Psychiatry - Suicide and deliberate self harm

Question 1

Definition of suicide

Answer 1

Intentional self inflicted death
Note - this is distinct from the definition of deliberate self harm, which is “intentional non fatal self inflicted harm”

Question 2

How common is suicide?

Answer 2

Approx 5000 per year

Question 3

Who is more likely to commit suicide?

Answer 3

M > F

Highest rates are amongst elderly men (over 65) but rates amongst young men in developing countries are increasing

Question 4

Aetiology of suicide

Answer 4

Multi factorial

1) Mental illness
2) Chronic painful illnesses
3) Decreased social support
4) Life events - e.g bereavement
5) Family history
6) Reduced BDNF
7) Genetics - e.g. Finno-Ugrian ethnicity

Question 5

Which mental illnesses carry the highest risk of suicide?

Answer 5

Depression - esp if severe, chronic and/or untreated
Schizophrenia (10% lifetime risk)
Biopolar
Alcoholism
Personality disorder (present in 30-60% of completed suicides)
Substance misuse (?increased suicide rates in young men)

Question 6

What is Anomic suicide?

Answer 6

One of Durkheim’s “types” of suicide
= reflects societies disintegration and loss of common values
Positive correlation between suicide rates and unemployment and homicide rates
Suicide is reduced during wartime and times of social unity

Question 7

Egoistic suicide

Answer 7

Individual’s separation from otherwise cohesive social groups
Higher suicide rates following bereavement and moving house, divorced or single, living alone

Question 8

Altruistic suicide

Answer 8

For the good of society - e.g. Kamikaze pilots

Question 9

Name some strategies for suicide prevention

Answer 9

1) Detect and treat psychiatric disorders
2) Be alert to risk and respond - most suicides seek help in the days/weeks prior
3) Safer prescribing - drugs used in overdose
4) Manage DSH - high risk of repetition including completed suicide

Question 10

Definition of deliberate self harm (DSH)

Answer 10

Intentional non fatal self inflicted harm

Question 11

How common is DSH compared to suicide?

Answer 11

DSH 20-30 times more common than completed suicide

Most cases involve drug overdose or physical self injury (e.g. cutting or stabbing)

Question 12

Which patients are most likely to self harm?

Answer 12

F>M - esp young women
Low SES
DSH is associated with psychiatric illness - esp depression and personality disorder (borderline)

Question 13

What is the first step in assessing a patient with DSH?

Answer 13

Priority is medical stabilisation

Question 14

Motives for DSH

Answer 14

DSH is often precipitated by undesirable life events
Motives can be to:
1) Interrupt a sequence of events seen as inevitable
2) Need for attention
3) Attempt to communicate
4) A true wish to die

Question 15

Factors suggesting high risk of recurrence following DSH

Answer 15

Act:

• Leaving suicide note
• Making a will
• Continued determination to die
• Precautions taken to prevent discovery
• High lethality risk

Patient:

• Older male
• Unemployed
• Socially isolated

Question 16

Outline an approach to DSH management

Answer 16

"MEDIATE"
Medically stabilise
Establish rapport
Diagnose and treat mental illness
Iatrogenic risk - prescribe safely 
Assess likelihood of recurrence 
Thoughts might return - make a plan
Evaluate social problems

Question 17

What psychological therapies are useful for DSH?

Answer 17

Self help groups

Dialectical behaviour therapy (form of CBT) can reduce repetitive self harm in emotionally unstable personality disorder

Question 18

What is the risk of a patient committing suicide following DSH?

Answer 18

1/5 of people who self harm repeat their act within a year

Risk of action suicide within a year is 1-2% (100 fold increase compared to general population)