3435-49051015202530351978-1980 1983-1985 1988-1990 1993-1995 1998-2000 2003-2005 2008-2010Three-year averageAge standardised death rate per 100,000 populationSource: ONS (ICD9 E950-E959, E980-E989, excluding E988.8; and ICD10 X60-X84, Y10-Y34, excluding Y33.9 up to 2006)Note: Deaths with a E988.8 or Y33.9 code were excluded to remove pending verdicts from the figures. This method may miss a small number of cases where there are pendingverdicts (assigned to codes other than E988.8 or Y33.9); it may also wrongly omit some cases where a verdict has been returned (included under codes E988.8 or Y33.9). Weexpect the error caused by this methodology to be negligible for figures in years up to and including 2006 and there will be no effect on more recent figures due to new codesintroduced in 2007.
  • Characteristics of elderly suicidecompleters Low attempt to completion ratio – 4:1Low attempt to completion ratio – 4:1 Self poisoning more common and drowningSelf poisoning more common and drowning Fewer warning signsFewer warning signs Greater planning and resolveGreater planning and resolve Low contact with mental health servicesLow contact with mental health services(11%)(11%)
  • Characteristics of elderly suicidecompleters Elderly suicide completion is also associated with:Elderly suicide completion is also associated with: Past history of suicide attemptPast history of suicide attempt Mental disorder ( 90%),Depression ( 66%)Mental disorder ( 90%),Depression ( 66%) Physical illness and functional impairmentPhysical illness and functional impairment Social isolationSocial isolation Recent life event/bereavementRecent life event/bereavement Suicide pactsSuicide pacts
  • Service utilisation of elderlysuicide completers But 54 % >75 known to services had contactBut 54 % >75 known to services had contactwithin last 7 dayswithin last 7 days 51 % under CPA51 % under CPA Only 6% reported suicidal ideation at last contactOnly 6% reported suicidal ideation at last contact 7% inpatients7% inpatients 19 % 3 months post discharge19 % 3 months post discharge 21 % viewed as preventable21 % viewed as preventable Majority see PCP within one month of suicideMajority see PCP within one month of suicide
  • Risk factorsGeneticsFamily HxPsychiatric disorderPersonalitySocial milieu
  • Studies on suicidal ideations Among 516 elderly aged 70 or above inAmong 516 elderly aged 70 or above inBerlin (Linden & Barnow, 1997):Berlin (Linden & Barnow, 1997): 14.7% said that life is not worth living14.7% said that life is not worth living(77.5% had depression)(77.5% had depression) 5.4% wished to be dead or thought about5.4% wished to be dead or thought aboutsuicide (95.7% had depression)suicide (95.7% had depression) 1.0% showed suicidal ideas or gestures1.0% showed suicidal ideas or gestures(100% had depression)(100% had depression)
  • Completer- 30/100,000Attempter – 100/100,000Suicidal Intentions – 1-5%Life not worth living – 15-19%Normal – 80%
  • NormalSlightlydepressedLifeNotWorthLivingSuicidalIntentionsAttempters CompletersTIME-LINE
  • Evidence-based means and tools Gotland study (RihmerGotland study (Rihmer et alet al, 1995):, 1995): depression-related suicide rates decreased withdepression-related suicide rates decreased withtraining programme for general practitioners ontraining programme for general practitioners onthe diagnosis and treatment of depressionthe diagnosis and treatment of depression In UK negative correlation between antiIn UK negative correlation between antidepressant prescribing and suicidedepressant prescribing and suicide TeleHelp-TeleCheck service (De LeoTeleHelp-TeleCheck service (De Leo et alet al, 2002):, 2002): reduction in elderly suicide rates afterreduction in elderly suicide rates afterintroduction of tele-help serviceintroduction of tele-help service
  • What do we know about elderlysuicide?5.5. Low utilisation rate of psychiatric service among elderly suicideLow utilisation rate of psychiatric service among elderly suicidecompleters may reflect lack of awareness and stigmatisation in thecompleters may reflect lack of awareness and stigmatisation in thecommunity (Chiucommunity (Chiu et alet al, 2004), 2004)6.6. Suicidal ideations and intentions are highly correlated withSuicidal ideations and intentions are highly correlated withdepressive disorder and are useful key markers for identification ofdepressive disorder and are useful key markers for identification ofat-risk individuals (Linden & Barnow, 1997)at-risk individuals (Linden & Barnow, 1997)7.7. Programme aimed at educating primary care physicians aboutProgramme aimed at educating primary care physicians aboutdepression has been shown to reduce suicide rate, e.g. Gotlanddepression has been shown to reduce suicide rate, e.g. Gotlandstudy (Rihmerstudy (Rihmer et alet al, 1995), 1995)8.8. Telecheck shown to be a useful tool in providing care for elderly atTelecheck shown to be a useful tool in providing care for elderly atrisk of suicide and reduce suicide rate (De Leorisk of suicide and reduce suicide rate (De Leo et alet al, 2002), 2002)9.9. Relevant and locally validated instruments are available, e.g. GDSRelevant and locally validated instruments are available, e.g. GDS
  • Strategies in suicide prevention Universal preventionUniversal prevention Selective preventionSelective prevention Indicated/targeted preventionIndicated/targeted prevention
  • Important features of Service Improved access:Improved access: Increased capacity for detection through theIncreased capacity for detection through theuse of standardised instruments and traininguse of standardised instruments and trainingof non-medical personnel ( Columbia )of non-medical personnel ( Columbia ) Free-flow of patients betweenFree-flow of patients betweenprimary/secondary care according to needsprimary/secondary care according to needsassessmentassessment
  • Early detection1.1. Raising the awareness of target referrers andRaising the awareness of target referrers andgeneral public:general public:a.a. Promotional and bibliographic materialPromotional and bibliographic materialb.b. Liaison with target medical referrersLiaison with target medical referrersc.c. Liaison with non-medical target referrersLiaison with non-medical target referrersd.d. EducationEducation
  • Early detection2.2. Improving access to serviceImproving access to servicea.a. Setting-up of Fast Track ClinicSetting-up of Fast Track Clinicb.b. Early intervention serviceEarly intervention servicec.c. Non-medical referral ?Non-medical referral ?
  • Effective and adequatemanagement1.1. Individual biopsychosocial assessment withIndividual biopsychosocial assessment withearly intervention serviceearly intervention service2.2. Multidisciplinary approach includingMultidisciplinary approach includinginvolvement of referrerinvolvement of referrer3.3. Regular case conferenceRegular case conference4.4. Adequate biological and psychosocial treatmentAdequate biological and psychosocial treatment5.5. Coordination of psychosocial support andCoordination of psychosocial support andmobilising resources from the communitymobilising resources from the community6.6. Intensive follow-up by home visitsIntensive follow-up by home visits7.7. Dedicated In-patient facilityDedicated In-patient facility
  • Assessment of suicidal risk Asking about suicidal inclinations does notAsking about suicidal inclinations does notmake suicidal behaviour more likelymake suicidal behaviour more likely Willingness to make tactful but directenquiries about a patient’s intention Be alert to factors that signify an increasedrisk of suicide
  • Assessment of suicidal risk Consider known risk factorsConsider known risk factors Assess current suicidal riskAssess current suicidal risk Assess suicidal intent – planning,Assess suicidal intent – planning,preparation, precaution against discovery,preparation, precaution against discovery,final rite, verbal cues, suicide notefinal rite, verbal cues, suicide note Collateral informationCollateral information
  • Suggested questioning sequence Whether the patient:Whether the patient: hopes things turn out wellhopes things turn out well gets pleasure out of lifegets pleasure out of life feels hopeful from day to dayfeels hopeful from day to day feels able to face each dayfeels able to face each day ever despairs about thingsever despairs about things feels life to be a burdenfeels life to be a burden wishes it would all endwishes it would all end
  • Suggested questioning sequence Whether the patient:Whether the patient: knows why he/she feels this wayknows why he/she feels this way has thought of ending lifehas thought of ending life has thought about the possible methodshas thought about the possible methods has ever acted on any suicidal thoughts orhas ever acted on any suicidal thoughts orintentionsintentions feels able to resist any suicidal thoughtsfeels able to resist any suicidal thoughts
  • Data Collection Method Face-to-face interviewsSample Design A random sample of 917 ethnicChinese people aged 60 andabove living in Hong KongFieldwork Period October 1999 - February 2000RESPONSE RATE : 73%
  • Significant factors to Suicidal WishesFactors Oddratio95% CI p-value Factors Oddratio95% CI p-valueFemale 1.00 PSMS 1.26 1.08 1.48 0.0037Widowed 1.94 1.03 3.65 0.0401 Freq. ofseeing doctor1.17 1.08 1.27 0.0003Self-ratedfinanciallyinsufficient2.37 1.32 4.27 0.0041 Life eventSelf-rated healthas unhealthy2.90 1.63 5.16 0.0003 Relationship 1.61 1.01 2.56 0.0438Incontinence 5.83 2.61 13.06 <0.0001 Robbed 5.41 1.44 20.36 0.0124Vision problem 1.82 1.30 2.56 0.0005 Court case 11.89 1.94 72.84 0.0074Hearing problem 1.59 1.15 2.20 0.0049 Active coping 0.86 0.79 0.93 0.0001IADL 1.11 1.03 1.18 0.0043 Depressed 13.48 7.34 25.76 <0.0001
  • Significant multiple risk factors to Suicidal WishesFactors Odd ratio 95% CI p-valueNumber ofdiseases1.76 1.07 2.90 0.0260Vision problem 3.34 1.24 9.04 0.0173Hearing problem 2.74 1.13 6.64 0.0255Court case 57.42 1.29 2557.90 0.0365Depressed 7.23 1.52 34.38 0.0129
  • Significant factors to DepressionFactors Oddratio95% CI p-value Factors Oddratio95% CI p-valueDivorced 3.76 1.38 10.23 0.0095 Vision problem 1.85 1.47 2.35 <0.0001Living alone 1.00 Hearing problem 1.22 0.96 1.53 0.0981Spouse only 0.38 0.19 0.73 0.0039 IADL 1.14 1.09 1.20 <0.0001Spouse & children 0.36 0.21 0.61 0.0002 PSMS 1.36 1.17 1.57 <0.0001Children only 0.36 0.20 0.64 0.0005 Freq. of seeingdoctor1.11 1.04 1.19 0.0021CSSA 2.31 1.44 3.72 0.0005 LSNS 0.93 0.91 0.95 <0.0001Self-ratedfinanciallyinsufficient5.01 3.35 7.51 <0.0001 Life eventSelf-rated health asunhealthy3.52 2.37 5.24 <0.0001 Relationship 1.71 1.22 2.40 0.0019Memory (cognition) 0.78 0.69 0.88 <0.0001 Financialproblems1.55 1.17 2.06 0.0021Number of diseases 1.28 1.10 1.50 0.0015 Active coping 0.83 0.78 0.88 <0.0001Chronic pain 2.84 1.90 4.25 <0.0001
  • Data Collection Method Face-to-face interviewsSample DesignControl group: a random sampleof 100 elderly people aged 60 andabove, with age and sex matchedto the suicide groupFieldwork Period March 2000 – June 2001Suicide group: 62 cases of peopleaged 60 and above who hadcommitted suicideRESPONSE RATE : 76%
  • Significant factors to predicting suicideFactors Oddratio95% CI p-value Factors Oddratio95% CI p-valueNo. of diseases 2.18 1.56 3.05 <0.0001Life events w/in1 yrCancer 9.14 2.5 33.35 0.0008 Change of livingarrangements6.53 2.37 17.99 0.0003IADL 1.28 1.15 1.43 <0.0001 Death/illness 15.13 4.95 46.26 <0.0001PSMS 1.53 1.13 2.07 0.0058 Relationship 21.97 2.79 173.05 0.0033Pain 23.66 6.75 82.96 <0.0001Constipation 29.99 3.85 233.86 0.0012Last seen a doctor 0.0002 NEO-PILess than a month 9.31 2.99 28.93 0.0001 Neuroticism 1.17 1.09 1.25 <0.00011 to <2months 4.34 1.15 16.45 0.0307 Extraversion 0.87 0.8 0.94 0.0007Hospitalised due topsychiatric disease24.20 5.43 107.91 <0.0001  Openness toexperience0.83 0.74 0.92 0.0009Suicide attempt 20.77 4.63 93.17 0.0001 Agreeableness 0.89 0.81 0.97 0.0104At least 1 Lifediagnosis16.54 4.68 58.48 <0.0001 Conscientious-ness0.79 0.71 0.88 <0.0001Major depressiondiagnosis10.32 2.85 37.39 0.0004 Current majordepressiondiagnosis41.91 11.96 146.84 <0.0001At least 1 currentdiagnosis68.2524.85 187.40 <0.0001
  • Summary Suicide rate fallen in elderly over last 20 yrsSuicide rate fallen in elderly over last 20 yrs No gender difference in elderly suicideNo gender difference in elderly suicide Most mentally ill, >70 % depressedMost mentally ill, >70 % depressed Risks include isolation, physical illness andRisks include isolation, physical illness andbereavementbereavement Self poisoning/hanging commonest methodSelf poisoning/hanging commonest method Suicide pacts (marital) more commonSuicide pacts (marital) more common Least engaged with mental health servicesLeast engaged with mental health services