Dealing With Suicidal Ideation
Dr J. Juneli, CT2 Psychiatry
Aims for session
• Awareness of the requirements for each written
exam
• Learning about the epidemiology of suicide
• Ability to do a suicide risk assessment
• Discussion of cases seen during on call
• CASC practice: assess risk of suicide, make a
plan of action, report to examiner
Written Exams
Paper 1
Paper 2
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History and Mental State
Descriptive Psychopathology
Cognitive Assessment
Neurological Examination
Assessment
Description and Measurement
Diagnosis
Classification
Aetiology
Prevention of Psychological Disorder
Basic Psychopharmacology
Human Psychological Development
Social Psychology
Basic Psychological Processes
Dynamic Psychopathology
Basic Psychological Treatments
History of Psychiatry
Basic Ethics and Philosophy of Psychiatry
Stigma and Culture
Neurosciences
Psychopharmacology
Genetics
Epidemiology
Advanced psychology
Paper 3
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General adult
Old age
Addictions
CAMHS
Forensic
LD
Psychotherapy
Psychopathology
Epidemiology of Suicides
• WHO: World Mental Health Survey
Initiative: Cross-national lifetime
prevalence:
– Suicidal ideation 9.2%
– Plans 3.1%
– Attempts 2.7%
– Ideation to attempt max 1 year in 60% cases
Epidemiology of Suicides
• Males commit more suicides on fewer
attempts
• Approximately 25 attempts per completed
suicide
• Most common method UK: overdose
(paracetamol/antidepressant); US:
Firearms
Risk factors for repeating self harm
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Past self-harm
Psychiatric history
Unemployment
Low social class
Alcohol/drugs
Criminal history
• Antisocial PD
• Lack of cooperation
with treatment
• Hopelessness
• High suicidal intent
Risk factors for completing suicide
• Past suicide
attempt/DSH
• Serious intent
• Older age
• Male
• Social isolation
• Antisocial PD
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Unemployment
Depression
Poor physical health
Access to means
Alcohol/drugs
Depression and suicide
• >90% of persons attempting suicide have got a
mental illness
• Most commonly associated with mood disorders
• Risk factors in depression: insomnia, anxiety
syptoms, panic attacks, anhedonia, alcohol use
(modifiable)
• Long-term factors: Hopelessness, past suicide
attempt, ongoing suicidal ideation
Schizophrenia and suicide
• 11.3% of persons developing first
psychotic episode will self-harm prior to
initial presentation to services
• Lifetime suicide prevalence of completed
suicide 4.9%
• Suicide is the major cause of death in
persons <35 y
• Most commonly occurring early or during
exacerbations.
Global Suicide Epidemiology
• Highest rates: Eastern Europe followed by Sri
Lanka and China
• High rates: Island nations generally (Cuba,
Japan, Mauritius, Sri Lanka)
• Lowest rates: Eastern Mediterranean Islamic
nations and some central Asian (former Soviet)
• Largest absolute number: Asia (population size)
• Number of suicides in China 30% greater than
whole Europe
Global Suicide Epidemiology
• Male:female ratio 3.5:1 for completed suicides
• Exeption China: Females have higher/equal
suicide rate
• Rise with age
• Rates are 6-8 times higher in elderly
• In absolute numbers more young people dying
• 55% all suicides fall within 5-44 years
• Some Islamic countries near zero rate: Kuwait
Global Suicide Epidemiology
• Hindu/Christian nations have mostly lowmoderate rate: India 10/100,000, Italy
11.2/100,000.
• Atheist nations have very high rates: China
25.6/100,000.
• Buddhist countries have also high rates: Sri
Lanka, Japan 18/100,000
• WHO Projection for 2020: Nearly 1.53 million will
die by suicide. 10-20 times more will attempt it
 One death every 20 seconds or one attempt
every 1-2 seconds
UK Suicide Epidemiology
• UK Household Survey (Office National Statistics)
2000:
• 14.9% had considered suicide at some point
• 3.9% in past year
• 0.4% in last week
• Ever attempted 4.4%
• Attempted last year 0.5%
• White>Black/South Asian (ideation)
• White=Ethnic minorities (attempt)
Suicidal thoughts
• Women
• Men
– Divorced 28%
– Married 13%
– DSH only 3%
• Greatest influence
– Number of stressful life events
– psychosis
– Divorced 25%
– Married 9%
– DSH only 2%
Suicide statistics
Global annual rate
1:6000/year
Male:female
2-4:1
Most common age
15-24 female
25-34 males
Common method
Hanging, OD
Little influence
LD, dementia, OCD
Common psych dx
Major depression
Alcohol dependence
Min 1 recorded DSH
40-60%
Will repeat DSH within 1 year
30%
Suicide statistics
Contact with mental health
12/12
25%
On psychiatry OP register
25%
Seen psychiatrist in 7/7
12.5%
Seen GP in 7/7
40%
Seen GP in 4/52
66%
Seen health worker in 3/52
33%
Inpatient first 7/7
25%
On routine IP observations
80%
Suicide statistics
Disengaging with services
4/52
Nearly 33%
Non-compliant with medication 20%
Within 3/12 of discharge
25% of suicides (10% before
first f/u)
Within 28 days of discharge
1 in 500-1000 patients
(0.1-0.2%)
Strongest risk history
DSH history
Risk of suicide within 1 year of 0.5% females, 1.1% males (66
DSH
times general population risk)
Adolescent suicides
School pupils self report
1 year prevalence
Commonest methods
Paracetamol OD and cutting
DSH 5-10y no mental illness
0.8%
DSH 5-10y anxiety
6.2%
DSH 5-10y other mental
illness
7.5%
DSH 11-15y no mental illness
1.2%
DSH 11-15y anxiety
9.4%
DSH 11-15y depression
18.8%
DSH 11-15y other mental
illness
8-13%
Adolescent suicides
School pupils self report
1 year prevalence
Requires hospital attention
<13%
DSH 15-16y
6.9%
Proportion of under 16y in
ED attendants with DSH
5%
Suicidal ideation young
females in 12/12
22%
Suicidal ideation young males
in 12/12
8.5%
No ethnic differences
Motives for suicide by young
persons
Motive Self-cutting, % (n/N) Self-poisoning, % (n/N)
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Escape from a terrible state of mind 73.3 (140/191) 72.6 (53/73)
Punishment 45.0 (85/189) 38.5 (25/65)
Death 40.2 (74/184) 66.7 (50/75)
Demonstration of desperation 37.6 (71/189) 43.9 (29/66)
Wanted to find out if someone loved them 27.8 (52/188) 41.2 (28/66)
Attention seeking 21.7 (39/180) 28.8 (19/66)
Wanted to frighten someone 18.6 (35/188) 24.6 (16/65)
Wanted to get back at someone 12.5 (23/184) 17.2 (11/64)
Suicide in family
• Suicidal acts <25 y is highly familial
• Greater number of affected family members is
associated with earlier age
• Suicidal behaviours familially transmitted
independently of mental illness
• In mood disorder, the offspring of a family with a
history of suicidal acts is 6 times more likely to
attempt suicide.
• Familial suicidal behaviour is also related to
familial transmission of sexual abuse and
increased impulsive aggression (Cluster B
personality traits) in offspring.
Homicides
• 50 homicides committed yearly by persons with
recent contact with mental health services
• This is 9% of all homicides
• 5% of perpetrators have schizophrenia
• Perpetrators with mental illness are less likely to
kill strangers.
• Alcohol and drugs contribute in 61% of cases.
Suicide Risk Assessment
• Not hard science: All measures are likely to class too many
people at high risk of repetition and possible future death and
to misclassify some people as low risk when in fact they are at
high risk (Department of Health, 2007).
• Risk factors are used to estimate the probability of the
occurrence of suicide in the immediate future. They do not
predict which person will or will not commit suicide or when
they might do it.
• Clinical interventions are guided by the clinician's estimation
of the probability of imminent suicide using risk factors as a
guide.
• The most predictive factors for imminent suicide are the
presence of a suicide plan and immediate access to lethal
means.
Suicide Risk Assessment
• Assessment of the 5 components of suicide:
ideation, intent now, plan, access to lethal
means, and history of past suicide attempts
• Evaluation of suicide risk factors (the above and
epidemiology)
• Evaluation of current experience (what's going
on?)
• Identification of targets for intervention. Is there
a psychiatric disorder?
• What resources are available?
Patient’s intentions at time of
suicide
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Planned/impulsive
Longer, careful plans more risky
Precautions against being found
Seeking help
Dangerous method (amount of drugs
Final act (suicide note, making a will)
Intent now
• Pleased to have been recovered
• Wishing had died
• Genuine change of resolve (serious
intent)?
• Current problems may/may not have been
resolved
• More serious remaining problem more
risky
• Loneliness/ill health particularly risky
Review of problems
• Systematic
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Intimate relationships
Relationships with children/relatives
Employment
Finance
Housing
Legal problems
Social isolation
Bereavement
Drugs/alcohol
Other losses
Suicide risk
• Continuing risk of suicide?
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1. Had intended to die
2. Intends to die now
3. Trigger/Problem still present
4. Mental disorder present
5. You decide on support required
• Risk of DSH
– DSH hx, prev psych tx, antisocial PD, alcohol/drug use,
criminal record, low social class, unemployment
– Brief history and MSE
Past suicidal behaviour
• Frequency, context (e.g., time, setting, planning,
substance use, impulsivity, witnesses)
• method (lethality of method, insight into lethality)
• consequences (medical severity, resulting treatment,
psychosocial consequences)
• and intent (expectation of lethality of method)
• attitude towards life (feeling about discovery and
survival) are important characteristics of past suicidal
behaviours that should be identified during the initial
assessment.
Factors predicting suicide
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Evidence of serious intent
Depressive disorder
Alcoholism/drug abuse
Antisocial PD
Previous suicide attempt
Social isolation
Unemployment
Older age group
Male sex
Examples of protective factors
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• Strong connections to family and community support
• Skills in problem solving, coping and conflict resolution
• Sense of belonging, sense of identity, and good self-esteem
• Cultural, spiritual, and religious connections and beliefs
• Identification of future goals
• Constructive use of leisure time (enjoyable activities)
• Support through ongoing medical and mental health care
relationships
• • Effective clinical care for mental, physical and substance use
disorders
• • Easy access to a variety of clinical interventions and support for
seeking help • Restricted access to highly lethal means of suicide
Practical suggestions
• Establish rapport
– Calm, patient, non-judgmental, empathic
– Supportive statements/open-ended questions
– Do not:
• allow personal feelings interfere with
assessment/treatment
• rush patient
• interrogate or force patient to defend their actions
Example questions to ask
Asking about suicidal ideation
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Have you thought that your life is not worth living?
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Have you thought about ending your life?
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Do you feel that your reasons for living outweigh your reasons for dying?
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If you had a way, would you try to take your own life?
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If you thought you were going to die, would you take steps to save yourself?
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How often do you think about dying?
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How long does it usually take for the thoughts to go away?
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Are thoughts about dying or taking your life overpowering to you?
Asking about suicidal intent and plan
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How do you feel when you start thinking about taking your own life?
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Have you ever thought of ways to take your own life?
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Have you ever had specific thoughts or plans about taking your own life?
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Do you have access to (method; e.g., pills, poisons, medication, weapon)?
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Have you set a time or place?
What are those plans?
Do you think you could get (method) if you needed to?
Do you think you would die if you used (method)?
Have you done anything or taken steps to prepare to take your own life (e.g., writing suicide note
or will, arranging method, giving away possessions)?
Do you think that you could take your own life?
Do you feel ready to die?
Support
• Is further assessment/treatment required
– Admission voluntary/not
– GP/CPN
– Counselling
– PCLT
– Emergency support contact details
Oncall cases
• Any you want to discuss?
Risk Assessment of Violence
Violence risk
Historical
Past (static)
documented
Clinical
Present (dynamic)
Observed
Risk Management
Future
(speculative)
Projected
Risk of violence
Historical (Past)
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•Previous violence
•Young age at first violent incident
•Relationship instability
•Employment problems
•Substance misuse problems
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•Major mental illness
•Psychopathy
•Early maladjustment
•Personality disorder
•Prior supervision failure
Risk of violence
Clinical (Dynamic)
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•Lack of insight
•Negative attitudes
•Active symptoms of major mental illness
•Impulsivity
•Unresponsive to treatment
Risk of violence
Risk management (Future)
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•Plans lack feasibility
•Exposure to destabilisers
•Lack of personal support
•Non-compliance with remediation attempts
•Stress
Risk of violence
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•Severity
•Imminence
•Frequency
•Duration of risk
•Likelihood
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•Risk-enhancing factors
•Risk-protective factors
•Monitoring
•Treatment
•Supervision
•Victim safety planning
Many thanks
• Questions?
• Discussions?
• CASC practice?
References
• RCPsych. 2009. MRCPsych Paper 2. Available
from:
http://www.rcpsych.ac.uk/examinations/about/mr
cpsychpaper2.aspx [Accessed 11.9.2012].
• Semple, D. Smyth, R. 2009. Oxford Handbook of
Psychiatry (2 ed) Oxford: Oxford University
Press.
• SPMM. 2010. MRCPsych Paper 2 Course
Online. Available from:
http://www.spmmpsychiatrycourse.co.uk/
[Accessed 10.9.2012].