Suicide Prevention – Case Studies

Introduction

These notes have been prepared to accompany the lecture “Suicide Why Do It?” The intended audience includes medical students, specialist health professionals and junior medical staff. Both the lecture and notes have been produced for a UK audience. We welcome feedback, and this is especially so if you are not from the UK.

Suicide is among the ten leading causes of death in most countries around the world for which information is available.  In the UK it is the third most important to life years lost after coronary heart disease and cancer.

Suicide accounts for approximately one per cent of all deaths, and in young males it is the second commonest form of death after accidents.  Depression, substance mis-use, and other mental health problems are more common in people who deliberately harm themselves and the rate of suicide in the year following an episode of deliberate self-harm is hundred times that of the general population.  The rate of suicide is also raised in the period following discharge from in-patient psychiatric care.

Suicide

The Act of Suicide

Suicide has been defined as an act with a fatal outcome that is deliberately initiated and performed by the person in the knowledge or expectation of its fatal outcome.  People who take their lives do so in several different ways.  In England and Wales, self-poisoning and using car exhaust fumes have become the most commonly used method for suicide by men, accounting for a third of all deaths.  Hanging is 28% and overdose 15%.  By contrast, in the USA, gunshot and other violent methods are frequent.  In women, drug overdose accounts for almost 50% of suicide in England and Wales.  Hanging, drowning, and jumping account for most of the remaining deaths.  Most completed suicides have been planned.  Precautions against discovery are often taken, for example choosing a lonely place or time when no one is expected.  However, in most cases a warning is given.

The Aetiology of Suicide

All categories of psychiatric illnesses carry an increased risk of suicide. The most consistent finding is that the large majority of those who died from suicide had some form of mental disorder at the time of death.

Personality disorder is diagnosed in a third to half of the people who commit suicide. It is estimated that about 6% of those who suffer from a mood disorder will die by suicide.  Risk factors include male, older age group, living alone, history of previous suicide, agitation, insomnia, impaired memory, self-neglect and hopelessness.

Patients with alcohol misuse show continuing risk of suicide with a lifetime risk of 7%. The risk factors include poor physical health, unemployment, and psychiatric co-morbidity, especially major depressive illness. Perhaps not surprisingly, drinking heavily in days prior to death, with little or no social support, are also risk factors.

Suicide in drug misuse is relatively common particularly in the young.

In schizophrenia, 4 – 10% commit suicide and this is most likely early on in the illness. Characteristics of schizophrenic patients who commit suicide are that they are male, young, chronically relapsing with a high pre-morbid functioning and educational attainment. Other factors are depression at last contact and expressing suicidal ideation. 60% of suicides happen within 6 months of discharge from hospital. There is also a possible association with akathesia.

Surprisingly there is a lower suicide rate in first postnatal year, despite higher rates of psychiatric disorder.

Social factors associated with suicide

Durkheim, the French Sociologist examined the suicide rates in various European countries.  He demonstrated that a range of social factors impacted on rates of suicide.  Rates were lower at time of war and revolution, and increased in periods of both economic prosperity and economic depression.  More recent studies have repeatedly demonstrated that areas with high unemployment, poverty, and social fragmentation have higher rates of suicide.  Another social factor that seemed to affect the rate of suicide is occupation, the profile of the incidence of suicide across all social classes form a U shaped curve. Suicidal behaviour clusters in families. It is possible that there are biological factors are work but this may be related to the underlying diagnosis.

Psychological Factors

Beck and Colleagues demonstrated that those who scored highly on a measure of hopelessness had very high rates of suicide over the following five to ten years.  More recent work indicates a range of psychological variables that maybe associated with suicidal behaviour and include impulsivity, dichotomous thinking, cognitive constriction, hopelessness, and problem solving deficit.

Individual correlates of suicide

To summarise, therefore, the following socio-demographic and clinical factors are associated with an increased risk of suicide.

1. Elderly
2. Male
3. Divorced, widowed, single
4. Unemployed or retired
5. Living alone
6. Physical illness
7. History of deliberate self-harm
8. Family history of affective disorder, alcoholism or suicide
9. Bereavement in childhood
10. Social class I and V
11. Certain personality traits, including impulsivity and aggression

Deliberate Self Harm

People who have deliberately harmed themselves commonly present to doctors, especially in emergency departments.  They are widely seen as unpopular, troublesome, and difficult to manage.  However it is evident that many have severe personal and social difficulties and that well planned care can help them.

Epidemiology

Two thirds of deliberate self-harm patients are under 35 years old.  It is commonest in 15 to 24 year old females and for males the peak incidence is in the mid-twenties.

The female to male ratio is 2:1 in 15-19 year old group and approaches 1:1 in over 50 year olds.  It is highest in divorced and higher in single than widowed and it is least for married. It is high in inner cities, areas associated with over crowding, lack of facilities, less social cohesion.  It has an inverse relationship with the social class and has strong association with unemployment both for males and for females.

Most have symptoms of psychological distress, but definite psychiatric illness is found in less than a third of patients.  Most common diagnosis are reactive depression, alcoholism, panic disorder, personality disorder both borderline and sociopathic types.

Causes of Deliberate Self Harm

People who deliberately harm themselves experience four times as many stressful life events in the six months before the act.

Familial and developmental factors predispose to self-harm in later life.  There is some evidence that early parental loss through bereavement or history of parental neglect or abuse is more frequent in cases of deliberate self-harm.  There is also evidence for personality variables.  They include poor skills in solving inter personal problems and in planning for the future.  Hopelessness and impulsiveness are the two psychological factors most often implicated in the aetiology of deliberate self-harm.

The motives or reasons for deliberate self-harm are usually mixed and can be difficult to identify for certain.  About a quarter say that they wished to die.  Another group admit that they were trying to influence someone for example, that they were seeking to make a relative feel guilty for having failed them in some way.  This behaviour has been referred to as a cry for help.

About 1% of patients who repeatedly self-harm commit suicide in the first year and the greatest risk is in the first six months, remaining high for five years.

The predictors for repetition include number of previous attempts, personality disorder, alcohol or drug abuse, previous psychiatric treatment, unemployment, lower social class, criminal record, history of violence, aged 25 – 54 years, single, divorced or separated.

Factors of self-harm favouring suicidal intent include

1. Isolation
2. Timing
3. Precautions to avoid intervention
4. Suicidal note
5. Anticipatory acts
6. Dangerousness of attempt

Among people who deliberately harm themselves there is scope for eventual suicide.  Thus the risk is greater among older patients who are male, depressed, or alcoholic.  A non-dangerous method of self-harm does not necessarily indicate a lower risk of subsequent suicide, partly because patients have little knowledge of the dangerousness of many methods.  However, the risk is certainly high when violence or highly dangerous drug overdoses have been used.

The assessment of patients after deliberate self-harm

During the interview think about these questions:

1. What were the patients’ intentions when he harmed himself?
2. Does he now intend to die?
3. What are the patients’ current problems?
4. Is there a psychiatric disorder?
5. What helpful resources are available to this patient?

Hazards which may mislead the assessment and management of suicide risk

1. Deliberate denial of suicidal ideas
2. Variability in degree of distress
3. Misleading clinical improvement due to removal from stress factors, yet problems remain unresolved
4. Anger, resentment
5. Unco-operative and difficult behaviour
6. Malignant alienation (staff antagonism)
7. Assumption that patient is manipulating with empty threats

Management of risk

Once significant risk has been identified it is necessary to monitor it regularly and manage the level of care appropriately.  For psychiatric in-patients most schemes involve a range from constant close contact reducing to monitoring every fifteen to twenty minutes.

Problems encountered in the management of inpatients at risk of suicide

• Danger times – this includes soon after admission, between staff shifts, patient on leave, bank holidays, premature discharge, follow-up period
• Physical hazards in the hospital environment
• Poor communication between staff
• Lack of clear code of practice in the care of suicidal patients
• Failure to warn others in treatment process
• Poor technique in assessing and monitoring risk
• Misleading clinical improvement
• Terminal progressive alienation of the patient that may complicate the management. This is especially so in those who relapse repeatedly in spite of intensive help and who may be challenging or even aggressive in their behaviour. Under such circumstances, the clinician may begin to evoke explanations such as manipulation and deliberate failure to co-operate or even manufacturing of symptoms. Most doctors and nurses prefer the situation where the patient wants and accepts help. Psychiatry can be demanding because sometimes the patient appears to be rejecting of help.

We all recognise the need to set limits of behaviour and to establish an effective therapeutic alliance with the patients we treat, but setting limits is probably the most difficult of all the clinical skills, and among the most challenging group of patients there are some who are at high suicide risk.  They can divide the opinion of any clinical team into those who feel that authoritarian measures should be implemented, often leading to discharge, and the remainder who believe that the patient should have a further chance.

Conclusion

The assessment of suicidal risk is very difficult. I would advise to err on the side of caution. Admission for a few days can be a good idea as a place of safety and to allow for a more considered assessment. Be aware of high-risk patients, these include:

• Those who live alone
• Those who have a bleak future and are hopelessness

Have a fall-back plan for the patient if they feel bad again. In addition, you might want to think about a visit from the community team or involving a home treatment or crisis team where they exist.