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Suicide: Risk Assessment and Prevention


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A lecture about suicide delivered by Dr Imran Waheed, Consultant Psychiatrist, to GPs (primary care physicians) in Birmingham, UK, on 25 February 2013

Published in: Health & Medicine
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Suicide: Risk Assessment and Prevention

  1. 1. Suicide:Risk Assessment and Prevention Dr Imran Waheed Consultant Psychiatrist
  2. 2. Overview• Context• Statistical update• DoH Suicide Prevention Strategy• Risk factors• Risk assessment and management
  3. 3. Coroner’s Inquest Media Coverage“Her GP Dr Ryley accepted that when he saw her on 24thMarch, a month before her death, he had considered only herproblems of tiredness and getting to school late and had notasked her about depression.”“He was concerned her problem could be due to iron deficiencyor low thyroid level and, as she was a vegetarian, he treated heraccordingly, he said.”“Asked by the coroner if he felt there had been a missedopportunity to help her, given her suicide bid at Beachey Head,Dr Ryley said "Certainly, in retrospect. I agree I would havelooked to enquire closely about mood and depression but Ididnt on that occasion.””
  4. 4. Statistical Update• 4,215 suicides recorded in 2010.• 3 year average for 2008-10 was 7.9 suicides per 100,000 general population, 17.9 % lower than in 1998-2000.• Most substantial decreases seen towards the beginning of this period and data show a very slight increase in deaths from suicide in more recent years.• West Midlands: 2007  245 & 2010  450
  5. 5. Statistical Update• Majority in adult males – 4 times more M than F in 25-29• Rate is now highest for middle age men – slight increase• 1 % of population have suicidal thoughts per week• Between a quarter and a half of those committing suicide have previously carried out a non-fatal act• Average estimated cost per completed suicide is £1.67m• Challenge is that suicide is rare event, prediction has very low specificity (so lots of false positives)
  6. 6. Mental Health Patient Suicide• About 1100 suicides by people in contact with mental health service in previous 12 months• About 70-80 psychiatric inpatients die annually by suicide• Highest risk: 14 days post-discharge (‘7 day follow up’)
  7. 7. Patient suicide frequency by diagnosis
  8. 8. Primary care and suicide• List size of 1000 – would take 8 years of consultations before a GP will consult with a patient who will shortly thereafter commit suicide• About 90% of those in contact with MH services will see GP in year preceding suicide, and about 45% in the month preceding suicide• Mean of 8 consultations with GP in year preceding death• Is there a role for suicide prevention in primary care?
  9. 9. DoH Suicide Prevention Strategy• Published in September 20121. Reduce risk in key high risk groups2. Tailor approaches to improve MH in specific groups3. Reduce access to the means of suicide4. Better information and support to those bereaved or affected by suicide5. Support the media in delivering sensitive approaches to suicide and suicidal behaviour6. Support research, data collection and monitoring
  10. 10. High risk groups1. Young and middle-aged men2. People in the care of mental health services, including inpatients3. People with a history of self-harm4. People in contact with the criminal justice system5. Specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers.
  11. 11. Suicide Prevention Strategy• “Those who work with men in different settings, especially primary care, need to be particularly alert to the signs of suicidal behaviour.”• “Accessible, high-quality mental health services are fundamental to reducing the suicide risk in people of all ages with mental health problems.”• “Emergency departments and primary care have important roles in the care of people who self-harm, with a focus on good communication and follow-up.”• “Depression is one of the most important risk factors for suicide. The early identification and prompt, effective treatment of depression has a major role to play in preventing suicide across the whole population.”
  12. 12. Primary Care• “GPs have a key role in the care of people who self-harm. Good communication between secondary and primary care is vital, as many people who present at emergency departments following an episode of self-harm consult their GP soon afterwards.”• “Work undertaken by the London School of Economics has shown that suicide prevention education for GPs can have an impact as a population level intervention to prevent suicide.” [ASIST course costs about £200 per GP]
  13. 13. Evidence base issues• Medication - only lithium and clozapine have good evidence for reducing suicide• Medication/hospitalisation have good face validity for being helpful, but limited evidence of ‘anti-suicidal’ effect• Medication/hospitalisation are not without risks• Treatment with medication can give access to means – a third of those who commit suicide and are in contact with MH services in last 12 months self poison with psychotropic medication• Side effects such as akathisia increase suicide risk• Hospitalisation – 30 per cent of community suicides in 3 months post-discharge
  14. 14. Risk factors for suicideBiopsychosocial Risk Factors•Mood disorders, schizophrenia, anxiety disorders andcertain personality disorders•Alcohol and other substance use disorders•Hopelessness/helplessness•Impulsive and/or aggressive tendencies•History of trauma or abuse•Some major physical illnesses•Previous suicide attempt•Family history of suicide
  15. 15. Risk factors for suicideEnvironmental Risk Factors•Job or financial loss•Relationship or social loss•Easy access to lethal means•Local clusters of suicide that have acontagious influence
  16. 16. Risk factors for suicideSociocultural Risk Factors•Lack of social support and sense of isolation•Stigma associated with help-seeking behaviour•Barriers to accessing health care, especiallymental health and substance abuse treatment•Certain cultural and religious beliefs (forinstance, the belief that suicide is a nobleresolution of a personal dilemma)•Exposure to, including through the media, andinfluence of others who have died by suicide
  17. 17. Assessment• “Asking a patient about suicide increases the increase risk of suicide” – T/F?• “Those who talk about suicide do not commit suicide” – T/F?• Use graded questions – open and closed• Explore suicidal ideas – is there a plan?• What are the means?
  18. 18. Assess seriousness• Intent• Planned vs. impulsive• Final acts• Attempts made to prevent discovery• How discovered and how brought to medical attention?• Use graded questions – open and closed• Explore suicidal ideas – is there a plan?• What are the means? (e.g. guns – greater risk)• How do they feel now?
  19. 19. Vignette 1• Sarah is a 22 year old girl who presents to A&E having taken 15 paracetamol and ½ a bottle of vodka. She had a fight with her boyfriend earlier in the evening. She used whatever she could find in the house and called an ambulance when she felt sick. She had wanted to end things at the time, but now regrets her actions.
  20. 20. Please make your selection...1. HIGH RISK - Admit2. Home with Home Treatment Team3. Home with secondary care follow up4. Home with primary care/GP follow up5. Home with no follow up
  21. 21. Vignette 2• Jennifer is a 43 year old divorced, unemployed mother of 2. She has been depressed for 6 months and was recently discharged from hospital. She was found by a neighbour in a newly bought car in the garage, with the motor running, and brought to A&E. She had sent her children away for the weekend and had parked her own car in front of the garage hoping no one would discover her. She is bitterly disappointed to have failed to end her life.
  22. 22. Please make your selection...1. HIGH RISK - Admit2. Home with Home Treatment Team3. Home with secondary care follow up4. Home with primary care/GP follow up5. Home with no follow up
  23. 23. Key messages• Suicide is major cause of death and major public health issue• Risk assessment is an important intervention• Risk is dynamic and needs regular reassessment• Early identification and treatment of depression is important• Good relationships between primary and secondary care essential
  24. 24. Fighting stigma - a final thought“Killing oneself is, anyway, a misnomer. We dont killourselves. We are simply defeated by the long, hardstruggle to stay alive. When somebody dies after along illness, people are apt to say, with a note ofapproval, "He fought so hard." And they are inclinedto think, about a suicide, that no fight was involved,that somebody simply gave up. This is quite wrong.”Sally Brampton, Shoot The Damn Dog: A Memoir Of Depression