Suicidal Behaviour

Terminology
Suicide
Death
by individual who died
“intentional”
act or omission
“completed” rather than “successful”
Self-Harm
 Attempted Suicide
 Deliberate Self-Harm
 Parasuicide
 Self-Poisoning or Self-Injury
 Self-Mutilitation

 Everything that doesn’t involve death – a behaviour not a

diagnosis
Suicide
Suicide Self harm

Demographics: An expression of emotional

• Male gender distress
• Older age. (e.g. sadness, loneliness,
• Single/Divorced. emptiness, grief)
• Professions (policemen or guards with access to An expression of social
firearms, bartender, medical professionals).(based on problems and trauma (e.g.
UK findings) difficult relationships,
Past psychiatric history: bullying)
• Previous suicide attempt. Problems with identity for
• Past history of depression or psychosis. example borderline
• Alcohol/drug misuse. personality disorder,
Past medical history: sexuality problem.
• Chronic painful illness (e.g. terminal cancer). Secondary to a psychiatric
Social factors: disorder(e.g. command
• Isolation/ lack of social network. hallucinations in
• Significant life event e.g. death, losing job, schizophrenia).
relationship breakdown, abuse.
Associations
 Unemployed and retired
 Divorced, never married
 Certain Professions
 Social class: I and V
 Country variation lower in LDCs than Western; China (females)
 Cultural variation
 Seasonal variation
 Highest April to June
Context
 1 in 6 leave notes

 1 in 2 have self harmed in the past

 Majority have told someone

 GP in previous month
Suicide and Psychiatry

 ?90% suffer from some mental disorder

 OCD may protect

Suicide and Schizophrenia
 10% mortality
 Risks with
Early in illness
Males, younger
Relapses
Akathisia
Recent discharge
Paranoid
( Roy, 1982 )
Suicide and Depression

 5-15% lifetime risk

 Melancholic depression

 Psychotic depression

 Family History
Self-Harm
Intentions

 Most neither want nor expect to die

 1/3 no thoughts
 Cry for help
 Escape

 Often impulsive
 20-40% alcohol on board
 Recent life stress
 20% repeats
 Self-Mutilation
 Punishment, Relieve tension
Associations

 Separated and divorced

 Low Socioeconomic status
 Urban > Rural
 Childhood disadvantage
 Lack of Social Support
 Lack of Religious affiliation
 Collective (Princess Di effect, clustering)
 Availability of means (paracetamol)
Aetiology of Suicidal Behaviour
Vulnerability – Stress
 Vulnerability
 Family history
 Impulsive/aggressive personality traits
 Childhood adversity/abuse
 Hopelessness
 Over generalised autobiographical recall

 Stress
 Life and esp interpersonal stress
 Physical illness

 Failed Inhibition
 Alcohol and Drugs
 Head Injury/ cognitive impairment

 Lack of Adaptive Coping

 social support, problem solving ability

 Maladaptive coping
 with alcohol, drugs (disinhibition)
Neurobiology

 Serotonin:
 Low 5-HIAA in CSF
 Reduced frontal 5-HT2A receptor biding
 5HT is involved in impulsivity
 5-HTTLP predicts self-harm following life stress
 HPA axis
 Hyperactivity predicts self-harm / completion in depressives
 Cholesterol
 Low cholesterol predicts
 Prefrontal Cortex
 Failed response inhibition
Repetition
Risk of Repetition
 Think of risk as immediate and long term

 Characteristics of attempt
 Characteristics of person
 Underlying psychiatric or physical disorder
Repetition and Suicide
 15% repeat by 1 year
 10%% suicide at long-term outome
 Lethal prior method
 Psychiatric disorder
 Older males
 Social isolation
 Repeated self-harm
 Avoiding discovery at time of self-harm
 Strong suicidal intent
 Substance misuse (especially in young people)
 Hopelessness
 Poor physical health
Enquiring about suicide
Asking about suicide

 Asking about it does NOT increase the risk

 It may decrease it!

 But do it sensitively
Ask sensitively
 Many people…
 After what you’ve told me…
 How do you think things will turn out ?

 Do you ever wish you would never wake up ?

 Have you thought about ending it all ?
 What would you do ?
Assess suicidal risk

 Current plans and intent

 Availability
 How far down the path have they gone
 Why not yet
 Current mental state

 Previous attempts
 Planning, precautions
 Dangerousness (real and perceived)
 What happened
 Supports and ability to access them
Initial Management
 Treat mental disorder
 Address needs
Alcohol
Finance
Relationships
 Give crisis contact details
Prevention
 Complex public health initiatives
 ? Reduce alcohol
 Identify and treat more Depression
 Lithium in Bipolar disorder
 Clozapine in Schizophrenia
 DBT in Borderline PD
Patient Suicide
 26% suicides had contact with mental health services in the 12 months prior

 Suicides less common following non-compliance/loss of contact with

services
 14% of all suicides are Psychiatric Inpatients

 70% of these occurred off the ward

 Inpatient suicides falling

 Fallen by 1/3 (50% less hanging/strangulation)

 Belts, shoelaces, sheets, towels

 Removal of non-collapsible curtain rails 2002

Psychiatric diagnosis

 Affective disorder (534)

 Schizophrenia (198 - stable)
 Personality disorder 104 - (fallen)
 Alcohol Dependence (83 - fallen)
 Drug Dependence (24 - fallen)
 Other (176)
Method

 Hanging, OD, Jumping

 Burning by petrol
 Hanging, jumping increased
 Overdose, CO poisoning decreased
 Drowning, firearms and burning stable