SUICIDE

1. SUICIDE Reference: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition (2007)

2. Suicide– taking one’s own life • a primary emergency for the mental health professional • almost always the result of a mental illness, usually depression, and is amenable to psychological and pharmacological treatment

3. STATISTICS ON SUICIDE • 90 % have depression or another diagnosable mental or substance abuse disorder. • Up to 15% who are clinically depressed die by suicide.

4. More than four times as many men than women die by suicide Women report attempting suicide about twice as often as men through overdose on medications Women usually use means from which they may be rescued, such as a drug overdose Mentend to use firearms or automobiles.hanging, or jumping from high places.

5. Suicide by firearms -most common method for completed suicide for both men and women. suicide rate in young people has increased dramatically.

6. adolescents aged 15 to 19, the gender ratio was 5:1 (males: females). Among young people aged 20 to 24, the gender ratio in this age group was 7:1 (males: females).

7. Men commit suicide more than four times as often as women Women, however, are four times more likely to attempt suicide than men. Men's higher rate of completed suicide is related to: use of firearms, hanging, or jumping from high places. Women commonly take an overdose of psychoactive substances or a poison

8. Globally, the most common method of suicide is hanging

9. FIGURE 34.1-2 Venn diagram summarizing suicide data and its relation to mood disorder and suicide attempts. (Courtesy of Alec Roy, M.D.)

11. CAUSES OF DEPRESSION • The causes of depression are often multi-factorial and may include: • Genetic predisposition • Stress at home, work or school

12. Loss of a parent or loved one • Alcohol or substance abuse • Breakup of a romantic relationship • Medications

13. Low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF) were associated with suicidal behavior. Studies support the hypothesis that reduced central serotonin is associated with suicide

14. Table 34.1-2 Evaluation of Suicide Risk (From Adam K. Attempted suicide. PsychiatrClin North Am. 1985;8:183, with permission.)

18. Factors that may be related to suicide are as follows: • Bullying and discrimination • Mental illness and disability • Poverty • Substance abuse

19. Crime — Criminals may commit suicide before they're caught, or before they get on trial. They would rather die than face the legal and social consequences of their actions. • Stress • Religious reasons (e.g. many suicide bombings in the Middle East have been based on Islamic fundamentalism)

20. Misery due to one's location • Anxiety • Hopelessness • Altruism (e.g. self-sacrifice to save someone else) • Physical Agony (eg. physical agony that just is not correctable)

21. Suicide rates increase with age. • Evaluation for suicide potential: • a complete psychiatric history • examination of the patient's mental state • inquiry about depressive symptoms suicidal thoughts, intents, plans, and attempts.

22. A lack of future plans, giving away personal property, making a will, and having recently experienced a loss all imply increased risk of suicide. The absence of a strong social support system, a history of impulsive behavior, and a suicidal plan of action are indications for hospitalization—treated as an emergency

23. Vigorous treatment with antidepressant or antipsychotic medication should be initiated Some medications (e.g., risperidone [Risperdal]) have both antipsychotic and antidepressant effects and are useful when the patient has signs and symptoms of both psychosis and depression.

24. Table 34.1-1 Variables Enhancing Risk of Suicide among Vulnerable Group • Adolescence and late life • Bisexual or homosexual gender identity • Criminal behavior • Cultural sanctions for suicide • Delusions • Disposition of personal property • Divorced, separated, or single marital status • Early loss or separation from parents • Family history of suicide • Hallucinations • Homicide • Hopelessness • Hypochondriasis

25. Impulsivity • Increasing agitation • Increasing stress • Insomnia • Lack of future plans • Lack of sleep • Lethality of previous attempt • Living alone • Low self-esteem • Male sex • Physical illness or impairment • Previous attempts that could have resulted in death • Protestant or nonreligious status • Recent childbirth

26. Recent loss • Repression as a defense • Secondary gain • Severe family pathology • Severe psychiatric illness • Sexual abuse • Signals of intent to die • Suicide epidemics • Unemployment • White race

27. Parasuicidal Behavior describe patients who injure themselves by self-mutilation (e.g., cutting the skin), but who usually do not wish to die. about 4 percent of all patients in psychiatric hospitals have cut themselves; the female-to-male ratio is almost 3 to 1.

28. Warning signs of Suicide Previous suicide attempts Recent suicide of a friend or relative Threats to suicide Depression Changes in personality or behavior

29. Warning signs of Suicide 6. Increased use of drugs and/or alcohol • Behavioral disturbances • Psychiatric illness • Preparation for death • Sudden lift in spirit

30. SUBSTANCE ABUSE Substance abuse is a risk factor for suicide. Substance abuse refers to the overindulgence in and dependence on a stimulant, depressant, chemical substance, herb (plant) or = effects that are detrimental to the individual's physical health or mental health, or the welfare of others.

31. Substance abuse is sometimes used as a synonym for drug abuse, drug addiction, and chemical dependency, but actually refers to the use of substances in a manner outside sociocultural conventions Addiction, or dependence - a cluster of 3 or more symptoms occurring at any time in the same 12-month period" (American Psychiatric Association)

32. SYMPTOMS OF SUBSTANCE ABUSE • tolerance, or needing more and more of a substance to achieve the same effect; • withdrawal, which involves unpleasant symptoms when the body is deprived of the substance, resulting in more frequent use to alleviate the negative symptoms;

33. taking the substance for a longer period of time or in larger amounts than originally intended; • unsuccessful desire to minimize use of the substance; • much time spent to obtain, use, or recover from the effects of the substance;

34. social, occupational, or recreational activities are missed because of substance abuse; and • substance use is continued despite knowledge of causing a problem. If neither tolerance nor withdrawal are present, then at least three of the remaining symptoms must be present

35. COMPLETED SUICIDES SHOWED THE FOLLOWING COMMON CHARACTERISTICS: • Ideation • Suicidal intent • Plan • Means

36. Table 34.1-3 Questions about Suicidal Feelings and Behaviors* • Begin with questions that address the patient's feeling about living • Have you ever felt that life was not worth living? • Did you ever wish you could go to sleep and just not wake up? • Follow on with specific questions that ask about thoughts of death, self-harm, or suicide • Is death something you have thought about recently? • Have things ever reached the point that you have thought of harming yourself? • For individuals who have thoughts of self-harm or suicideWhen did you first notice such thoughts?

37. What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)? • How often have those thoughts occurred, including frequency, obsessional quality, controllability? • How close have you come to acting on those thoughts? • How likely do you think it is that you will act on them in the future? • Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)?

38. What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)? • Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?) • Do you have guns or other weapons available to you? • Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)? • Have you spoken to anyone about your plans? • How does the future look to you?

39. What things would lead you to feel more (or less) hopeful about the future (e.g., treatment, reconciliation of relationship, resolution of stressors)? • What things would make it more (or less) likely that you would try to kill yourself? • What things in your life would lead you to want to escape from life or be dead? • What things in your life make you want to go on living? • If you began to have thoughts of harming or killing yourself again, what would you do? • For individuals who have attempted suicide or engaged in self-damaging action(s), parallel questions to those in the previous section can address the prior attempt(s).

40. Additional questions can be asked in general terms or can refer to the specific method used and may include: • Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)? • What thoughts were you having beforehand that led up to the attempt? • What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)? • Were other people present at the time? • Did you seek help afterward yourself, or did someone get help for you?

41. Had you planned to be discovered, or were you found accidentally? • How did you feel afterward (e.g., relief versus regret at being alive)? • Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)? • Has your view of things changed, or is anything different for you since the attempt? • Are there other times in the past when you have tried to harm (or kill) yourself? • For individuals with repeated suicidal thoughts or attemptsAbout how often have you tried to harm (or kill) yourself?

42. When was the most recent time? • Can you describe your thoughts at the time that you were thinking most seriously about suicide? • When was your most serious attempt at harming or killing yourself? • What led up to it, and what happened afterward? • For individuals with psychosis, ask specifically about hallucinations and delusions • Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus nonrecognizable)?

43. What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples.) • How do you cope with (or respond to) the voices?Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?) • Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?) • Are you worried about having a serious illness or that your body is rotting? • Are you concerned about your financial situation even when others tell you there's nothing to worry about?

44. Are there things that you've been feeling guilty about or blaming yourself for? • Consider assessing the patient's potential to harm others in addition to him- or herself • Are there others who you think may be responsible for what you are experiencing (e.g., persecutory ideas, passivity experiences)? • Are you having any thoughts of harming them? • Are there other people you would want to die with you? • Are there others who you think would be unable to go on without you?

45. THE END