March 13, 2003 Robbie N Drummond MD

2. Approach to Suicide Risk and Assessment in the ER Resident Presentation March 13, 2003 Robbie N Drummond MD

3. OVERVIEW • Statistics for our Region • Some basic epidemiology • Causes of Suicide • Risk Factors • Psychiatric Illness and Suicide • The No Harm Contract and Medico-legal Aspects of Suicide • A summary of my discussion with Dr. Phil Stokes

5. Case 1 • 39 year old accountant presents with 3 suicide attempts in one day • sat for 3 hours in car with hose from exhaust when it did not work cut wrist and sat in hot tub then drank approx 100 cc’s methyl chloride paint thinner • former alcoholic quit x 2 years • physical abuse in childhood • recently fired from job due to embezzlement of funds • wife left him suddenly for Ontario with 2 children • when she called said he was safe despite having just attempted suicide • friend found him • evidence of depressed affect on exam • foot note CO carboxyhemoglobin stayed high despite high fiO2

6. Case 2 • 21 year old Scandinavian youth • aristocratic background presents with agitation • says he is not sleeping at nights up pacing on the roof of his building • cannot concentrate on his studies recently quit college • feelings of guilt and that he is being punished • feeling very down socially isolating himself from his family • recent stressors sudden death of his father • not drinking • has hallucinations his dead father telling him to kill his uncle who has recently remarried to his mother

7. Suicide Note • To be, or not to be: that is the question:Whether 'tis nobler in the mind to sufferThe slings and arrows of outrageous fortune,Or to take arms against a sea of troubles,And by opposing end them? To die: to sleep;No more; and by a sleep to say we endThe heart-ache and the thousand natural shocksThat flesh is heir to, 'tis a consummationDevoutly to be wish'd. To die, to sleep;To sleep: perchance to dream: ay, there's the rub;For in that sleep of death what dreams may comeWhen we have shuffled off this mortal coil,Must give us pause: there's the respectThat makes calamity of so long life;.........

8. Suicide and Depression Emerg Med Cl may 2000 Harwitz • “Just as a consultation request for a patient with complaints of chest pain is more efficient when accompanied by a concise history, list of medications current vital signs, electrocardiogram, blood chemistry and response to initial management such is the case in referral of a suicidal patient”

9. Richard Bukata Emergency Medicine Abstracts 2002 • “The implication of routine consultation in the setting of suicide attempts is either that others are perceived to know more about assessing suicidality than we are or that we want someone to agree with us who has some psychiatric credentials of some sort. The bottom line is we the initially treating physicians are ultimately left with the disposition decision.”

10. “A person who is determined to kill himself or herself will probably prevail despite the best efforts of family members and health care professionals, However the overwhelming majority of people who decide to kill themselves at one time will feel very different after improvement in their depression or after receiving help with other problems”

19. Contact with mental health and primary care providers before suicideLuoma Am J Psychiatry 2002 • review of 40 studies • 3/4 suicide victims contact with primary care providers within year of suicide • 45% within one month • 1/3 with mental health within one year, 1/5 one month • especially older patients not so much young men • future research re mechanisms of action in contacts

20. Suicide Maris The Lancet 2002 • 1999 deaths by suicide made up 1.2 % of all deaths in the USA • fell steadily from 1990 to 1999 (14% REDUCTION IN RATE Over that time suicide had dropped from the eighth to the eleventh leading cause of death • 30000 deaths per year in USA • 18.7 per 100.000 men, 4.4 per 100,000 women • <1 per 100000 in Syria >40 per 100000 in USSR • whites >2x African Americans • third leading cause of death in persons 15 to 34 • A Current perspective of Suicide and Attempted Suicide Mann Ann Int Med 2002

21. Identification of Suicide Risk Factors Using Epidemiologic Studies Moscicki 1997 psy Cl North America • in USA firearms account for nearly 60% of all suicides • 10 studies show that a whether handgun or rifle in the house even if unloaded increases the risk of suicide in adults and youths strongest proximal risk factor • independently increases the risk of suicide for both genders and across all age groups even after correcting for confounding factors • women: drugs medications, second; for men: hanging

22. Assessment and Treatment of Suicidal Patients Hirschfield NEJM 1997 • Up to one third of persons in the general population have suicidal ideation at some point in their lives • Physicians are sometimes reluctant to ask patients about suicide fearing that the question may lead to suicidal thinking and precipitate suicidal acts. There is no evidence to support this concern • Most patients are ambivalent and relieved to talk • forecasting the weather vs predicting astronomical events • predicting short term risk 24 -48 hours more reliable than longterm • Approximately 25% of suicidal patients do not admit to being suicidal (Fawcett et al., 1990). • one of eighteen attempts is completed

23. suicidal ideation: thoughts of ending one’s life • passive: absence of plan “I wish I were dead” • active: presence of plan “I’ve saved my medicines..... • Suicidal gesture: no realistic expectation of death • suicidal attempt: clear expectation of death • National Comorbidity Survey • suicide ideation to suicide plan were 34% • plan to attempt were 72% • transition directly from ideation to an unplanned attempt was 26% • 90% of unplanned and 60% of planned first attempts happened within one year of suicide ideation

24. Criteria for Screening Diseases WHO • 1) the disease is prevalent • 2) the disease may not be evident to the person who has it • 3) the disease is treatable • 4) early intervention is advantageous • 5) the screening test is reliable • 6) the cost and burden of screening is moderate

25. An educational intervention for front-line health professionals in the assessment and management of suicidal patients (the STORM project Applebee Psychological Medicine 2000 • previous study Morriss et al suicide risk assessment and management skills do not change without training • training delivered to 167 health professionals primary care accident and emergency departments • 47% of all available staff two training sessions in 6 month period • non mental health professionals improved significantly in assessment, clinical management and problem-solving • with marked improvement in confidence • satisfaction with training was high

26. Teaching Front line health and voluntary workers to assess and manage suicidal patients Morriss et al J of Affective Disorders 1999 • four two hour sessions to 33 health and voluntary workers using role-playing,interview skill training and video feedback • overall risk assessment and management skills retained for at least 1 month confidence improved • training too brief to produce improvements in general interview skills • may require up to 6 months to attain

27. Gotland Study • education of general practitioners in the recognition and treatment of depression in 1983 was associated with increased antidepressant prescriptions and a decrease in the annual suicide rate from 20 to 7 per 100,000. The high level of medical contact before suicide means that effective preventive treatment is possible

28. The Neurobiology of Suicide Risk,Mann J Cl Psych 1999 • genetic modulation of serotonergic activity • aggression and impulsivity changes found in substance abuse and depression • 18 studies look a 5 hydroxyindoleactic acid 5HIAA in CSF • low levels in suicide attempters • the more lethal the attempt the lower the level of 5 HIAA • gene for tryptophan hydroxylase is affected • altered serotonin function lack of serotonin transporter binding in nerve terminal • changes in prolactin responses to serotonin responsivity • increased serotonin receptors on platelets • PET scanner shows significant reduction of resting glucose metabolism in prefrontal cortex of murderers and skewed serotonin circuitry in suicidal patients • suicidal patients have higher serum cortisol levels

30. Genetics of Suicide in DepressionRoy et al J clin Psych 1999 • 11% of completed suicides had another first degree relative who had committed suicide (Hemmingway family grandfather, father, son, granddaughter) • significantly more in a patient that had made a violent attempt • genetic transmission of psychiatric disease • twin and adoption studies high concordance for suicide rates • of 35 twins for whom 1 twin had committed suicide 10 of the 26 living monozygotic twin had attempted compared to 0 of the dizygotic twins • significantly more of adopted children of biological parents who committed suicide themselves committed suicide Copenhagen study • genetic susceptibility to suicide only likely to manifest in times of severe stress or when ill with major psychiatric illness • heritable trait analogous to other disorders e.g. bipolar

31. Childhood Abuse, Household Dysfunction and the Risk of Attempted Suicide Throughout the Life Span Dube et al JAMA 2001 • well designed study: 9367 women, 7970 men • retrospective cohort study of 17,337 adults HMO members • survey of childhood abuse household dysfunction and suicide attempts • lifetime prevalence of 1 suicide attempt: 3.8% • adverse childhood experiences increased the risk 2 -5 fold • emotional, physical and sexual abuse, household substance abuse, mental illness, and incarceration, and parental domestic violence, separation, or divorce • as number of adverse experiences increase the risk increses dramatically • 67 % of suicide attempts are attributable to traumatic childhood experiences

32. 5 Questions • do you ever get so depressed that you think life is not worth living? • do you think of hurting yourself or taking your own life? • do you have a plan? • do you have the means to follow through with the plan? • have you ever attempted suicide?

33. Demographic Risk Factors • gender women three times as likely to attempt men four times as likely to die • race whites and native Americans • age 60 years and older • leading cause of death in 10 to 49 years old in our region • lack of social support unmarried divorced or widowed • financial difficulties unemployment • the risk factors for suicide are additive

34. nontraditional risk factors: • drinking within three hours of the suicide attempt • changing residences within the past 12 months • existing medical conditions • impulsive behavior • 50% of people who died by suicide in Chicago had no close friends the presence of of a therapist, spouse, or other person (only one other person) is crucial • the difficulty with risk factor for suicides is that they lead to many false positive predictions

35. SAD PERSONS: a mnemonic for assessing suicide risk • S Sex (male) • A Age (elderly or adolescent) • D Depression • P Previous suicide attempts • E Ethanol abuse • R Rational thinking loss (psychosis) • S Social supports lacking • O Organized plan to commit suicide • N No spouse (divorced > widowed > single) • S Sickness (physical illness) • Adapted from Patterson et al (12). • 0 -3 close follow up consider admit, 4 -5 consider admit, >5 admit

36. No Hope Scale • N No framework for meaning • O Overt change in clinical condition • H Hostile interpersonal environment • O Out of hospital recently • P Predisposing personality factors • E Excuses for dying are present and strongly believed • only three scales have predictive validate Beck’s hopelessness scale, Linehan’s reasons for living and Cull and Gill’s suicide probability scale • no one psychological test is highly predictive of suicidal acts • Risk factors fall into 2 categories predisposing factors and potentiating factors • the combination of psychiatric disorder and a stressor

39. The best predictor of completed suicide is a history of attempted suicide • subsequent attempts greater lethality and intent • careful inquiry about past suicide attempts essential part of tisk assessment • two thirds of suicides occur with first attempt • the greatest risk occurs within 3 months of the first attempt

40. Suicide after ParasuicideRuneson BMJ 2002 • The risk of suicide is generally most prominent during the first months after psychiatric care • The risk of repetition and consequently of suicide is believed to be highest during the first one or two years after an episode of parasuicide • the initial high risk declines each year

41. Suicide rate 22 years after parasuicide:cohort study Jenkins BMJ 2002 • The rate of suicide for people who have had an episode of parasuicide is 100 times higher in the year following the episode than that of the general population • traced record 22 years 63% of the original sample • the risk of suicide for people with a history of parasuicide persists over many years 4.3 per 1000 per year > 3 x normal rate

42. More than 90% of suicide victims have a diagnosable psychiatric illness • main protective factors accurate, early diagnosis and effective treatment of psychiatric disorders • important to be aware of Axis formulation • Axis 1 major psychiatric disorder including substance abuse • Axis 2 personality disorder including impulsivity and aggressivity • Axis 3 major contributing physical illness esp in elderly • Axis 4 recent major stressors • Axis 5 highest level of functioning which would include withholding factors • Axis 1, 2, and 3 predisposing factors Axis 4, and 5 potentiating

43. Risks depending on diagnosis: • 60% have mood disorders • followed by schizophrenia, alcoholism, substance abuse and personality disorder • most people with psychiatric disorder never attempt suicide • lifetime risk: • Bipolar 20% • alcoholism 18% • major depression 15% • schizophrenia 10% • borderline and antisocial personality disorder 5-10%

44. Depression Screening as an Intervention Against Suicide Jacobs J clin Psychiatry 1999 • prevalence of current major depression has been estimated 4.9% • lifetime prevalence is 17.1% • less than 40 % of lifetime depression are diagnosed • less than 20% current depression were in treatment • national depression screening day 30 sites malls libraries corporations army bases hospitals started Quincy Mass • October during Mental Illness Awareness Week • Zung Self Rated Depression Scale • 400,000 screened followed by one on one interview and referral • 20% found to have severe depression 1444 hospitalized • only 15% of a sample of individuals who killed themselves had received antidepressant medication in New York 84% of a sample of people who committed suicide had not taken any antidepressant or neuroleptics Maris the Lancet 2002

45. SIG ME CAPS (prescribe me caps) • Usually one uses either the Hamilton or Beck depression inventory or scale, since suicide outcomes correlate highly with depressive disorders • five symptoms to make diagnosis in 2 week period • S = sleep • I = interest • G = guilt • M = mood • E = energy • C = concentration • A = appetite • P = psychomotor retardation or agitation • S = suicidal ideation

46. hard to find conclusive evidence of the syllogism that clinical depression is the leading cause of suicidal behaviour, that depression is highly treatable and adequate treatment should reduce suicide risk • however statistics in USA show decline likely due to increased awareness and use of newer antidepressants

47. Suicidality and Substance Abuse in Affective Disorders Goldberg J CLin Psych 2001 • 5- 10 fold increase • more medically dangerous attempts • abuse higher in bipolar than any other Axis 1 diagnosis • alcohol worsens the course of all affective illnesses • 56 % male bipolar suicide are alcoholic • impulse control disorders 40% alcohol dependence • likely higher levels of aggression • greater levels of panic disorder, phobic disorders and GAD • serotonin dysfunction implicated: • impulsivity, aggression, alcohol dependence, suicide and affective disorders

48. up to 50% of all people who commit suicide are intoxicated at the time of death 18% of alcoholics will die by suicide • increases brain serotonin at first depletes later • reduces impulse control • adolescent suicide victims with alcohol abuse more vulnerable to interpersonal losses and psychosocial stressors • social isolation and alcohol abuse linked to suicide middle-aged men • SSRI’s diminish alcohol symptoms as well as depressive features in depressed alcoholics with suicidality • specific psychotherapies cognitive behavioral therapies, dialectical behavioral therapy effective in borderline personality, alcoholism, depression • Intoxicated or psychotic patients unknown to clinician who say they are suicidal should be transported securely to the nearest crisis center. These patients can be dangerous and impulsive.

49. Personality Traits • more subjective depression and hopelessness • greater lifetime aggressively and impulsivity • patients with a history of violence greater lifetime risk of self harm • personality based suicide results from feelings of anger aggression or vengeance • psychoanalyst says adamancy is main trait

50. Chronic suicidality among patients with borderline personality disorder Paris J Psychiatric Serv June 2002 • One in ten completes suicide • not preventable usually does not occur in treatment • chronic suicidality a way of communicating distress • hospitalization unproven benefit possible negative effects • fear of litigation not a reason to admit • suicide risk not a contraindication for OPD treatment