Suicide Flashcards
Theories of suicide
Theories of suicide
1. Sociological hypothesis (Durkheim)
a) Altruistic - for the good of country
b) Egoistic - individual has lost social integration with the group
c) Anomic - society undergoing such change that it lacks ‘collective
order’; loosened bonds and norms
2. Ecological hypothesis (Sainsbury)
a) rates increase due to social mobility and isolation
3. Psychiatric hypothesis (Esquirol, Lindemann)
a) mental disorder underlies suicide
4. Analytic hypothesis (Freud, Meninger)
a) attack on internal hated object
· Thomas Browne (17th Century) coined the tern suicide, meaning ‘self murder’
· Aaron Beck : “wilful self-inflicted life-threatening act resulting in death”
Epidemiology, prevalence
· completers are more often : · male · psychiatric disorder · have made a plan · used a dangerous method Prevalence · lifetime prevalence (USA): · 21 % morbid thoughts · 10.2 % suicidal thoughts · 2.9 % attempted suicide · annual prevalence : · 1 % of all deaths · suicide rates for UK are 16 per 100,000 males, 5 per 100,000 females during 1986-88 (Charlton et al. 1993) · GP : (2,500 patients) · 1 suicide every 4 years · Psychiatrist (catchment area 50,000) · 1 suicide every 3 months
Sociodemographic correlates of suicide
Sociodemographic correlates of suicide
1. Age, Sex :
a) incidence increases with age – 47 % of male suicides occur after age 50
b) recent rise in rates among adolescents and elderly (Meehan et al. 1991)
– 1980- 1986 :
i) 21 % increase in suicide in over-65-year-olds
ii) 20 % increase in suicide in 15-19-year-olds
iii) young males (aged 15-24) - 75 % increase since 1982; 2nd
commonest cause of death
c) M:F = 3:1; males > females for all groups
d) suicide pacts more common in the elderly
2. Marital status :
a) divorced > widowed > single
3. Employment :
a) unemployed / retired / living alone (social isolation)
4. Urban/ Rural :
a) urban > rural
5. Seasonal :
a) highest rates in spring (April, May, June)
b) lowest rate in December
6. Social Class :
a) highest in lowest social groups
b) lowest in middle groups
c) rates are higher in social class V (unskilled workers) and social class I
(professional) (Charlton et al. 1993)
7. Religion :
a) strong religious affiliation is a protective factor
8. Occupation :
a) higher risk groups are doctors, lawyers, hotel and bar trade owners
b) also higher rates in policemen, musicians, and insurance agents
c) vets have 3 x the expected rate, and pharmacists, farmers, and doctors
have 2 x the expected rate (Charlton et al. 1993)
9. Physical illness :
a) terminal illness / malignancies
b) debilitating illness and disability
c) disfigurement
d) chronic pain
e) renal dialysis / failed transplant
f) Peptic ulcer (x 2) – likely to be due to overlap with alcoholism
g) CNS disorders :
i) Huntington’s disease
ii) HIV / AIDS, especially in the first 6 months after diagnosis
iii) spinal cord injuries (x 4)
iv) risk in epilepsy patients is 4 times general population (Sainsbury
1986)
h) CVD
i) SLE
j) risk of suicide reported to be higher in people with low cholesterol,
particularly for males – relationship poorly understood (Hawton et al.
1993)
10. Prison population :
a) increased in recent years
b) age > 30
c) on remand
d) prisoners convicted of murder/ violent/ sexual crimes
e) long sentence for serious offence
f) 1/3 of have previous psychiatric history, ½ have history of previous
DSH
g) 90 % occur by hanging
h) ½ occur in first 3 months of imprisonment
11. Other associations :
a) history of DSH (1/3- ½ of completers)
b) family history of affective disorder / alcoholism / suicide
c) birth trauma
d) death of a parent in childhood
e) suicide by a friend or colleague
f) recent bereavement
12. Homicide :
a) in the USA 5 % of homicides end in suicide
b) 2 % of all suicides also involve homicide
Association of suicide and mental illness
· all psychiatric illness (apart from OCD) increase risk by 90-95 %
· 9/ 10 people who die from suicide have some form of mental disorder (Robins et al.
1959)
Suicide and depression
Depression (risk 3.6 - 8.5 % = 30 x general population risk)
· 11 - 17 % of people who have suffered a severe depressive disorder at any time will
eventually commit suicide (Fremming 1951; Black et al. 1987)
· risk is lower in manic subtype than bipolar or unipolar depressed (Newman and
Bland, 1991)
· more common at the onset or during the recovery phase: it is rare in remission
· Risk factors :
· persistent insomnia
· self-neglect
· impaired memory
· agitation
· panic attacks
· delusions
· desperation (predicts short term risk)
· hopelessness (predicts long term risk)
SUICIDE and schizophrenia
Schizophrenia (risk 5 - 10 %) (Roy, 1982)
· schizophrenia accounts for 3 % of suicides (Drake and Cotton 1986)
· 10 % of schizophrenics kill themselves
· 60 % within 6 months of discharge from hospital
· Risk factors (Modestin et al. 1992) :
· younger
· unemployed
· chronic relapsing illness
· previous DSH
· depressive episodes with anorexia and weight loss
· high premorbid function and educational attainment with fear of
deterioration
· non-psychotic
· akathisia
· abrupt cessation of drugs
Alcohol dependence and suicide
Alcohol dependence (risk 3.4 - 6.7 %)
· alcohol abuse is present in 25 % of suicides (Robins et al. 1959)
· 15 % of alcoholics kill themselves, late in illness, majority are depressed
· lifetime risk is 2 % in untreated alcoholics, 2.2 % among out-patients, and 3.4 %
among inpatients (Murphy and Wetzel 1990)
· among alcoholics admitted for inpatient psychiatric care, over a five year period the
risk is 80 times that of the general population (Kessel and Grossman 1965)
· Risk factors (Murphy et al. 1992) :
· male
· poor physical health
· 40-60 years
· high dependency
· chronic
· depressed mood – psychiatric co-morbidity with major depressive illness
· unemployed; poor work record in last 4 years
· disrupted relationship
· loss in previous 8 years
· drinking heavily in days prior to death
Organic disorder and suicide
Organic disorder
· epilepsy (especially TLE)
· brain injury
· mild dementia
Suicide and personality disorder
Personality disorder · personality disorder is detected in 33 % of suicides (Seager and Flood 1965) · High risk : · antisocial · lability of mood · aggressivness · impulsivity · peer alienation · younger, broken home violent and substance abusing sub-culture`
Suicide and neurosis
Neurosis
· mostly depression
· panic disorder – at 7 year follow up, 3 of 74 panic disorder patients had died by
suicide, 5 had made serious suicide attempts (Noyes et al. 1991)
· PTSD – combat-related guilt is predictor of suicide (Hendin and Haas, 1991)
· anorexia, bulimia
· not OCD – rate of suicide in depressed OCD patients is 6 times less than in
depressed patients without OCD
Suicide in the elderly
Elderly
· rate increasing
· 80-90 % of elderly suicides have depressive illness
· often first episode of depression
· DSH is more closely associated with completed suicide
· denial of suicide more common
Suicide and inpatients
Inpatients
· Highest risk :
· first week of admission
· early stages of recovery
· between shifts of staff
· on leave (patients and staff)
· bank holidays
· discharge (premature)
· risk is increased 30 x in the month after discharge
· two-thirds of people had consulted their GP in the previous month and 40 % had
done so in the previous week (Barraclough et al. 1974)
Aetiology of suicide
Aetiology
Genetics
· suicidal behaviour clusters in family
· MZ : DZ = 11.3 % : 1.8 % (Roy et al. 1991)
Neurochemical
1. Serotonin :
a) serotonin deficiency – suicide completers had lower CSF 5-HIAA than
attempters (Asberg et al. 1986)
b) decreased CSF 5-HIAA is the most consistent finding in patients with
DSH (Mann et al. 1992)
c) post-mortem autoradiography shows decreased 5-HT receptors in the
frontal cortex and hippocampus
2. Opiate :
a) increased receptor density
3. Noradrenaline :
a) decreased cortical alpha-1-noradrenergic receptor density
Assessment of suicidal risk
Assessment of suicidal risk The Beck Suicidal Intent scale (>5 is significant) 1. Preparation a) planning in advance b) suicide note c) final acts 2. Circumstances a) alone b) intervention unlikely c) precautions against delivery 3. After the act a) didn’t seek help b) stated wish to die c) believed the act would result in death d) regrets its failure · 1 in 100 people who express suicidal intent will kill themselves
DSH types
Deliberate Self Harm
· Non-fatal Deliberate Self Harm (DSH) (Morgan 1979) : “Deliberate non-fatal act
known to be potentially harmful, or if an overdose, that the amount taken is
excessive”
· Parasuicide (Kreitman 1977) : “Behavioural analogue of suicide without
considering psychological orientation towards death”
· Attempted Suicide (Stengel & Cook) : “Every act of self injury consciously aimed
at attempts to kill themselves. But it acknowledges the gravity of the situation”
· Deliberate self-poisoning (Kessel and Grossman 1965) : ‘deliberate self injury’
substituted for ‘attempted suicide’ because many patients ‘performed their acts in
the belief that they were comparatively safe’
- Deep self-cutters / suicidal :
a) serious attempt - Self-mutilators / psychotic :
a) schizophrenics acting on hallucinations
b) transsexuals - Superficial self-cutters :
a) younger (16-24)
b) injure to relieve tension, sense of emptiness/ loss
c) associations :
i) eating disorders
ii) menstrual and sexual disturbance
iii) broken homes before 5 years old
iv) lack of early parental warmth and physical contact
v) hospitalization and surgery before 5 years
vi) low self esteem – dislike of body
vii) poor verbalization (i.e. act out)
viii) obsessional and borderline personality traits
ix) alcohol or drug misuse in 50 %
d) precipitants :
i) recent loss
ii) rejection or impasse in relationships
