Suicidal Behaviour
Dr E Cassidy
CUH
January 2011
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
Deaths classified as suicide in Ireland
(1996-2009)
500
Men
450
Women
Number of deaths
400
350
300
250
200
150
100
50
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year 2008 and 2009 figures are provisional
Trends in undetermined deaths in
Ireland
(1996-2009)
160
Men
Number of deaths
140
Women
120
100
80
60
40
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year 2008 and 2009 figures are provisional
SUICIDE IN IRELAND
•500 per year
•Peak M 20-24yo (34/100,000)
•Peak F 45-54yo
•Males @ 80%
•Hanging, Poisoning, Drowning
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
Incidence of deliberate self harm 2003-2009
Total number of DSH episodes: 75,119
Total number of individuals involved: 48,206
Year
Male rate*
% diff
Female rate*
% diff
2003
179
2004
170
-5%
229
-5%
2005
165
-3%
227
-1%
2006
160
-3%
210
-8%
2007
162
+2%
216
+3%
2008
179
+10%
221
+2%
2009
197
+10%
221
+0.4%
241
85yrs+
80-84yrs
75-79yrs
70-74yrs
600
65-69yrs
60-64yrs
55-59yrs
50-54yrs
45-49yrs
40-44yrs
35-39yrs
30-34yrs
25-29yrs
20-24yrs
15-19yrs
10-14yrs
Rate per 100,000
Incidence of DSH by age and gender,
Average rates 2003-2009
700
Male
Female
500
400
300
200
100
0
Main method of self harm
(Average 2003-2009)
Men
Women
Alcohol
2%
4%
17%
25%
60%
3%
Overdose
Poisoning
2%
2%
1%
0%
Hanging
76%
6%
2%
1%
Drowning
Cutting
Other
Alcohol was involved in 46% and 38%
of male and female acts, respectively
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)
Cumulative probability of repeated DSH
by DSH method and number of previous episodes
Ka
pla
n-Meie
rf a
ilurees
t ima
te
s
Ka
pla
n-Meie
rf a
ilurees
t ima
te
s
0.70
0.70
0.60
0.60
0.50
0.50
0.40
0.40
0.30
0.30
0.20
0.20
0.10
0.10
0.00
0.00
0
3
6
9
Time
to to
DSH
(months)
Time
DSH
(months)
Self-cutting & overdose
Self-cutting only
Other
Attempted drowning
Attempted hanging
Drug overdose only
12
0
3
6
9
12
Time to DSH (months)
Four previous DSH presentations
Three previous DSH presentations
Two previous DSH presentations
One previous DSH presentation
No previous DSH presentation
The burden of repeated
deliberate self harm
Number of
DSH acts in
2003-2009
Persons
Presentations
Number
(%)
Number
(%)
One
37690
(78.2%)
37690
(50.2%)
Two
5874
(12.2%)
11748
(15.6%)
Three
2023
(4.2%)
6069
(8.1%)
Four
881
(1.8%)
3524
(4.7%)
Five
496
(1.0%)
2480
(3.3%)
Six
345
(0.7%)
2070
(2.8%)
Seven
203
(0.4%)
1421
(1.9%)
Eight
132
(0.3%)
1056
(1.4%)
Nine
109
(0.2%)
981
(1.3%)
10 or more
453
(0.9%)
8080
(10.8%)
Factors associated with repetition
independent of previous repetition

Women aged 35-44 years had the highest risk of
repetition (+33%)

Among women, those who engaged in self-cutting only
(+57%) and those with self-cutting with drug overdose
(+48%) had the highest risk of repetition

Among men, those engaging in self-cutting in
combination with drug overdose had the highest risk
(+49%)
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
NATIONAL CONFIDENTIAL
INQUIRY
INTO SUICIDE AND HOMICIDE
BY PEOPLE WITH MENTAL
ILLNESS
England and Wales
Annual report
2009
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
Hanging, jumping increased
Overdose, CO poisoning decreased
Drowning, firearms and burning stable
Reach Out National Suicide Strategy
2005-2014