Suicide Flashcards
Factors Associated with Non-Remission
History of chronic or recurrent depression
Comorbid psychiatric and general medical conditions
Anxious or psychotic features
Minority ethnic/racial status
Lower quality of life and function prior to treatment
Socioeconomic challenges
Non-Remission: What to do
Review the basics: Correct primary diagnosis Treatment adherence Comorbidity Pharmacokinetics - Rapid metabolizers - Drug drug interactions - Absorption, metabolism, excretion
Pharmacological Approaches
- Switching
- Augmentation
- Combination
Epidemiology of Suicide
Major public health problem
- 10th leading cause of death (all ages) in US
- 15th internationally
- 2nd leading cause of death among 15-29 year olds and 3rd for 15-44 year olds
- In 2013, more than 41,000 die annually in US
- 10-20 times more attempts than deaths
Leading cause of malpractice cases in psychiatry
1 Suicide death every 40 seconds worldwide
1 Suicide attempt every 1-2 seconds worldwide
90 will die
1800-3600 will attempt
Risk Factors- Psychiatric Disorders
Mood disorders most commonly associated, with depression one of the most important risk factor
Schizophrenia: up to 10% die by suicide (young, unmarried males)
Substance use, personality disorder, panic disorder
Risk Factors- Social Factors
Variations between countries (higher in more affluent countries)
Age: Elderly account for 25% of suicides, make up only 10% of population
Sex: Males more than females. Males use violent methods
Race: White nearly twice that among nonwhites. Immigrants who feel alienated have higher rates than natives of either adopted country or country of origin
Marital Status: Single, divorced, widowed higher than married
Employment: Unemployed higher
Risk Factors- Psychological Factors
Aggression turned inward, loss, rage, guilt, hopelessness
Risk Factors- Biological Factors
Reduced central serotonin
Low concentration of serotonin metabolite 5-HIAA in lumbar CSF
Suicide victims post mortem show modest decreases in serotonin and serotonin binding sites
Cholesterol level lower in suicide attempters
Toxoplasma Gondii: 10 times greater risk of non fatal suicide attempts in seropositive for T. Gondii. Possible brain cell damage from antibodies to T. Gondii and possible role of inflammation in some suicides
Risk Factors- Genetic Factors
Higher completed suicide rate in monozygotic twins MZ > DZ (24% vs. 2.8%)
Adoption studies
Relatives of suicide victims (2-4.8 times)
Risk Factors- Physical Disorder
Postmortem studies show a physical illness present in 25-75% of suicide victims
CNS disease (epilepsy, MS, TBI, dementia)
Impulse, depression, available means
Suicide – Special issues
Post partum psychosis - new mother with symptoms of psychosis – i.e. paranoia, hallucinations or delusional thinking.
- Rule out suicidal or homicidal ideation (most frequently directed toward the child) and then treat with antipsychotic and antidepressant medication as symptoms dictate
Early dementia – rule out depressive pseudo dementia which would put the patient at risk for a suicide attempt
Suicide – Attempters vs. Completers
Attempts occur 5 to 20 times more frequently
Women are 3 times as likely to attempt, but men are 10 times as likely to be successful
Attempters are impulsive, reach out to others (make provisions for rescue), are less lethal
Completers tend to be male, well organized and carry out their plans in a solitary place
Completers use more lethal means (firearms)
Impact
Family:
Surviving the loss of loved one to suicide is a risk factor for suicide
Experience range of complex grief reactions including guilt, anger, abandonment, denial, helplessness and shock
Various estimates: 6-32 survivors exist for each suicide
Caregivers:
Traumatic response (dissociation, denial, nightmares, shame, guilt)
Affective response (depression, hopelessness, suicidal)
Relationship with colleagues, questioning specialty
Legal concerns
Effect on treating other patients
Community:
Clusters, “copycat”
Assessment
Psychiatric Evaluation
- Suicidal thoughts, plans, intent
- Methods
- Hopelessness, impulsiveness
Psychiatric Illnesses
- Mood disorders, psychotic disorders, substance disorder
History
- Past suicide attempts, aborted attempts, self harm behavior
- Family history of suicide attempts or mental illness
Psychosocial Situation
- Acute/Chronic Stressors
- Employment status, living situation
- Cultural or religious beliefs
Strength/Weaknesses
- Coping Skills
- Personality traits
Documenting the suicide assessment is essential
Suicide Assessment Scales
Useful as aid to the assessment
Not predictive, not substitute for complete clinical evaluation
“No harm contracts”
Not absolute indicator
Not substitute for complete clinical evaluation
Dependent on therapist/patient relationship so not useful in emergency settings or unknown inpatients
