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  • Worldwide, Eastern Europe, the Soviet Republic and China have rates that exceed those of the U.S. Canada and Australia and portions of western Europe are roughly equivalent to the US
  • However, if we examine attempts separately from deaths, we see that the proportion of attempts, shown in light yellow compared with suicide deaths is large, especially in the younger years. However the proportion of deaths to attempts increases significantly with age. We can see that although the rates per 100,000 of suicide deaths is high, the number of attempts is staggering. There are over 23,000 male deaths per year
  • Switching to females, we can see that females have a much lower death rate than do males, but it important to remember that there are 5,800 deaths per year
  • phychiatry.Suicide.(dr.rebwar)

    1. 1. SUICIDE Dr. Rebwar G. Hama University of Sulaimani Faculty of Medical Sciences School of Medicine
    2. 2. <ul><li>“ Suicide is not chosen; it happens when pain exceeds resources for coping with pain.” </li></ul>
    3. 3. Suicide <ul><li>Suicide has occurred since the beginning of recorded history. </li></ul><ul><li>Is derived from the Latin word for ”Self murder” </li></ul><ul><li>Has been defined as an act with a fatal outcome, that’s deliberately initiated & performed by the person in the knowledge or expectation of it’s fatal outcome. </li></ul>
    4. 4. The Scope Of The Problem <ul><li>Suicide is among the ten leading causes of death in most countries around the world. </li></ul><ul><li>In the UK it’s the 3 rd most common contributor for death after coronary heart disease & cancer, while it’s the 8 th leading cause of death in the US. </li></ul><ul><li>Suicide is particularly tragic because it’s one of the leading cause of death among younger age groups & because it’s almost entirely preventable. </li></ul>
    5. 5. General recommendations <ul><li>Take all suicide threats seriously , even if they are manipulative. </li></ul><ul><li>Any patient who conveys a sense of hopelessness must be questioned about suicide. </li></ul><ul><li>Patients with history of frequent accidents should be asked about life problems, alcohol & drug use, depression & self destructive feelings. </li></ul>
    6. 6. <ul><li>4. Patient who have been depressed & suddenly improved must be asked about suicide. </li></ul><ul><li>5. If the patient refuses to discuss suicidality at all, it’s helpful to ask friends & family about the patients behavior. </li></ul>
    7. 7. <ul><li>Goals of evaluation of suicide:- </li></ul><ul><li>1. Evaluate the patient for: </li></ul><ul><li>a. suicidal thinking. </li></ul><ul><li>b. suicidal intent. </li></ul><ul><li>c. suicidal plan. </li></ul><ul><li>d. future orientation, if any. </li></ul><ul><li>e. relevant mental status. </li></ul><ul><li>2. Establish sufficient rapport with the patient so that the patient does not withhold information & will not resist the physician’s eventual intervention. </li></ul><ul><li>3. Determine the patient’s personal & demographic risk factors for suicide. </li></ul>
    8. 8. Epidemiology <ul><li>Each year more than 30.000 persons die by suicide in the U.S. </li></ul><ul><li>The number of attempted suicides is estimated to be 650.000. </li></ul><ul><li>There are about 85 suicides a day in U.S {about 1 in every 20 minutes} </li></ul><ul><li>The suicide rate in the U.S has averaged 12.5 per 100.000 in the 20 th century. </li></ul><ul><li>The suicide rate in the U.K. is about 10 per 100.000 per year. </li></ul>
    9. 9. <ul><li>The suicide rate in the Eastern European countries the so-called (SUICIDE BELT) is 25 per 100.000 </li></ul><ul><li>The prime suicide site of the world is the Golden Gate Bridge in San Francisco, with more than 800 suicides since the bridge opened in 1937 </li></ul><ul><li>Suicide accounts for about 1% of all deaths </li></ul>
    10. 10. Source: World Health Organization (WHO) Suicide Rates Vary Globally
    11. 11. Male Gender Suicide Deaths & Attempts Age-Adjusted Rates per 100,000 Population, 2000 CDC Data
    12. 12. Female Gender Suicide Deaths & Attempts Age-Adjusted Rates per 100,000 Population, 2000 CDC Data
    13. 13. Personal & Demographic Risk Factors for Suicide <ul><li>Major depression </li></ul><ul><li>Alcoholism </li></ul><ul><li>History of suicide attempt </li></ul><ul><li>Male sex </li></ul><ul><li>Increasing age </li></ul><ul><li>Widowed or never married </li></ul><ul><li>Unemployed & unskilled </li></ul><ul><li>Chronic illness or chronic pain </li></ul><ul><li>Terminal illness </li></ul><ul><li>Guns in the home </li></ul>
    14. 14. Psychiatric Disorders and Suicide <ul><li>Large majority of those who die from suicide have some form of mental disorder at the time of death. </li></ul><ul><li>(Almost 95% of all person who commit or attempt suicide have a diagnosed mental disorder)-Kaplan </li></ul><ul><li>Depressive disorder 80% of this figure </li></ul><ul><li>Schizophrenia – 10% </li></ul><ul><li>Dementia or Delirium 5% </li></ul><ul><li>Among all person of mental disorders, 25% are also alcohol dependant & have dual diagnosis. </li></ul>
    15. 15. <ul><li>Personality disorder; Up to a third to half of people who commit suicide. (5% of Antisocial, 3 times more in Prisoner)- Kaplan </li></ul><ul><li>Mood disorder; 6% of those suffer from mood disorder will die by suicide, If the depressed patient is also experiencing psychotic symptoms {delusional depression}, the risk of suicide is markedly increased. (suicide risk of depressive disorder is 15%)- Kaplan </li></ul><ul><li>Alcohol misuse; Life time risk of 7% when (male, old age, long history, depression, physical complication, marital problem, arrest for drunkenness),(50 times higher in alcohol d.)-Kaplan </li></ul><ul><li>Drug misuse; Relatively common, particularly in young. ( Suicide in Heroin dependent is about 20 times the rate for general population)- Kaplan </li></ul>
    16. 16. <ul><li>Schizophrenia; Life time risk is 7% when (Relapses, Depressive symptoms, Turned academic success into failure), (Up to 10% of schizophrenic patients die by committing suicide, In U.S 4000 each year)-Kaplan </li></ul><ul><li>Postpartum psychiatric disorders; are associated with some increased risk of suicide. </li></ul><ul><li>Psychoses; create risk of suicide in certain situations </li></ul><ul><li>a. If the symptoms include paranoia or command hallucinations urging self-destruction. </li></ul><ul><li>b. If a depressed patient has delusions. </li></ul><ul><li>c. If a patient is schizophrenic. </li></ul>
    17. 17. Faces of pain
    18. 18. <ul><li>Suicide is uncommon prior to adolescent. </li></ul><ul><li>Among males frequency increases with age, peaking at age of 75. Among females successful attempts is between 55 & 65. (male suicide peak after age 45, female 55)-Kaplan </li></ul><ul><li>Sex: </li></ul><ul><li>Females attempt suicide 3-4 times more frequently than males. </li></ul><ul><li>Males are successful 2-3 times more frequently than females. </li></ul>Age:
    19. 19. Social Factors <ul><li>Marital status affects suicide risk in the following manner: never married> widowed, separated or divorced> married without children>married with children. </li></ul><ul><li>Patients who live alone & those who have lost a loved one or failed in a love relationship within the past year are at increased risk. </li></ul><ul><li>Urban dwellers are at higher risk than rural population. </li></ul>
    20. 20. Occupational Factors <ul><li>The unemployed & unskilled are at greater risk than the employed & skilled. </li></ul><ul><li>Among professions, there is a higher rate of suicide among police, musicians, insurance agents, lawyers, dentists, & physicians. (Farmer – Poisons & Guns) </li></ul><ul><li>A sense of failure in a particular role is a risk factor. </li></ul>
    21. 21. Health Factors <ul><li>Half of all patients who attempt suicide have a physical illness. (25-75%)-Kaplan. </li></ul><ul><li>Risk is especially increased by: </li></ul><ul><li>Chronic pain. </li></ul><ul><li>Recent surgery . </li></ul><ul><li>Chronic disease. </li></ul><ul><li>Terminal illness. </li></ul>
    22. 22. Family History <ul><li>Patients with a positive family history of suicide & suicide attempts are more likely to make attempts. </li></ul><ul><li>There may be independent genetic risk for suicide, or a family history may create a sense of permission for suicide in other family members. </li></ul><ul><li>A positive family history for affective disorders is helpful in diagnosing an underlying affective disorder in a suicide patient. </li></ul><ul><li>Access to lethal means may be an independent risk factor for suicide. </li></ul>
    23. 23. PROTECTIVE FACTORS <ul><li>Children in the home, except among those with postpartum psychosis </li></ul><ul><li>Pregnancy </li></ul><ul><li>Deterrent religious beliefs </li></ul><ul><li>Life satisfaction </li></ul><ul><li>Reality testing ability </li></ul><ul><li>Positive coping skills </li></ul><ul><li>Positive social support </li></ul><ul><li>Positive therapeutic relationship </li></ul>
    24. 24. Comparison of Suicide & Deliberate self harm <ul><li>Factors Suicide D. self harm </li></ul><ul><li>Age Older Younger </li></ul><ul><li>Sex Male Female </li></ul><ul><li>Psychiatric disorder Common, severe Less common, less severe </li></ul><ul><li>Physical illness Common Uncommon </li></ul><ul><li>Planning Careful Impulsive </li></ul><ul><li>Method Lethal Less dangerous </li></ul>
    25. 25. Choice of Treatment & Disposition <ul><li>The judgment will depend on the following: </li></ul><ul><li>The degree to which the patient wants to commit suicide. </li></ul><ul><li>The strength of the patient’s will to fight suicidal impulses. </li></ul><ul><li>The quality of external controls available to the patient. </li></ul><ul><li>The physician must project into the immediate future & ask whether the patient risk of suicide is likely to increase. </li></ul>
    26. 26. Possible Disposition <ul><li>Sending the patient home with out-patient follow up. </li></ul><ul><li>Admission to general hospital. This may be necessary if the patient is medically unstable following an attempt. If a patient admitted to medical or surgical service, ongoing psychiatric consultation will be needed. </li></ul><ul><li>Admission to an open psychiatric unit. </li></ul><ul><li>Voluntary admission to locked psychiatric unit. </li></ul><ul><li>Involuntary hospitalization. </li></ul>
    27. 27. Choosing a Disposition <ul><li>The physician’s thinking should be well documented. If the physician is unsure of what to do after making the evaluation, it’s safest to obtain a psychiatric consultation. Patients who are judged severely suicidal but refuse treatment will require involuntary hospitalization. </li></ul><ul><li>2. Patients who are not severely suicidal & who are at low risk for immediate worsening can be sent home. Patients should not be sent home if they are going to be alone. Patients who are sent home should have an emergency no. to call or should be instructed to return to the emergency room if their suicidal feelings become more severe. </li></ul>
    28. 28. <ul><li>3. Suicidal patient should be asked to remove from the home any means of suicide the patient considered. </li></ul><ul><li>4. Chronically suicidal individuals need a long term relationship with a clinician or agency who will get to know them well. </li></ul><ul><li>5. With patients at higher risk for suicide, increasingly restrictive forms of treatment must be chosen. Hospitalization acts both to prevent suicide & to allow more aggressive treatment of patient’s psychiatric illness. </li></ul>
    29. 29. Suicide Prevention <ul><li>Warning Signs </li></ul><ul><ul><li>Signs are often not verbal. </li></ul></ul><ul><ul><li>Giving away beloved objects. </li></ul></ul><ul><ul><li>Changes in eating or sleeping habits. </li></ul></ul><ul><ul><li>Displaying a sense of calmness after a period of agitation. </li></ul></ul>
    30. 30. Practical Measures for Helping <ul><li>Characteristic </li></ul><ul><li>Unbearable pain </li></ul><ul><li>Frustrated needs </li></ul><ul><li>Seeking a solution </li></ul><ul><li>Hopelessness </li></ul><ul><li>Cognitive tunnel vision </li></ul><ul><li>Communication of intention </li></ul><ul><li>Guideline </li></ul><ul><li>Reduce the pain </li></ul><ul><li>Fill needs </li></ul><ul><li>Provide alternatives </li></ul><ul><li>Provide hope </li></ul><ul><li>Increase options </li></ul><ul><li>Listen, involve others </li></ul>
    31. 31. <ul><li>References: </li></ul><ul><li>Shorter Oxford Textbook Of Psychiatry </li></ul><ul><li>Manual Of Psychiatric Emergencies </li></ul><ul><li>Synopsis of psychiatry </li></ul>
    32. 32. <ul><li>RELAX </li></ul>