Hong Kong College of Mental Hong Kong College of Mental

Health NursingHealth Nursing

Assessment of Risk of Assessment of Risk of SuicideSuicide

Tsang Fan Tsang Fan KwongKwongCastle Peak HospitalCastle Peak Hospital20 November 200920 November 2009

Scope of this lectureScope of this lecture

risk factors for suiciderisk factors for suiciderisk factors for deliberate self harmrisk factors for deliberate self harmIdentify suicidal patientsIdentify suicidal patientsManagement of suicidal patientsManagement of suicidal patientsEconomic upheaval and suicideEconomic upheaval and suicide

Definition

Stengel(1952) suicide & attempted suicideKessel(1965) deliberate self-poisoning

deliberate self-injury Kreitman(1977) parasuicideMorgan(1979) deliberate self harm

Risk factors for suicideRisk factors for suicideSevere psychiatric illness: 6Severe psychiatric illness: 6--11 times 11 times higher higher ((HirschfeldHirschfeld and and DavisionDavision 1988; 1988; GarfinkelGarfinkel BD et al BD et al 1982)1982)

Dementia: 11% > 65 years yet Dementia: 11% > 65 years yet contribute to 25% completed suicide contribute to 25% completed suicide (Margo (Margo & & FinkelFinkel 1990)1990)

Hopelessness Hopelessness ((PrezantPrezant & & NeimeyerNeimeyer 1988; Beck AT 1988; Beck AT 1985 & 1990; 1985 & 1990; SchlebuschSchlebusch & & WesselsWessels 1988)1988)

Personality disorderPersonality disorderLethality of the attempt: the more violent Lethality of the attempt: the more violent and painful the greater risk and painful the greater risk (Rich 1990)(Rich 1990)

Risk factors for suicideRisk factors for suicide

Depression: 15% untreated major Depression: 15% untreated major depression died of suicide depression died of suicide (Murphy 1983)(Murphy 1983)

Repression: aggression turn inwards Repression: aggression turn inwards (Goldberg & (Goldberg & SakinofskySakinofsky 1988; 1988; ApterApter et al 1989)et al 1989)

Lack of obvious message/ secondary Lack of obvious message/ secondary gaingainEarly loss or separation from parents Early loss or separation from parents (Wasserman & (Wasserman & CullbergCullberg 1989)1989)

Anxiety disorder: panic disorder Anxiety disorder: panic disorder ((WeissmanWeissman MM 1989)MM 1989)

Risk factors for suicide Risk factors for suicide Accident proneness Accident proneness (Black 1985) (Black 1985)

AkathisiaAkathisia (Drake & Ehrlich 1985)(Drake & Ehrlich 1985)

Homicide: aggression and impulse Homicide: aggression and impulse control control ((VirkkunenVirkkunen 1989; Griffith & Bell 1989; 1989; Griffith & Bell 1989; HolingerHolinger 1980; Rosenbaum 1990)1980; Rosenbaum 1990)

Criminal Criminal behaviourbehaviour ((AlessiAlessi 1984)1984)

Discontinuation of medication for Discontinuation of medication for BADBAD ((SchouSchou & & WeekeWeeke 1988)1988)

StressStress ((KoskyKosky 1983; Cohen1983; Cohen--Sandler 1982)Sandler 1982)

Epidemics Epidemics ((LesslerLessler RC 1988; Rosen & RC 1988; Rosen & Walsh 1989; Robbins & Walsh 1989; Robbins & KulbockKulbock 1988)1988)

Risk factors for suicideRisk factors for suicideSetting to avoid being foundSetting to avoid being foundLow selfLow self--esteemesteemFamily problems Family problems ((HawtonHawton 1982)1982)

Child abuse and Child abuse and HxHx of incestof incestSpring & Fall Spring & Fall ((HillardHillard 1981)1981)

Widowed, divorced and separated: Widowed, divorced and separated: single is twice rate as married; single is twice rate as married; MANBISMANBISlowest rate lowest rate (Roy 1983)(Roy 1983)

Woman more attempt but men succeed Woman more attempt but men succeed moremoreAge: >65 for men, for women, peak at Age: >65 for men, for women, peak at 65 then drop65 then drop

Risk factors for suicideRisk factors for suicide

Religion and cultural norms: low among Religion and cultural norms: low among Jews & Catholic, high among ProtestantsJews & Catholic, high among ProtestantsCreative sensitive person Creative sensitive person (Clayton 1985; (Clayton 1985; SlabySlaby1991)1991)

Socioeconomic status: highest among Socioeconomic status: highest among the lowest and highest classesthe lowest and highest classesSevere InsomniaSevere InsomniaSubstance abuseSubstance abuseSchizophreniaSchizophreniaCommand hallucination & delusionsCommand hallucination & delusions

Risk factors for suicideRisk factors for suicide

Being gay when young without social Being gay when young without social support or being oldsupport or being oldPhysical illnessPhysical illnessFamily Family HxHx of suicideof suicidePrevious suicidal attempts Previous suicidal attempts ((GoldacreGoldacre & & HawtonHawton1985; Steer 1988; Lo & Leung 1985)1985; Steer 1988; Lo & Leung 1985)

Living alone , contact with health care Living alone , contact with health care provider reduced riskprovider reduced risk

Risk factors for suicideRisk factors for suicide

HypochondriasisHypochondriasisRecent childbirth and operationRecent childbirth and operationunemployment and financial hardshipunemployment and financial hardshipeducation: higher among the education: higher among the educatededucatedOccupation: higher among Occupation: higher among professionals and least among professionals and least among artisans and farm workersartisans and farm workers

Warning ?!Warning ?!Robin (1959)Robin (1959)

2/3 expressed suicidal ideas2/3 expressed suicidal ideas1/3 expressed clear suicidal intent 1/3 expressed clear suicidal intent often to more than one personoften to more than one person

BarracloughBarraclough (1974) (1974) 2/3 consulted GPs in the previous 2/3 consulted GPs in the previous month month 40% in the previous week40% in the previous week1/4 were psychiatric out1/4 were psychiatric out--patients, patients, 50% of which had seen a psychiatrist 50% of which had seen a psychiatrist in the week before the suicide in the week before the suicide

Warning ?!Warning ?!

Lo WH & Leung TM (1985)Lo WH & Leung TM (1985)40% communicated their suicidal 40% communicated their suicidal intention to othersintention to others19% left a note 19% left a note 20% had previous attempts and 1/3 20% had previous attempts and 1/3 occurring within 6 months of their occurring within 6 months of their completed suicidecompleted suicide

Shneidman(1976)Shneidman(1976)1/6 left a suicidal note 1/6 left a suicidal note

Suicidal noteSuicidal note

ShneidmanShneidman 19761976ask for forgivenessask for forgivenessaccusing or vindictiveaccusing or vindictivedrawing attention to failings in drawing attention to failings in relatives or friendsrelatives or friends

CapstickCapstick 19601960express concern for those remain express concern for those remain alivealive

Suicide following attempted suicideSuicide following attempted suicide

A previous attempt in past 1 year increase the risk by 100XA previous attempt in past 1 year increase the risk by 100X

Suicidal Suicidal attempts (No.)attempts (No.) FU (years)FU (years) Suicide (%)Suicide (%)

KesselKessel & McCulloch & McCulloch (1966)(1966)

511511 11 1.61.6

BuglassBuglass & Horton(1974)& Horton(1974) 28092809 11 0.80.8

Greer & Bagley(1971)Greer & Bagley(1971) 204204 1.51.5 2.02.0

Stengel & Cook(1958)Stengel & Cook(1958) 210210 2 2 -- 55 1.41.4

BuglassBuglass & & MuCulloch(1970)MuCulloch(1970)

511511 33 3.33.3

HawtonHawton & Fagg(1987)& Fagg(1987) 13351335 88 2.82.8

Risk factors (summary)Risk factors (summary)Man >45Man >45single, divorced or widowedsingle, divorced or widowedunemployed or retiredunemployed or retiredliving alone or lack of social supportliving alone or lack of social supportchronic physical illnesschronic physical illnesssevere mental illnesssevere mental illnessalcohol and substances abusealcohol and substances abuserecent life events e.g. loss, death of recent life events e.g. loss, death of spouse,etcspouse,etcprevious attempts and expressed suicidal previous attempts and expressed suicidal intentionintention

Mean annual rates of attempted suicide persons in Oxford 1980-84

0

100

200

300

400

500

600

700

800

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

Rat

es /1

00 0

00

Female

Male

Age distribution of suicidal attempts seen at Tuen Mun hospital 1993-96

0

20

40

60

80

100

120

140

160

11 to15

16 to20

21 to25

26 to30

31 to35

36 to40

41 to45

46 to50

51 to55

56 to60

61 to65

66 to70

over70

Female

Male

Risk for attempted suicide Risk for attempted suicide DemographicDemographic

Female, 15Female, 15--30 30 2/3 <352/3 <35Female : male = 1.5Female : male = 1.5--2 : 12 : 1male >65male >65social isolationsocial isolationlower social classlower social class1/3 visit GPs in the month prior to the 1/3 visit GPs in the month prior to the attempt and used the prescribed drugs attempt and used the prescribed drugs for the attempts for the attempts ((HawtonHawton & & BlackstockBlackstock 1976)1976)

Risk for attempted suicide Risk for attempted suicide Precipitating Precipitating

recent threatening life eventsrecent threatening life eventsquarrel with spouse, girlfriend or boy quarrel with spouse, girlfriend or boy friendfriend50% of the male attempters had 50% of the male attempters had employment problememployment problemrejection by a sexual partnerrejection by a sexual partnerIllness of a family memberIllness of a family memberPhysical illnessPhysical illnesscourt appearancecourt appearancerecent bereavement or significant lossesrecent bereavement or significant lossesfinancial difficultiesfinancial difficulties

Risk for attempted suicide :Risk for attempted suicide :Predisposing Predisposing

long term problems in marriage, long term problems in marriage, children, work and healthchildren, work and health

Bancroft 1977Bancroft 19772/3 marital problem2/3 marital problem50% men involved in extramarital 50% men involved in extramarital relationshiprelationship1/4 men c/o wives were unfaithful1/4 men c/o wives were unfaithfulor the unmarried, 50% had or the unmarried, 50% had problems with the sexual partnersproblems with the sexual partners

Risk for attempted suicide: Risk for attempted suicide: PredisposingPredisposing

Morgan 1975: 1/3 DSH men were Morgan 1975: 1/3 DSH men were unemployedunemployedHolding 1977: 50% were Holding 1977: 50% were unemployedunemployedlong term poor physical healthlong term poor physical healthepileptics 6x more DSH epileptics 6x more DSH ((HawtonHawton1980)1980)early parental loss or parental early parental loss or parental neglected/abuseneglected/abuse

Risk for attempted suicide: Risk for attempted suicide: Psychiatric disorderPsychiatric disorder

affective disorderaffective disorderpersonality disorderpersonality disorderschizophreniaschizophreniadependence on alcoholdependence on alcoholsubstances abusesubstances abuseBancroft 1977: 50% Bancroft 1977: 50% onsultedonsulted a GP, a GP, psychiatrists or social worker in the psychiatrists or social worker in the previous weekprevious week

Risk for attempted suicide: Risk for attempted suicide: UnemploymentUnemployment

parasuicideparasuicide and suicide are always and suicide are always high among the unemployedhigh among the unemployedaggregate longitudinal analyses aggregate longitudinal analyses reveal a significant reveal a significant positive positive associationassociation between between unemployment and suicide in US unemployment and suicide in US and some European countries but and some European countries but not not in UKin UK

Stephen Platt (1984)

Motivation of DSHMotivation of DSHfew admitted an premeditated actfew admitted an premeditated act25% wished to die25% wished to diemajority uncertain to die or notmajority uncertain to die or notleave the fate to decideleave the fate to decideseeking temporary escape from seeking temporary escape from intolerable situationintolerable situationattempt to influence someoneattempt to influence someoneto punish or to induce guilt feeling to to punish or to induce guilt feeling to someonesomeone

a cry for helpa cry for help

Bancroft 1979

Stengel & Cook 1958

Common methods used in suicidal attempt(Tsang FK 1997)

others 5%jump fromheight 3%

wrist cutting17%

hanging 4%Gas 5%

Overdose66%

Drugs used in attempted suicide

other prescribed

drugs 10%

Disinfectant

10%

Others 5%

Pesticide 2%

Cleaning agent

13%

NSAID

28%

Sedative

32%

DSH and suicideDSH and suicideOverlap between the two groupsOverlap between the two groupsKreitman(1977): 1Kreitman(1977): 1--2% of attempters 2% of attempters kill themselves within one year; 1/3 to kill themselves within one year; 1/3 to 1/2 of the completed suicide had a 1/2 of the completed suicide had a hxhxof DSH of DSH HawtonHawton 1985: 161985: 16--25% make further 25% make further attempts within one yearattempts within one yearhxhx of previous attempts and serious of previous attempts and serious acts increased further attemptsacts increased further attemptsOvenstoneOvenstone 1973: attempted suicide: 1973: attempted suicide: completed suicide = 10.8: 1completed suicide = 10.8: 1

Assessment of suicideAssessment of suicide

Risk of the suicideRisk of the suiciderisk of repetitionrisk of repetitionidentify psychiatric disorderidentify psychiatric disorderclarification of current problemsclarification of current problemsobtain independent information from obtain independent information from GP, relatives and friendsGP, relatives and friendsarrange help for the patientsarrange help for the patients

Stages in the assessment interviewStages in the assessment interviewEstablishing rapportEstablishing rapportunderstanding the attemptunderstanding the attemptclarification of current difficultiesclarification of current difficultiesbackgroundbackgroundcopingcopingassessment of mental state at interviewassessment of mental state at interviewlist of current problemslist of current problemsestablishing what further help is requiredestablishing what further help is requiredcontractcontract

Establishing rapportEstablishing rapport

Introduction by name Introduction by name explanation of the purpose of the explanation of the purpose of the interviewinterviewreassurancereassuranceprivacy and confidentialprivacy and confidential

Understanding the attemptUnderstanding the attempt

Detailed account of events in the 48 hours Detailed account of events in the 48 hours preceding the attemptpreceding the attemptcircumstances surrounding the act:circumstances surrounding the act:

degree of planningdegree of planningisolationisolationsuicide notesuicide notemotivesmotivesaction after attempt action after attempt whether alcohol was takenwhether alcohol was taken

Clarification of current difficultiesClarification of current difficulties

Nature of problems and their Nature of problems and their duration and recent changesduration and recent changesareas to covered: areas to covered:

psychological and physical problemspsychological and physical problemsrelationship with partner and family, relationship with partner and family, children and friendschildren and friendswork and studywork and studyconsumption of alcohol and consumption of alcohol and substancessubstances

BackgroundBackground

Relevant family and personal historyRelevant family and personal historyusual personalityusual personalitysocial supportsocial supportpossible protective factorspossible protective factors

CopingCoping

Personal resourcesPersonal resourcessocial social assets(friendsassets(friends, social agencies , social agencies and GP)and GP)previous ways of coping with previous ways of coping with difficultiesdifficulties

Stages in the assessment interviewStages in the assessment interview

Assessment of mental state at interview : Assessment of mental state at interview : especially mood and cognitive stateespecially mood and cognitive state

List of current problems: List of current problems: formulated together formulated together with the patientwith the patient

Establishing what further help is required: Establishing what further help is required: what the patient wants and is prepared to what the patient wants and is prepared to acceptedacceptedwho else should be involvedwho else should be involved

Contract: Contract: terms of further involvement of the terms of further involvement of the assessor or other agencies made explicit and assessor or other agencies made explicit and agreedagreed

DisposalDisposal

Admission to a mental hospitalAdmission to a mental hospitaloutpatient treatmentoutpatient treatmentsupportive psychotherapysupportive psychotherapycrisis interventioncrisis interventionMSW,CP, GP, relatives and friendsMSW,CP, GP, relatives and friendssuicidal cautionsuicidal cautionclose observationclose observation

Psychiatric Diagnosis of suicidal attempters(Tsang FK 1997)

Acute stressreaction41%

Anxiety disorders9%

No PsychiatricDiagnosis11%

Depression20%

Substances abuse5%

Personaliyproblems4%

Schizophrenia10%

Further disposal(Tsang FK 1997)

others

5%

PsychiatricOutpatientfollow-up35%

admission tomental hospital10%

Home

50%

Assessment of suicidal riskAssessment of suicidal riskBeck suicidal intent scaleBeck suicidal intent scale(1974a)(1974a)

15 items in two groups15 items in two groupsobjective circumstances elated to objective circumstances elated to suicide attemptsuicide attemptselfself--reportreport

each items score 0,1 or 2 with a each items score 0,1 or 2 with a total score from 0 to 30total score from 0 to 30high score means high suicidal risk, high score means high suicidal risk, helpful when correlate with clinical helpful when correlate with clinical findingsfindings

Beck suicidal intent scaleBeck suicidal intent scaleObjective circumstances related to Objective circumstances related to

suicide attemptsuicide attempt1. Isolation1. Isolation2. timing2. timing3. precautions against 3. precautions against

discovery/interventiondiscovery/intervention4. acting to get help during /after the 4. acting to get help during /after the

attemptattempt5. final acts in anticipation of death5. final acts in anticipation of death6. active preparation6. active preparation7. Suicide note7. Suicide note8. Overt communication of intent before 8. Overt communication of intent before

Beck suicidal intent scaleBeck suicidal intent scale

SelfSelf--reportreport9. Alleged purpose of the attempt9. Alleged purpose of the attempt10. expectations of fatality10. expectations of fatality11. Conception of method11. Conception of method’’s lethalitys lethality12. Seriousness of attempt12. Seriousness of attempt13. Attitude towards living/dying13. Attitude towards living/dying14. Conception of medical 14. Conception of medical rescuabilityrescuability15. Degree of premeditation15. Degree of premeditation

High risk factorsHigh risk factorsMan > 45Man > 45unemployed or retiredunemployed or retiredseparated, divorced or widowedseparated, divorced or widowedliving aloneliving alonepoor physical healthpoor physical healthreceived medical treatment within 6 received medical treatment within 6 monthsmonthspsychiatric disorder including alcoholismpsychiatric disorder including alcoholismusing violent methodsusing violent methodspresence of a suicide notepresence of a suicide notehxhx of previous attemptof previous attempt

Tuckman & Youngman (1968)

Assessment of risk of repetitionAssessment of risk of repetition

problems in use of alcoholproblems in use of alcoholDxDx of of sociopathysociopathyprevious psychiatric treatmentprevious psychiatric treatmentprevious outprevious out--patient psychiatric patient psychiatric treatmenttreatmentprevious DSHprevious DSHnot living with relativesnot living with relatives

Buglass & Horton (1974)

Management of suicidal patientsManagement of suicidal patientsSuicidal cautionSuicidal cautionPrevent successful attemptsPrevent successful attemptsMotivate relatives to take up part of the Motivate relatives to take up part of the prevention roleprevention roleTreat urgent situation / crisis interventionTreat urgent situation / crisis interventionConsider admission for protectionConsider admission for protectionTreat underlying causesTreat underlying causesManagement of suicidal patients in general Management of suicidal patients in general wardswardsIn case of successful attempts: debriefing, In case of successful attempts: debriefing, mortality meeting/reviewmortality meeting/review

Suicide and unemployment

cross-sectional individual studies: parasuicide and suicide rates among the unemployed are always considerably higher than among the employedaggregate-cross-sectional studies: no evidence of a consistent association between unemployment and completed suicide , but a significant geographical association between unemployment and suicide were found

Stephen Platt(1984)

Suicide and unemployment

•individual longitudinal studies: more unemployment, job instability and occupational problems among suicides compared to non-suicides•aggregate longitudinal analyses: a significant positive association between unemployment and suicide in the U.S. and some European countries. The negative relationship in the U.K. during the 1960s and early 1970s was due to unique decline in suicide rates due to the unavailability of the most common method of suicide

Stephen Platt(1984)

Parasuicide and unemployment

in 1982, the ratio of parasuicide rate among the unemployed man to that among the employed in Oxford was 15.4if man unemployed for more than one year, the relative risk has ranged 26 and 36.6highest parasuicide rates among the unemployed are found in the 30-49 age group

Hawton & Rose (1986) Oxford Study

Parasuicide and unemployment

in 1982, the parasuicide rates for unemployed to that of the employed were 1345:114 , giving a relative risk of 11.8relative risk for man unemployed for more than one year were ranged 13.5 and 20.4highest parasuicide rates among the unemployed are found in the 25-54 age group

Platt & Kreitman (1985a) Edinburgh Study

Parasuicide and unemployment

unemployment may exacerbate or precipitate factors known to increase the risk of suicidal behaviour, such as social and interpersonal difficulties, poverty and psychiatric disorder

Hawton & Rose (1986) Oxford Study

Parasuicide and unemployment

conclude that their findings are compatible with the hypothesis that unemployment is a cause of parasuicideparasuicide risk increases with greater duration of unemploymentprolonged unemployment might be a significant predisposing factor in suicidal behaviour

Platt & Kreitman (1985a)

Prolonged unemployment leads to

an increase in family tensionarguments and violencemore depressionHopelessnessincreasingly isolation from otherschanges in role structure within familyfinancial hardship and material deprivationloss of self-esteem and self-confidencefelling of reduced self-worth

What is the local scene ?

Economy and attempted suicide

economic upheaval began in October 1997data on attempted suicide cases seen at Tuen MunHospital and Pok Oi Hospital were collected regularlystatistics during the period 1 October 1996 to 30 September 1997 were compared with that during 1 October 1997 to 30 September 1998assumption: suicidal attempts increase when there is an economic repression and high unemployment rate

No. of suicidal attempts seen at Tuen Mun Hospital & Pok Oi Hospital from 1.10.1996 to 30.09.1997 and 1.10.1997 to 30.9.1998

Female Male F:M Total

1.10.1996-30.9.1997 366 156 2.35 522

1.10.1997-30.9.1998 409 242 1.69 651

% Change +11.7 +55.8 - + 24.7

No. of monthly suicidal attempts seen at TMH & POH and seasonally adjusted unemployment and underemployment statistics

0

2

4

6

8

4/97

6/97

8/97

10 /9712 /97

2/98

4/98

6/98

8/98

10 /9812 /98

2/99

4/99

6/99

8/99

No. of monthly suicidal attempts seen('0)seasonally adjusted unemployment statisticsseasonally adjusted underemployment statistics

Age distribution of suicidal attempts seen at Tuen Mun Hospital 1993-96 (Tsang FK 1997)

0

20

40

60

80

100

120

140

160

11 to15

16 to20

21 to25

26 to30

31 to35

36 to40

41 to45

46 to50

51 to55

56 to60

61 to65

66 to70

over70

Female

Male

Age distribution of Male suicidal attempts seen at Tuen Mun Hospital 96/97 and 97/98

05

101520253035404550

<16 16 to20

21 to25

26 to30

31 to35

36 to40

41 to45

46 to50

51 to55

56 to60

61 to65

66 to70

over70

Male (10/96-9/97) Male (10/97-9/98)

Age distribution of Female suicidal attempts seen at Tuen Mun Hospital 96/97 and 97/98

0

20

40

60

80

100

120

140

<16 16to20

21to25

26to30

31to35

36to40

41to45

46to50

51to55

56to60

61to65

66to70

over70

Female (10/96-9/97) Female(10/97-9/98)

Reasons for the attempts for the 96/97 and 97/98 group (in %)

3.4

3.7

4.5

3.1

7.4

10

3.6

0.9

10.8

7.8

1.6

4.8

14.1

5.7

12.1

27.6

24.6

8.1

33.5

12.7

0 5 10 15 20 25 30 35 40

marital problem

boy/girl relationship

family problem

other relationship

unemployment

finance

study

health

mental illness

others

96/97 (n=522) 97/98 (n=651)

Psychiatric diagnosis in the suicidal attempts (in % ) for the 96/97 and 97/98 groups

22

19

20

10.7

9.4

4.1

14.8

30

25.8

16.1

9.3

1.7

4.9

12.2

0 5 10 15 20 25 30 35

acute stress reaction

adjustment disorders

depression

schizophrenia

anxiety disorders

others

no psychiatric disorder

96/97 group(n=533) 97/98 group (n=651)

Summary of the attempted suicide findings for the year 96/97 and 97/98 for cases seen at TMH & POH

No. of cases seen increase by 24.7%(n=129), yet the population increased in the district is just 6%the male attempts increased by 55%, with the highest increased at the 26-30 age group(58%), 31-35 age group(210%) and 36-40 age group(44%)the female attempts increased by 11.7%, with the highest increased at the 26-30 age group(58%), 31-35 age group(55%), 36-40 age group(25.8% and the 41-45 age group(177%)

Summary of the attempted suicide findings for the year 96/97 and 97/98 for cases seen at TMH & POH

The no. of overdose decreased by 13.4% yet the no. of overdosed by anxiolytics increased by 37.8%(prescribed medications)more cases attempted to kill themselves by more dangerous method, e.g., hanging or strangulation, gas or burning carbon, jumping from height and taking insecticide/rat killers, etc. (overall increased by 14.3%)cases using dangerous methods largely belonged to the 25-45 age groups

Summary of the attempted suicide findings for the year 96/97 and 97/98 for cases seen at TMH & POH

14.9% used two methods or more (10% only in the 93-96 group)more than 20% of them took alcohol before the attempts13 cases attempted to die by burning charcoal, 8 of them were man, majority of the charcoal burners were having financial difficulties

How about completed suicide ?How about completed suicide ?

Suicide rates (per 100 000)1969-71 1986-88

Country M/F M/FFrance 21/8 36/11 Greece 5/2 6/2Italy 7/3 10/3Netherlands 8/6 15/9Spain 5/2 6/2West Germany 31/13 25/9UK 11/6 16/5USA 20/10 24/6Finland 49/12 59/13Sweden 35/16 31/13Hong Kong 11.7/9.4(1987)Taiwan 11.1/7.3(1987)Beijing 8.6/9.4(1987)

Local suicide deaths 1980-99 (Demographic Statistics Section, HKSAR)

460555

727645

882819

689

679

609569

601641684

405

497

580

638

741718

646

0

100

200

300

400

500

600

700

800

900

1000

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Local suicide deaths by sex 1980-99

0

200

400

600

800

1000

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Male Female Total

0

2

4

6

8

10

12

14

81 83 85 87 89 91 93 95 97

HK Taiwan Beijing

Suicide rates (per 100 000) (Paul Yip 1996 )

Method of suicide (81-94) HK(Paul Yip 1996)

0

10

20

30

40

50

60

70

1981

1983

1985

1987

1989

1991

1993

Poisoning Hanging Jumping Others