Clinical Challenges in Suicide Prevention Associate Professor Dr Andrew Mohanraj
Clinical Challenges in Suicide Prevention
United Nations University , Institute of Global Health Kuala Lumpur , 23 February 2015
“The suffering of the suicidal is private and inexpressible, leaving family members, friends and colleagues to deal with an almost unfathomable kind of loss , as well as guilt. Suicide carries in its aftermath a level of confusion and devastation that is, for the most part , beyond description”
‐Kay Redfield Jamison , the author of UNQUIET MIND
Outline of presentation •
•
•
•
•
•
•
Definition of Suicide and Parasuicide
Burden of Suicide Epidemiology of Suicide
Assessment of Suicidal Risk Challenges in suicide prevention Future directions
Recommendations Definitions of Suicide and Parasuicide
• Suicide is a complex issue which involves the interplay of a variety of psychological, social, biological, cultural and environmental factors.
• Suicide is the act of deliberately ending one’s own life. Self‐harm is an intentional self‐
inflicted injury or poisoning, which may or may not have a fatal intent or outcome.
• Parasuicide is the attempt of taking one’s own life that does not end in death It is an apparent attempt at suicide, commonly called a suicidal gesture. For example, a sublethal drug overdose or wrist slash which does not end in death • Failed suicides are suicidal processes that failed for technical reasons but in whom death was intended .
• Accidental suicides are parasuicides that end in death .
Burden of Suicide •
One million people die from suicide very year . It is estimated that during 2012 for each adult who died of suicide there were over 20 others who made suicide attempts. The number of lives lost through suicide exceeds the number of deaths due to homicide, terrorist acts and war combined ( WHO report ‐2012) •
Unipolar depression ( main cause of suicide) was the fourth most important cause of disease burden worldwide in 2014 as measured in Disability Adjusted Life Years ‐WHO Burden of Illness 2014
•
Adolescent suicides growing fast in many developing countries including Malaysia •
For each suicide prevented, the United States could save an average of $1,182,559 in medical expenses ($3,875) and lost productivity ($1,178,684). (The National Institute of Mental Health 2009)
•
Nearly 85 percent of all suicides occur among the nation’s workforce, Americans ages 25‐65. About 24,000 deaths were reported in 2006 for this age group.(Centers for Disease Control and Prevention)
•
The annual cost of workforce‐related suicides has been calculated to be approximately $13 billion in 2005 dollars.( www.researchamerica.org/uploads/factsheet21suicide)
Epidemiology of Suicide Country Rate per 100,000
Age group with highest rates Japan 23.8
Adults 50‐65
India 17.38
Adults 30‐59
Malaysia 13.1
Young adults 20‐30
Pakistan
0.65
Young adults
Sri Lanka 23.9
Young adults
New Zealand 12.8
Older adults ( 85+) &Young adults ( 20‐29 ) Australia
10.4
Young adults Epidemiology of Suicide in Asia ,Herbert Hendin , Lakshmi Vijayakumar et al ,2009 Note : According to Malaysian Suicide Registry 2002, suicide rate in Malaysia is 1.3 per 100,000.
Methods of Suicide –Malaysia ( national suicide registry 2012) Risk factors of suicide
•
•
•
•
•
•
•
•
•
•
•
Sex
Age
Marital Status
Race
Religion
Occupation
Methods
Physical Health Mental Health Psychiatric Patients Genetic Assessment of suicidal risk –
High Risk Low Risk Over 45 years ,Male, Divorced ,Unemployed Below 45 years , Female, Married, Employed
Chaotic , conflictual family background
Stable family background
Chronic physical illness, Excessive substance intake
Good physical health , low substance use
Mental illness‐ Depression, Psychosis, Personality disorder ,Substance Abuse , Hopelessness
Mild Depression , Neurosis, Normal Personality , Social drinker, Optimistic
Planned suicide attempt , Multiple attempts , Clear wish to die, Rescue unlikely , Multiple attempts, Lethal method
First attempt , Impulsive, Likely to be rescued, Low lethal method, Anger externalized Poor social support , Unresponsive family, Poor insight
Socially well integrated , Good insight , Concerned family Clinical challenges •
Primary care settings not well equipped to detect and treat.
•
No specific screening tools . Questionable reliability of screening at primary care populations. •
Most suicides detected at hospital settings and therefore “potential” suicides are not “captured” •
Efficacy of antidepressants , psychotherapy and ECT not well optimised
•
Does “treatment” result in decreased suicide attempts or completions?
•
Insufficient follow up and “chain of care”
•
Dramatic differences in suicide behaviours among men and women and among different racial and ethnic groups have drawn little attention. •
Relevant only to persons who access clinical care, which means that a large portion of the population may be ignored
Future Directions
•
•
•
•
•
•
•
Physician Education.
Pharmacotherapy. Gatekeeper Education Screening Psychotherapy Chain of Care Deeper understanding of local socio cultural aspects of shame and humiliation guilt which are culture specific.
Recommendation Education and awareness programs for the general public and professionals Screening methods for high‐risk persons
Treatment of psychiatric disorders
Restricting access to lethal means
Media reporting of suicide
Support services like “Hotline” , Websites for those crying out for help . [ Befrienders in Malaysia]
• Legal and ethical factors • National Strategy for Suicide Prevention •
•
•
•
•
•
References •
National Center for Injury Prevention and Control. WISQARS (Web‐based Injury Statistics Query and Reporting System). Accessed athttp://www.cdc.gov/ncipc/wisqars/on 2 December 2003.
•
National Institute of Mental Health. Suicide facts. Accessed athttp://www.nimh.nih.gov/SuicidePrevention/suifact.cfmon 1 April 2014.
•
Office of the Surgeon General. The Surgeon General's Call to Action to Prevent Suicide. Washington, DC: Department of Health and Human Services, U.S. Public Health Service; 1999.
•
Druss B, Pincus H. Suicidal ideation and suicide attempts in general medical illnesses. Arch Intern Med. 2000; •
National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2001.
•
National Suicide Malaysia 2012 •
WHO Country Reports •
Patsiokas AT, Clum GA. Effects of psychotherapeutic strategies in the treatment of suicide attempters. Journal of Psychotherapy. 1985.
•
Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979
•
Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE. Reducing Suicide: A National Imperative . Washington, DC: National Academies Press; 2002
•
Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med. 2002
•
Barraclough B, Bunch J, Nelson B, Sainsbury P. One hundred cases of suicide: clinical aspects. Br J Psychiatry. 1974;