Suicide & DSH

1. Suicide & DSH MRCPsych Course Peninsula Medical School Plymouth Maung Oakarr MBBS, MRCPsyh Consultant Psychiatrist

2. SUICIDE An act with a fatal outcome, that is deliberately initiated and performed by the person in the knowledge or expectation of its fatal outcome.

3. Theories of Suicide • Sociological hypothesis ( E Durkheim) • Altruistic – for the good of country (eg. kamikaze, kaitens) • Egoistic - individual has lost social integration with the group (eg. Lack of religious faith) • Anomic – society undergoing such change that it lacks ‘collective order’ ; loosened bonds and norms ( social fragmentation) • Ecological hypothesis (P Sainsbury) rates increase due to social mobility and isolation

4. Overview • Around 5000 suicides per year in the UK • Amongst the 10 commonest cause of Death • Considerable increase in the numbers of young adults • Under reported due to Coroners as ‘accidental death’ or ‘open verdict’. • Methods- OD, hanging, shooting, jumping, cutting, car exhaust..ect

5. Epidemiology Suicide rates by sex, United Kingdom, 1991-2007 National Statistics

6. Epidemiology (2) • Suicide rates in both men and women continued to fall in 2007, reaching the lowest rates since 1991. • In 2007 the rate for men was 16.8 per 100,000 population. • Male suicide rates reached a peak of 21.1 per 100,000 in 1998. • Female suicide rates have been consistently much lower than males and have decreased more steadily. • The rate for women in 2007 was 5.0 per 100,000 population. • In 2007 there were 5,377 suicides in adults aged 15 and over, 177 less than in 2006 (5,554) and 940 less than in 1991 (6,317). • Three-quarters of the suicides in 2007 were men, and this proportion has remained fairly constant throughout the 1991-2007 period.

7. Epidemiology (3) Suicide rates by sex and age-group, United Kingdom, 1991-2007

8. Epidemiology (4) • In the early 1990s the highest suicide rates in the UK were among men aged 75 and over. Rates in this age group have since decreased from 25.1 per 100,000 population in 1991 to 15.2 in 2007, the lowest rate across the three male age bands. • Since 1997 the highest rates have been in men aged 15-44, peaking in 1998 and then steadily decreasing. In 2007 the rate for this age group was 17.6 per 100,000 population. • Suicide rates among men aged 45-74 have fluctuated less throughout the period, although the rate for this group decreased from 17.3 per 100,000 population in 2006 to 16.0 per 100,000 in 2007. • Women aged 75 and over show a similar trend to men in the same age group, with rates peaking at 9.4 per 100,000 population in 1993 and falling to 4.3 per 100,000 in 2007. • Since 2004 the highest suicide rates among women have been in those aged 45-74 and in 2007 the rate was 6.2 per 100,000 population. • Suicide rates in women aged 15-44 have consistently been the lowest across the 1991-2007 period and fell to 4.2 per 100,000 population in 2007.

9. Variations • Falls during the two world wars • A rise during the economic depression and high unemployment in the 1930’s • A fall after 1960 when Carbon monoxide was removed from domestic gas. • Highest in Spring and Summer (Apr, May, June) • Lowest in Winter (December) • Male > Female • Divorcees, widows and widowers > married • Social Class 1 & 5 > social class 2 & 3 • Unemployed > employed • Among employed – university students, doctors, lawyers, farmers, policemen, insurance agents. • Inner city areas with social deprivation, social isolation

10. Psychiatric factors Mental disorder in five psychological autopsy studies on completed suicides • Depressive disorder 36 – 90% • Alcohol dependence or abuse 43 – 54% • Drug Dependence or abuse 4 – 45% • Schizophrenic disorders 3 – 10% • Organic mental disorders 2 – 7% • Personality disorders 5 – 44% (Barrachlough et al 1974, Cheng and Lee 2000, Lennqvist, J.K.2000) • 90% of suicides have a psychiatric illness • The risk was greater in the first year of mental illness, especially with a major affective disorder. • 22% of suicide occurred in the first year of illness. • 15% had more than five hospital admissions prior to the suicide.

11. Physical illness • Terminal illness / malignancies • Debilitating illness and disability • Disfigurement • Chronic pain • Renal dialysis / failed transplant • Peptic ulcer • CNS disorder ( Huntington’s d/s, HIV/AIDS, spinal cord injuries, epilepsy) • CVD • SLE

12. Aetiology • Suicidal behaviour clusters in family • MZ : DZ (11.3% : 1.8%) Roy et al 1991 • Serotonin deficiency- lower CSF 5-HIAA in completed suicide than attempters (Aberg et al 1986) • Increased 5-HT receptors in the frontal cortex and hippocampus • Increased Opiate receptor density • Decreased cortical alpha 1 noradrenergic receptor density

13. DSH • Non-fatal Deliberate Self Harm (DSH)(Morgan 1979) Deliberate non-fatal act know to be potentially harmful, or if an overdose, that the amount taken is excessive. • Para suicide (Kreitman 1977) Behavioural analogue of suicide without considering psychological orientation towards death • Attempted Suicide (Stengel & Cook 1966) Every act of self injury consciously aimed at attempts to kill themselves. But it acknowledges the gravity of the situation. • Suicidal Act (Campbell & Hale 1991) The conscious or unconscious intention at the time of the act to kill the self’s body.

14. EPIDEMIOLOGY • Official rates (3-20%) DSH unreliable (by at least 30% in UK) • Prevalence is around 600 persons per 100000 per year • Rates increased in the 1960s & 1970s , fell in 1980s, rose again in the 1990-possible reasons: social changes in attitude to : self-harm, marriage breakdown, drinking + changes in prescribing habits. (Hawton & Catalan) • More common in young people, females, divorced, teenage wives, lower social classes • Higher rates in areas with high unemployment, overcrowding, social disintegration & mobility

15. Epidemiology 2 • Around 90% of DSH acts are drug overdoses, most commonly with NSAIDs, anxiolytics, and antidepressants (in that order). • Around 80% use prescription drugs (70% their own, 10% other people’s). • 50% of men and 25-45% of women have taken alcohol within the last 6 hours. • Of non-overdose DSH, self-laceration is the most common, otherwise it tends to comprise failed violent suicide attempts.

16. DSH and Mental illness • Less than 1/3 of patients • Depression, personality disorder, alcohol • 50% of suicide had h/o DSH • 1 in 100 committed suicde • Lesch-Nyahan syndrome • Prada Willy syndrome

17. Assessment • Evaluation of the characteristics of the attempt • Degree of suicidal intent • Seriousness of the attempt • Problems experienced by the patient • Serous social difficulties • mental state • Psychopathology and lifetime risk of suicide • Continue to have suicidal thought • Past history of suicide / DSH • Mental illness • Alcohol/substance abuse • psychotic symptoms • family history • Psychological factor • Family/Social Support

18. MCQ • 1. The following are true: A. Durkheim wrote about ecological views on suicide B. Esquirol suggested a psychiatric viewpoint on suicide C. Durkheim suggested altruistic, egoistic, and analytic types of suicide D. Thomas Browne coined the term ‘suicide’ E. In the Health of the Nation UK 1992, the Government set out plans to reduce suicide in the mentally ill by 15 % • 2. Associations of suicide include: A. Unemployment B. High rates in winter months C. Highest rates in lowest social group D. Low rates in upper social class E. Increased rates in vets • 3. Increased rates have been reported with: A. Renal dialysiss B. SLE C. Epilepsy D. Patients with high cholesterol E. Peptic ulcer • 4. Features contributing to higher rates among the prison population include: A. Prisoners convicted of minor crimes B. Prisoners on remand C. Previous psychiatric history D. Short sentence E. Hanging is least common method

19. MCQ • 5. Risk factors in depression include: A. Panic attacks B. Delusions C. Persistent insomnia D. Hopelessness E. Agitation • 6. Risk factors in schizophrenia include: A. Older patient B. Low level of premorbid function C. Ongoing psychosis D. Akathisia E. Short duration of illness  • 7. Risk factors in alcohol dependence include: A. Female B. Younger age (less than 40) C. Period of abstinence prior to attempt D. Unemployment E. Currently married   • 8. Risk factors in neurotic illness include: A Obsessive compulsive disorder B. Panic disorder C. Anorexia D. PTSD E. Bulimia  

20. MCQ 9. DSH is more common in: A. Females B. Lower social classes C. Asian subcultures D. Rural areas E. Over 35 years  s 10. Predictors of repetition of DSH include: A. Male sex B. Personality disorder C. Alcoholism D. Previous DSH E. Intact personality 11. Suicide and deliberate self-harm in adolescence: • Self-harm is usually premeditated • The highest risk of repetition is seen in older females. • 1-2% of those attempting suicide will eventually succeed. • There is a recurrence rate of approximately 20% within a year following one episode of DSH. • Cutting often has a dysphoric reducing effect. 12. Suicide • The profile of the incidence of suicide across all social classes forms U-shape curve. • Upper social classes have the highest suicide mortality. • The risk of suicide is greater in personality disorder than in schizophrenia. • Adverse life events are probably not especially common before suicide. • Higher rates of suicide are negatively correlated with unemployment.

21. MCQ 13. Correlates of deliberate self-harm include • Social class III • Overcrowded accommodation • At present address less than 1 year • Males under 18 years. • Significant debts 14. Risk factors for suicide in patients admitted to hospital following deliberate self-harm include. • Female gender. • Advancing age in men • Long-term sue of hypnotics. • Repeated attempts • Absence of psychiatric disorder.