Hanipsych, suicide


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  • Indeed, the suicidal risk is greatly increased in untreated depressed patients. This was shown by the Swiss cohort of J. Angst for which it was possible to access the very long term prognosis.
  • Emphasize increased risk of suicide attempts in year following initial onset of suicidal ideation. - Kessler
  • Remember to read the suicide note and document that you read it.
  • Hanipsych, suicide

    1. 1. Suicide can be prevented? Presented by: Hani Hamed Assist. Prof. of Psychiatry Acting Head, Psychiatry Department, Beni-Suef University Supervisor of Psychiatry Department , El-Fayoum University Member of American Psychiatric Association Alex, May, 2013
    2. 2. Agenda  Introduction  Risk and Protective Factors  Suicide Warning Signs  Suicide Prevention Programs  Future Directions
    3. 3. World Suicide Prevention Day  September 10 is World Suicide Prevention Day, a day not widely celebrated or even known about.  According to WHO, every year approximately one million people worldwide commit suicide--almost one death every 40 seconds.  Suicide rates are reported to be rising steadily in developing countries, primarily amongst those between the ages of (15 – 44).
    4. 4. U.S. Suicide Statistics  Average of 83 suicides per day*  8th leading cause of death for males, 19th leading 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 = firearms Source: National Institute of Mental Health *Suicide Prevention Resource Center – U.S. Suicide Prevention Fact Sheet
    5. 5. Challenges Suicides ■ 850,000 suicides per year worldwide 920,000 deaths caused by malaria Major lethal risk ! ■ The suicide risk in depressed patients is up to 30times higher than in the general population ■ 30 to 50 % of suicide attempts are due to depression ■ Approximately 15% of severely depressed patients die by suicide WHO 2009
    6. 6. Challenges (%) 40 Zurich Cohort, N=147 deaths p <0.01 35 1959 -1997 Untreated 30 Treated 25 20 15 10 5 0 p <0.01 p <0.01 Neoplasm Cardiovascular Cerebro- p <0.01 Accidents Suicide p <0.01 Other All causes vascular Angst et al, 2002
    7. 7. http://nitawriter.wordpress.com , 2007
    8. 8. Suicide in Egypt  As for Egypt, it is reported to have an annual suicide rate of less than 6.5 per 100,000--or fewer than 5070 deaths by suicide each year.  Exactly how many Egyptians do commit suicide each year? Estimates are available, but there are no definitive statistics.
    9. 9. Introduction  About 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder.
    10. 10. Introduction  Evidence pertaining to potential anti-suicidal effects of various psychotropic drugs on suicide risk has been strikingly limited as well as inconsistent and inconclusive.  Particularly surprising, there is only inconsistent evidence that antidepressants may help prevent suicides.
    11. 11. Terminology and definitions in suicide research  Suicide: the act of intentionally ending one's own life.  Nonfatal suicidal thoughts and behaviors: – suicide ideation: thoughts of engaging in behavior intended to end one's life – suicide plan: the formulation of a specific method through which one intends to die – suicide attempt: engagement in potentially self-injurious behavior in which there is at least some intent to die. – Nonsuicidal self-injury : self-injury in which a person has no intent to die
    12. 12. Suicide can be prevented  While some suicides occur without any outward warning, most do not.  The most effective way to prevent suicide among loved ones is to learn how to recognize the signs of someone at risk, take those signs seriously and know how to respond to them.  The emotional crises that usually precede suicide are most often both recognizable and treatable.
    13. 13. Risk Factors  Demographic factors – Suicide: male, an adolescent or older adult, non-Hispanic White or Native American (in the US) – Suicidal behaviors: female, younger, unmarried, having lower educational attainment, unemployed  Psychiatric factors – Mood, impulse-control, alcohol/substance use, psychotic, personality disorders  Psychological factors – Hopelessness , anhedonia, impulsiveness .
    14. 14. 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,…
    15. 15. FAMILY PSYCHOPATHOLOGY  Family history of abuse, violence, or other selfdestructive behaviors place individuals at increased risk for suicidal behaviors (Moscicki 1997, van der Kolk 1991).  Histories of childhood physical abuse and sexual abuse, as well as parental neglect and separations, may be correlated with a variety of self-destructive behaviors in adulthood (van der Kolk 1991).
    16. 16. PSYCHOSOCIAL SITUATION: LIFE STRESSORS  Recent severe, stressful life events associated with suicide in vulnerable individuals (Moscicki 1997).  High risk stressor: humiliating events, e.g., financial crisis, being arrested or being fired (Hirschfeld and Davidson 1988) – can lead to impulsive suicide.  Identify stressor in context of personality strength, vulnerabilities, illness, and support system.
    17. 17. RISK FACTORS (Yellow= modifiable) Demographic male; widowed, divorced, single; increases with age; white Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access Psychiatric psychiatric diagnosis; comorbidity Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system Psychological Dimensions hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism Behavioral Dimensions impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt Cognitive Dimensions thought constriction; polarized thinking Childhood Trauma sexual/physical abuse; neglect; parental loss Genetic & Familial family history of suicide, mental illness, or abuse
    18. 18. Protective Factors • Children in the home, except among those with postpartum 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
    19. 19. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric Illness Co-morbidity Personality Disorder/Traits Neurobiology Impulsiveness Substance Use/Abuse Hopelessness Suicide Severe Medical Illness Access To Weapons Life Stressors Family History Psychodynamics/ Psychological Vulnerability Suicidal Behavior
    20. 20. Areas to Evaluate in Suicide Assessment Psychiatric Illnesses Comorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders. History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness Individual strengths / vulnerabilities Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain Psychosocial situation Acute and chronic stressors; changes in status; quality of support; religious beliefs Suicidality and Symptoms Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation Adapted from APA guidelines, part A, p. 4
    21. 21. DETERMINATION OF RISK Psychiatric Examination Risk Factors Modifiable Risk Protective Factors Factors Risk Level: Low, Med., High Specific Suicide Inquiry
    22. 22. DIRECT QUESTIONING ABOUT SUICIDE: THE SPECIFIC SUICIDE INQUIRY Ask About:  Suicidal ideation  Suicide plans Give Added Consideration to:  Suicide attempts (actual and aborted)  First episode of suicidality (Kessler 1999)  Hopelessness  Ambivalence: a chance to intervene  Psychological pain history Jacobs (1998)
    23. 23. COMPONENTS OF SUICIDAL IDEATION  Intent: Subjective expectation and desire for a self-destructive act to end in death.  Lethality: Objective danger to life associated with a suicide method 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 therapeutic relationship, positive support system - including work) Beck et al. (1979)
    24. 24. WHAT TO DOCUMENT IN A SUICIDE ASSESSMENT  Document: • The risk level • The basis for the risk level • The treatment plan for reducing the risk
    25. 25. Suicide Warning Signs Depression or Paranoia Expresses guilt/shame over offense Statements about suicide or death Self-harm attempts  Each attempt should be taken seriously!
    26. 26. 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 to them  Appetite and sleep changes
    27. 27. Suicide Warning Signs (continued) Mood/behavior changes  May refuse treatment  Withdraws from others, may demand to be celled alone  Neglects personal hygiene or appearance Preoccupied with past – doesn’t deal well with present Packing/giving away belongings
    28. 28. Suicide Warning Signs (continued)  Writes a will  Hallucinations and Delusions  May hear voices or see visions that tell inmate to harm self
    29. 29. MYTH OR FACT? 1. Myth: People who threaten suicide don’t go through with it Fact: Most people who commit suicide have made direct or indirect statements about their suicidal intentions 2. Myth: Suicide happens suddenly and without warning Fact: Most suicidal acts represent a carefully thought out strategy for coping with their problems
    30. 30. MYTH OR FACT? 3. (continued) Myth: People who attempt suicide have gotten it out of their system Fact: Any individual with one or more prior suicide attempts is at much greater risk than those who have never attempted suicide 4. Myth: Suicidal people are intent on dying Fact: Most suicidal people have mixed feelings about killing themselves; they are doubtful about living, not intent on dying. MOST WANT TO BE SAVED!
    31. 31. MYTH OR FACT? 5. (continued) Myth: Asking offenders about suicidal thoughts or actions will cause them to kill themselves Fact: You cannot make someone suicidal when you are discussing the possibilities of suicide  Concerned, non-judgmental questions encouraging the person to discuss his/her ideas may help relieve the psychological pressure 6. Myth: All suicidal individuals are mentally ill Fact: A suicidal person is extremely unhappy but not necessarily mentally ill; a “normal” person can be suicidal.
    32. 32. Prevention/intervention programs  Means-restriction programs: can decrease suicide rates by 1.5–23%.  Primary-care physician education and training programs: show reductions of 22–73%.  Although effective prevention programs exist many people engaging in suicidal behavior do not receive treatment of any kind.
    33. 33. Suicide Prevention Training  Increase their awareness of suicide and see prevention opportunities they may otherwise miss.  Become more alert to clues and communications that someone may be thinking of suicide.  Ask about suicide and respond in ways that show understanding and assess risk.  Work with persons at risk to increase their safety.  Facilitate links with further help from family, friends and professional helpers as needed.
    34. 34. Treating suicidal individuals • Need to assess suicidal risk and ensure adequate supervision of attempter •Deal with life crisis swiftly •Therapy focused on building protective factors and reducing risk factors, through a variety of different approaches • Encourage open talk about suicidal ideation
    35. 35. Communicating With Suicidal Patients 1. Listen Patiently  Encourage the person to talk, including about suicide plan 1. Trust Your Own Judgment  If you believe patient is in danger of suicide, implement suicide prevention protocols and keep the person in a safe place
    36. 36. Is Suicide Screening Effective? Still no Clear Answer  Trying to separate out the large population at risk for suicide from those who go on to die by suicide is difficult.  Preventive Services Task Force found, there is currently a limited evidence basis for suicide-specific screening.  However, It is important to remember that for those primary care practices that use collaborative care for depressiontreatment models, screening for depression is supported by the task force. Psychiatric News, 2013
    37. 37. Take Home Message… Suicide Prevention Efforts YOU form the bridge of communication with potentially suicidal persons by:  Observing daily behaviors  Interacting with and listening to him  Reporting concerns to medical/mental health staff promptly
    38. 38. Future Directions
    39. 39. Blood Test for Suicide Risk?  Suicidal thoughts and behavior may be uniquely linked to inflammatory markers in patients with major depressive disorder (MDD), new research suggests.  A study of 122 adults in Ireland showed that those with MDD and high suicidal ideation had significantly higher levels of inflammation (as shown through blood draws) than both those with MDD and low suicidal ideation and healthy peers without MDD. Depression Anxiety. 2013;30:307-314
    40. 40. Blood Test for Suicide Risk?  A composite score comprising the proinflammatory cytokines interleukin-6 (IL-6) and tumor necrosis factor–alpha (TNF-α), the anti-inflammatory cytokine interleukin-10 (IL10), and C-reactive protein (CRP) was used as an inflammatory index.  Circulating levels of adrenocorticotropic hormone (ACTH) and cortisol were also measured to assess hypothalamic-pituitaryadrenal (HPA) axis abnormalities. Depression Anxiety. 2013;30:307-314
    41. 41. Blood Test for Suicide Risk?  Results showed higher inflammatory index scores for the group with MDD and high suicidal ideation compared with the group with MDD and low suicidal ideation (P = .009) and compared with the control group (P < .001).  There were no significant differences between any of the groups on ACTH or cortisol levels. Depression Anxiety. 2013;30:307-314