wpa educational programme on depressive disorders: depression in population groups part 5:...

WPA Educational Programme on Depressive Disorders: Depression in population groupsPart 5:

Prevention of Suicide; Issues for General PractitionersProf Danuta Wasserman

Dr Susanne Ringskog Vagnhammar

Copyright © 2012 World Psychiatric Association

Definitions of suicide

• Suicide is a deliberate, determined, self-inflicted and life-threatening act resulting in death

• Suicide attempt, or parasuicide, is a self-inflicted, self-destructive act with non-fatal outcome and which is aimed at realising changes which the subject desires

Copyright © 2012 World Psychiatric Association 2


Classification of Suicide Behaviors: Steps in the Suicidal Process

• Suicidal ideas

• Suicidal gestures

• Medically less serious suicide attempts

• Medically serious suicide attempts

• Completed suicide


Increase in Suicides World-Wide

In the year 2000:

1 million people committed suicide

In the year 2020:

It is estimated that 1.53 million people will commit suicide


Suicide and Gender

• World-wide more men than women commit suicide

(with some exceptions, eg China)


Why do more men than women commit suicide?

• Men often use more violent suicide methods

• Depression in men often escape diagnosis and treatment (because of atypical symptoms)

• Men often have difficulties communicating and may not turn to medical care for help

• Men and women react differently to stress- men: ”fight-or-flight”, - women: ”tend-and-befriend”

• Difference in cultural values


The Stress Vulnerability Model (1)

• Suicidal behaviors:

Not an illness but a process that is influenced by many different risk factors



Suicidality is a function of several risk factors;

• Genetic predisposition• Mental ill-health• Somatic illness• Traumatic life events• Alcohol- or drug abuse• Difficult relationships• Socio-economic difficulties



The two most common risk factors for suicide:

• Loss of hope• Previous suicide attempt


Factors influencing the suicidal process

• Risk factors• Protective factors


Risk factors for suicide

• Loss of hope• Earlier suicide attempt• Mental disorders, especially depression• Alcohol/drug abuse• Genetic influence• Environmental (in its widest sense) influence• Violence, violation, Mental trauma ( bullying, neglect)• Losses, of all kinds (relationships, health, economy, culture/country etc)


Protective factors

• Family patterns; good relationships, experience of caring parents etc• Cognitive style and personality; confidence, readiness to seek help,

openness to others• Cultural and social factors; good social integration• Environmental factors; good diet, enough sleep and physical exercise


Strategies in Suicide Prevention

• Two perspectives:- Health care perspective- Public health perspective


Health Care Strategy

Aims:

Increasing and improving access and quality of health care

Suicide and attempted suicide can be prevented


Public Health Strategy

Focuses on influencing attitudes to increase the awareness about suicide and suicide prevention in certain targeted populations

Goal: increase identification of and support for

vulnerable individuals


Educational S-preventive Programmes

• D/ART; Depression/Awareness, Recognition and Treatment (USA, 1988)• The Defeat Depression Campaign (United Kingdom, 1992 – 1996)• Beyond Blue (Australia, 2004, 2005, 2008)• Choose Life (Scotland, 2006, 2007)• AFSPP; Air Force Suicide Prevention Programme; USA, 1995 – 1999• Nuremberg Alliance Against Depression, (2001-2002)• European Alliance Against Depression, 2004 –• Saving and Empowering Young Lives in Europé (SEYLE) 2009 – 2012

(BMC Public Health. 2010 Apr 13;10:192.)


Diagnostics (1)

People who commit suicide turn to their GP some time

before the fatal step

Diagnosis:

1. anamnestics, (case story)

2. rating scales (depression, anxiety, alcohol/drug abuse etc)

3. listening to the next-of-kin


Diagnostics (2)

• Depression• Anxiety Disorders• Alcohol and drug abuse• Psychotic disorders• Suicide and co-morbidity


Diagnostics: Depression (3)

1. Anamnestics (case story)

2. MADRS-S ( Montgomery Asberg Depression Rating Scale)


Diagnostics: Anxiety (4)

1. Anxiety is related to elevated risk for suicide attempts and suicide

2. Highest risk when both anxiety and affective disorders are present

3. HAD – Hospital Anxiety and Depression Scale


Diagnostics -Alcohol and drug abuse (5)

1. Mortality of people with alcohol dependence:

Four times that of the normal population

AUDIT – diagnostic interview alc. dependence

DUDIT – diagnostic interview drug dependence


Diagnostics – Psychotic Disorders (6)

10 percent of patients with schizophrenia die as a result of suicide

• Note: Schizophrenia is not uncommon – prevalence 1 percent all over the world

Diagnosis: crucial to listen to the family

Immediate referral to psychiatric clinic


Diagnostics: comorbidity (7)

• Highest suicide rates:

Depression comorbid with alcohol/drug abuse

Important:

Under reported; the connections of:

– Women/alcoholism/suicide– Elderly/ alcoholism/suicde


Diagnostics:Somatic disease and suicide (1)

Elevated risk for suicide:

• Neurological diseases (MS, spinal chord injuries, epilepsy, migraine, stroke, also mental retardation)

• Cancer (especially period around diagnosis)• Conditions involving severe and chronic pain• Tinnitus in elderly men• Crohn´s disease and ulcerous colitis


Somatic disease and suicide (2)

Please note:• Somatic illness in itself is not enough to elicit suicidal

behavior

• Usually a combination with feelings of - Loneliness- Being abandoned- Hopelessness- Psychological problems- Psychiatric disease


Special groups: Child and adolescent suicide (1)

• Suicide in children younger than 10 is rare (concept of death not adequate until the age of 10 – 12)

• Risk for children suicidality related to risk factors in parents


Special groups (2)Child and adolescent suicide

Adolescents 15 – 19 years of age:

• Suicide is the third highest cause of death

• Rising trend among young men (genetic factors + men less prone to seek help)

• Risk group: socially underprivileged children cared for by the welfare system

• Trauma: physical, sexual, etc.


Special groups (3)Suicide in the elderly

• Risk of dying from suicide increases with advancing age

• Risk factors for suicide in the elderly:- Widowhood- Impaired physical health- Having moved to home for elderly- Social isolation- Mental illness- High suicidal intent


Special groups (4)Suicide in prisons

• Suicide rate in prisons higher than in the male population in general

”Preventing Suicide: A Resource for Prison Officers” (WHO 2000) from:

www.who.int/mental_health/resources/suicide


Suicide Risk Assessment

• Suicide risk analysis

”Preventing suicide. A resource for general practitioners” (WHO, 2000) www.who.int/mental_health/resources/suicide


Checklist of risk factors for suicidality (1)

1. Psychiatric symptoms ?• Depression?• Strong anxiety?• Psychotic ideation?• Violent tendencies?• Alcohol/drug abuse?

2. Previous suicide attempt?

3. Suicidal model?


Checklist of risk factors for suicidality (2)

4. Severe somatic illness?

5. Social network ?

(Failing, missing or supportive)

6. Suicidal intention?• Hopelessness? Thoughts about death? Wishes for death? Suicide thoughts?

Suicide wishes/impulses? Suicide note? Suicide plan/method?

• Time fixed for putting plan into work? =(extremely high risk)


Suicidal communication

• Communication;

– Means there IS a part of the person open to persuasion to hang on to life

– Use that opening in persuading the person to go on with his life


Relationship between attempted suicide and suicide

• 11 583 patients were followed-up 15 years after their suicide attempt

• 300 had died from suicide

• Thus, the suicide risk in this sample was 66 times greater than in the general population


Ask for previous suicide attempt

• Always ask a suicidal patient if he has ever made a suicide attempt

• This considerably heightens the risk of completed suicide


Predictors of Completed Suicide

Higher risk of suicide when:

• Male sex• Age over 45 years • Separated, divorced or widowed• Unemployed or retired• Chronic somatic illness• Major psychiatric disorder, especially depression• Addiction to alcohol/other substances• Use of violent methods for suicide attempt• Having left a suicide note


Treatment

Pharmacological treatment of individuals who are suicidal• Treat the underlying psychiatric condition:

- Anti-depressants• Plus supportive therapy• Plus short period of anxiolytics • Should be relatively safe in overdose• Adherence and effectiveness dependent on the relationship between

patient and the GP – call the patient, follow-up

- Lithium (bipolar disorders, by psychiatric specialists)

- New antipsychotics (psychiatric specialists)


Suicide and antidepressant use

• 60 % of people who die from suicide suffer from depression

- but only 15 % received prescriptions for antidepressants


Undertreatment of depression – explanations:

• Only 70 % respond to antidepressant medication• Adherence to treatment depends ,mostly, on the doctor –

patient relationship• Many patients distrust medication, don’t even try it• Because of medication side effects, patients stop taking

the pharmocological treatment


Psychological treatment of suicidal people

• Psychotherapy:- A form of counselling that can help to develop problem-solving

strategies

• Evidence-based therapies- CBT, cognitive-based therapy- DBT, dialectical behavior therapy


CBT and DBT: view on suicidal behavior

• Suicidal behavior as a learned coping response that originates under conditions of extreme emotional pain and anxiety

• Goal of CBT and DBT: help suicidal individuals find alternative ways of solving their emotional problems


Importance of combining pharmacological and psychological treatments for suicidal patients

• Patients suffering from a very deep depression need to be treated with antidepressants first,before starting a psychotherapy

• During this initial treating phase, they need a frequent, supportive contact with their doctor


Reducing repetition of deliberate self-harm

1. Protect the patient against repeated suicide attempts (reduce suicidal possibilities)

2. Reduce feelings of hopelessness

3. Treat the patient with pharmacological and psychological methods, or refer to specialist

4. Improve the person´s subjective quality of life (network, societal resources and facilities)

5. Societal resources can help with housing and employment


Training and support

1. Training for general practitioners and their staff

2. Supporting healthcare staff

3. Traning GP:s in the treatment of depression and in suicide prevention strategies


1. Training for general practitioners and their staff

• The supportive contact between GP and patient is of decisive value

• It is the quality of this relationship that will decide what the patient gains from medication treatment


2. Supporting healthcare staff

• Staff should learn about, and practice, suicide preventing strategies

• Clinical supervision

• Continuous education

• GPs taking responsibilities also for the well-being of their staff


3. Training GP:s in the treatment of depression and suicide prevention strategies

• Educating GPs how to diagnose and treat depression and how to identify patients at risk for suicide


Finally: example of a Successful implementation of an intervention programme

1. level one: training of family doctors and staff

2. level two: public relations campaign, information about depression

3. level three:cooperation with community facilitators ( teachers, clergy, local media)

4. level four: support for self-help and high-risk groups


Thank youwww.ki.se/suicide

Danuta Wasserman & Susanne Ringskog Vagnhammar

wpa educational programme on depressive disorders: depression in population groups part 5:...

Documents

suicide copyright

definitions of suicide

suicide prevention

serious suicide attempts

death suicide attempt

prevention of suicide

china copyright

stress men