Suicide AssessmentNajran Armed forces Hospital programme

Continues medical education Programme

Psychiatric department

March 28, 2010

Hisham Afaneh, MD

Jordanian Board of Psychiatry ,

Definition of suicide

Suicide is a verdict or a category of death which is broadly defined by the following requirements:

the death was unnatural It was the result of the victim`s own

actionThe victim intended of kill him self suicide (beck)A willful self- inflicted life threatening act

which has resulted in death.

Definition of self-harm

``Deliberate self-injury`` substituted for `` attempted suicide`` because many patients performed their acts in the belief that they were comparatively safe.(kessel)

Parasuicide refers to a behavior analogue of suicide but without considering a psychological orientation towards death being in anyway essential to the condition(kreitman)

Types of suicide Euthanasia and assisted suicide Murder-suicide Suicide attack Mass suicide Suicide pact Metaphorical suicide

Suicide-More Background10th leading cause of death worldwide with

about a million people dying by suicide annually

11th leading cause of death in 2000 (28,322) 2005 suicides in the U.S. outnumber homicides

by nearly 2 to 1,China, India and Japan may account for 40%

of all world suicides3rd leading cause of death for 15-24 year olds,

5th leading for 5-14 years old.1.3% of all deaths are from suicide (double the

rate of AIDS).Males 4x more likely to commit suicide.Estimates suggest that between 8-25

unsuccessful attempts for every successful.

Epidemiology of suicide (1)

Lithuania (42 suicides per 100,000)

Japan (23.8) China (13.9), 13 (per 100,000) and that

for women 14.8

Spain (8.2), UK (6.9)Islamic & Arab countries Iran (2),Libanon (1)

Kuwait, (2) Egypt (0)

Jordan (0) (0.23)

Epidemiology of suicide (2)

Age :- incidence increased e age 47% of male suicide over 45 years 21% Increased in suicide over 65 y 20% increased in suicide ~ 15-19 y Sex :- Male <female for all age groups suicidal attempt more common than female Marital status :- highest ( Divorced &widowed) Urban < rural area Seasonal highest in spring& lowest in winter Social class : 1, V Religion : catholic > protestants and Jews Occupation :- doctors , lawyer and musicians unemployed

Profile of the Suicide

30,000 suicides per year in the US

0.01% annual incidence rate (11.4/100,000)

80% suicides are in males (4:1 m/f ratio)

Third leading cause of death in the 15-24 age

group representing 20% of suicides

Associated with severe depression

Majority not in mental health treatment

75% have seen a physician in previous six months

No one factor predictive of suicide

60% suicide on first attempt

No medication has ever been proven to cause suicide

Accutane FDA (PRI 006 Jacobs) 10

Definitional Issues - Suicidal BehaviorSuicidal Ideation:

– A) nonspecific -- thoughts of death

– B) specific -- the thought of death includes an intent to die with a plan of action

Prevalence of suicidal ideation = 2.6%

Thoughts of death = 28.2%

Suicidal ideation (definition B) is associated with a psychiatric disorder, primarily depression

Suicide Attempts: – A) (U.S.) Potential or actual self-

injurious behavior accompanied by intent to die

– B) (Europe) Parasuicide -- a self-harmful act with nonfatal outcome -- intent not included in definition

(U.S.) Current prevalence estimates: 0.3 to 0.8%– Male/Female ratio 1:3 (inverse

of suicides)– Attempts/completion 18/1

Higher incidence of attempts in 15-24 age population: 100/1 (parasuicide)

Serious suicide attempts indicative of severe psychiatric illness

Methods of suicide Non-violent (drugs and poison) Violent which are more commonly by men and mentally ill. In U.k suicide by hanging and by poisoning with vehicle exhaust

fume account for 2 in 3 male suicide but only 1 in 3 women IN USA Firearms account for 55-60% of suicides (Baker 1984, Sloan 1990). Firearms at home increase risk for adolescents: Guns are twice as likely to be found in the homes of suicide

victims as in the homes of attempters (Brent et al 1991) Type of gun (handgun, rifle, etc.) was not statistically correlated

with increased risk for suicide

Risk management point: Inquire about firearms when indicated and document instructions and response

SUICIDE PREDICTION vs .SUICIDE ASSESSMENT

• Suicide Prediction refers to the foretelling of whether suicide will or will not occur at some future time, based on the presence or absence of a specific number of defined factors, within definable limits of statistical probability

• Suicide (risk) Assessment refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail. Risk assessment carried out in a systematic, disciplined way is more than a guess or intuition – it is a reasoned, inductive process, and a necessary exercise in estimating probability over short periods.

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

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

PROTECTIVE FACTORS

Children in the home, except among those with postpartum psychosis

Pregnancy

Deterrent religious beliefs

Life satisfaction

Reality testing ability

Positive coping skills

Positive social support

Positive therapeutic relationship

DETERMINATION OF RISK

Psychiatric Examination

Risk Factors Protective

Factors Specific Suicide

Inquiry Modifiable Risk

Factors

Risk Level: Low, Med., High

RISK FACTORS (blue = 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

COMPONENTS OF SUICIDE ASSESSMENTAppreciate the complexity of suicide /

multiple contributing factorsConduct a thorough psychiatric

examination, identifying risk factors and protective factors and

distinguishing risk factors which can be modified from those which cannot

Ask directly about suicide; The Specific Suicide Inquiry

Determine level of suicide risk: low, moderate, high

Determine treatment setting and planDocument assessments

SUICIDE RISKS IN SPECIFIC DISORDERS

Prior suicide attempt 38.4 0.549 27.5Eating disorders 23.1Bipolar disorder 21.7 0.310 15.5Major depression 20.4 0.292 14.6Mixed drug abuse 19.2 0.275 14.7Dysthymia 12.1 0.173 8.6Obsessive-compulsive 11.5 0.143 8.2Panic disorder 10.0 0.160 7.2Schizophrenia 8.45 0.121 6.0Personality disorders 7.08 0.101 5.1Alcohol abuse 5.86 0.084 4.2Cancer 1.80 0.026 1.3

General population 1.00 0.014 0.72

Condition RR %/y %-Lifetime

Adapted from A.P.A. Guidelines, part A, p. 16

COMORBIDITY

In general, the more diagnoses present, the higher the risk of suicide.

Psychological Autopsy of 229 Suicides44% had 2 or more Axis I diagnoses31% had Axis I and Axis II diagnoses50% had Axis I and at least one Axis III

diagnosisOnly 12 % had an Axis I diagnosis with no

comorbidityHenriksson et al, 1993

AFFECTIVE DISORDERS AND SUICIDE

High-Risk Profile: ( 15%)• Suicide occurs early in the course of illness• Psychic anxiety or panic symptoms• Moderate alcohol abuse• First episode of suicidality • Hospitalized for affective disorder secondary

to suicidality• Risk for men is four times as high as for

women except in bipolar disorder where women are equally at risk

SCHIZOPHRENIA AND SUICIDE

High-Risk Profile: Previous suicide attempt(s) Significant depressive symptoms - hopelessness Young ,Male gender, single First decade of illness – (however, rate remains

elevated throughout lifetime 6-10%) high previous premorbid functioning or educational attainment

Current substance abuse Poor current work and social functioning Recent hospital discharge

15% of alcoholics kill themselves

Suicide occurs later in the course of the illness with communications of suicidal intent lasting several years

In completed suicides, men have higher rates of alcohol abuse, women have higher rates of drug abuse

Increased number of substances used, rather than the type of substance appears to be important

Most have comorbid psychiatric disorders, females have Borderline Personality Disorder

High Risk Profile: Recent or impending interpersonal loss Comorbid depression

ALCOHOL / SUBSTANCE ABUSE AND SUICIDE

PERSONALITY DISORDERS AND SUICIDE

Borderline Personality Disorder Lifetime rate of suicide - 8.5% With alcohol problems -19% With alcohol problems and major affective disorder -38%

(Stone 1993). A comorbid condition in over 30% of the suicides. Nearly 75% of patients with borderline personality disorder

have made at least one suicide attempt in their lives.

Antisocial Personality disorder 5% Suicide associated impulsivity. 3x risk of suicide than G.P

Family history of abuse, violence, or other self-destructive 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).

FAMILY PSYCHOPATHOLOGY

FAMILY HISTORY/GENETICS

Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal

subjects.

Twin studies indicate a higher concordance of suicidal behavior between identical rather than

fraternal twins.

Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives .

Suicide appears to be an independent, inheritable risk factor.

(Baldessarini, to be published)

PSYCHOSOCIAL SITUATION:LIFE STRESSORS

Recent severe, stressful life events associated with suicide in vulnerable individuals (Moscicki 1997).

Stressors include interpersonal loss or conflict, economic problems, legal problems, and moving (Brent et al 1993b, Lesage et al 1994, Rich et al 1998a, Moscicki 1997).

High risk stressor: humiliating events, e.g., financial ruin associated with scandal, 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.

All studies are reviews

Social variable

Emile Durkheim states that we must understand the relationship between

individual and society.Egoistic suicide: suicide of isolated

individual.(single)Altruistic: over involvement with society.

Suicide undertaken on behalf of the group.Anomic: when society fails to regulate its

members (adolescent rejected by peer group, farmer ruined by economic structure)

Fatalistic: excessive regulation (e.g., prisoners, slaves)

Biochemical variable

Dysfunction of monoaminergic neurotransmission ( serotonergic and noradrenergic systems)

low 5 HIAA Concentration IN C.S.F ( most consistent finding in patient with completed suicides)

Post mortem ligand binding – increased nr. Of 5 HT receptors in prefrontal cortex

and hippocampus Abnormalities of opoid receptors

( increased destroy ) and abnormalities of N/A ( decreased alpha 1 cortical N/A

density)

Firearms account for 55-60% of suicides (Baker 1984, Sloan 1990).

Firearms at home increase risk for adolescents:• Guns are twice as likely to be found in the homes of suicide

victims as in the homes of attempters (OR 2.1) or in the homes of control group (OR 2.2) (Brent et al 1991)

• Type of gun (handgun, rifle, etc.) was not statistically correlated with increased risk for suicide

Risk management point: Inquire about firearms when indicated and document instructions and response.

PSYCHOSOCIAL SITUATION:FIREARMS AND SUICIDE

Explanations for Suicide

PsychologicalFreud: Suicide is murder turned around

180 degrees. Person identifies themselves with a lost person or object.

They become angry at loss and turn their anger inward.

INDIVIDUAL STRENGTHS/ VULNERABILITIES:PSYCHODYNAMICS FROM MENNINGER

Menninger KA. “Psychoanalytic Aspects of Suicide” International Journal of Psychoanalysis. 14 (1933) 376-390.

Believed that suicide could be understood through the interplay of three internal wishes:

• Wish to kill• Wish to be killed• Wish to die

DIRECT QUESTIONING ABOUT SUICIDE:THE SPECIFIC SUICIDE INQUIRY

Ask About:Suicidal ideationSuicide plans

Give Added Consideration to:Suicide attempts (actual and aborted)First episode of suicidality (Kessler

1999)HopelessnessAmbivalence: a chance to intervenePsychological pain history

Jacobs (1998)

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. Lethality is distinct from and may not always

coincide with an individual’s expectation of what is medically dangerous.

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)

Circumstances suggesting high suicidal risk

Planning in advance - telling other about their intent

Giving away beloved objects.Changes in eating or sleeping habits.Displaying a sense of calmness after a

period of agitation.Precaution to avoid discoveryCarried out alone No attempts to obtain help of othersViolent methodsFinal act (suicide

PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SUICIDE

HopelessnessImpulsivity / AggressionAnxietyCommand hallucinations

PSYCHIATRIC SYMPTOMATOLOGY:IMPULSIVITY / AGGRESSION

May contribute to suicidal behaviorIt is important to assess level of

impulsiveness when assessing for suicidality (Sher 2001, Fawcett et al,

in press)Suicide attempters may be more likely

to present traits of impulsiveness / aggression regardless of psychiatric

diagnosis (Mann et al 1999).Important in assessing risk of murder-

suicide

PSYCHIATRIC SYMPTOMATOLOGY:

ANXIETY Anxiety symptoms (independent of an anxiety

disorder) associated with suicide risk: Panic Attacks Severe Psychic Anxiety (subjective anxiety) Anxious Ruminations Agitation

In a review of inpatient suicides 79% met criteria for severe or extreme anxiety or agitation

PSYCHIATRIC SYMPTOMATOLOGY:COMMAND HALLUCINATIONS

Existing studies are too small to draw conclusions, patients with command hallucinations may not be at greater risk, per se, than other severely psychotic patients.

However, the majority of patients with suicidal command hallucinations should be considered seriously suicidal

Management of patients with chronic command hallucinations requires consultation and documentation

Adapted from A.P.A. Guidelines, Part A, p. 20-21

DETERMINATION OF THE LEVEL OF RISK

Clinical judgment based upon consideration of relevant risk factors, present episode of illness, symptoms,

and the specific suicide inquiry.

Seek consultation / supervision as needed

Suicide risk will need to be reassessed at various points

throughout treatment, as a patient’s risk level will wax and wane.

DETERMINE TREATMENT SETTING AND PLAN

Attend to issue of patient’s safety.

Assess treatment plan/setting/alliance.

Somatic treatment modalities:ECT – used to treat acute suicidal behaviorBenzodiazepines – may reduce risk by treating anxietyAntidepressantsLithium, AnticonvulsantsAntipsychotics, recent study on Clozapine

Psychotherapeutic intervention – widely viewed as helpful for suicidal patients, evidence is limited

Provide education to patient and family.

Monitor psychiatric status and response to treatment.

Reassess for safety and suicide risk frequently.

SOMATIC TREATMENTS

ECT Evidence for short-term reduction of suicide, but not long-term.

Benzodiazepines May reduce risk by treating anxiety

Antidepressants A mainstay treatment of suicidal patients with depressive illness / symptoms. No conclusive evidence of suicide reduction

Lithium and Anti-convulsants

Lithium has a demonstrated anti-suicide effect; anticonvulsants do not

Antipsychotics Evidence for Clozapine reducing suicidality in schizophrenia and schizo-affective disorders

Psychotherapy Regardless of theoretical basis, key

element is a positive and sustaining therapeutic relationship

Recommended (primarily from clinical consensus)

To target issuesDenial of symptomsLack of insight

To manage high risk symptomsHopelessnessAnxiety

Effective treatment in high risk diagnosesDepressionPersonality disorders (use of D.B.T.)

Adapted from APA Guidelines, Part A, p. 40

SUICIDE CONTRACTS

Problems:•Commonly used, but no studies

demonstrating ability to reduce suicide.•Not a legal document, whether signed or

not.•Used pro-forma, without evaluation by

psychiatrist.

Possibilities:•Useful when there is positive therapeutic

relationship (do not use when covering for colleague).

•If employed, outline terms in patient’s record.

•Useful when they emphasize availability of clinician.

•Rejection of contracts have significance.

Bottom line – still considered within standard of care but usage should be

“shrinking”

At first psychiatric assessment or admission.

With occurrence of any suicidal behavior or ideation.

Whenever there is any noteworthy clinical change.

For inpatients:• Before increasing privileges/giving passes• Before discharge

The issue of firearms:• If present - document instructions• If absent - document as pertinent negative

WHEN TO DOCUMENT SUICIDE RISK ASSESSMENTS

WHEN A SUICIDE OCCURS

Despite best efforts at suicide assessment and treatment, suicides can and do occur in

clinical practice

Approximately, 12,000-14,000 suicides per year occur while in treatment.

To facilitate the aftercare process:Ensure that the patient’s records are

complete

Be available to assist grieving family members

Remember the medical record is still official and confidentiality still exists

Seek support from colleagues / supervisors

Consult risk managers

WHAT TO DOCUMENT IN A SUICIDE ASSESSMENT

Document:• The risk level• The basis for the risk level• The treatment plan for reducing the risk

Example: This 62 y.o., recently separated man is experiencing his first

episode of major depressive disorder. In spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of his serious suicide attempt and his continued anxiety and hopelessness. The plan is to hospitalize with suicide precautions and medications, consider ECT w/u. Reassess tomorrow.

References

Jacobs DG, ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA. Jossey-Bass Publisher, 1998.

Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. American Journal of Psychiatry (Suppl.) Vol. 160, No. 11,

November 2003