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Depression and SuicideDepression and Suicide

Dr. Tsang Fan Dr. Tsang Fan KwongKwong20 October 200620 October 2006

The Hong Kong College of The Hong Kong College of Mental Health NursingMental Health Nursing

Depression : a common disorderdepressive symptoms : 1/3 of the populationmajor depression :

lifetime prevalence for 16.1%incidence : female : 1.98% ; male: 1.1%

bipolar disorder:lifetime prevalence: 3.6%incidence: female:7-32/100 000; male:9-15/100 000

dysthymia: lifetime prevalence: 1.3%Alan Doris, Klaus Ebmeier, Polash shajahanThe Lancet Vol 354 1999 1369-75

Depression: a common disorder

Age of onset female: 23male: 26

WHO: by the 2020one of the most important causes of ill health overall340 million people will suffer from depression

Alan Doris, Klaus Ebmeier, Polash shajahanThe Lancet Vol 354 1999 1369-75

Unipolar depression: summary of life-course

Recurrent rate 85-100% Mean no. of episode 3≧ Range 1 to >6 Chronic course 12% Full recovery after 1 year 50%

Modified from Angst(1986) and Keller et al(1982, 1984, 1992)

Depression: a common disorderDisability caused higher than that of hypertension, DM or CVA60% will have a recurrence within 5 years and up to 75% within 10 yearsdepression is easily amenable to treatment one of the most common disorder in the primary care setting in the US (74% of American who had depression will go to a primary care physician)

C. Brendan MontaroJ clin Psychiatry 55:12(Supp) Dec 1994

Depression: a common disorder

Diagnosis of depression is missed in 50% of primary care casesless than 10% of the diagnosed received appropriated treatmentUS HMO setting, about 60% of depression is undiagnosed

15% of patients died of suicide if not treated 15% of patients died of suicide if not treated properlyproperly

C. Brendan MontaroJ clin Psychiatry 55:12(Supp) Dec 1994

Depression: under diagnosis

Present with somatic symptoms to the primary care physician, e.g. sleep disturbance, headache, gastrointestinal upset, fatigue or weight losspatients reluctant to disclose depressive symptoms because of shame fear that the doctor will not have time to listenattitude of the clinician: no eye contact, put all effort on physical problems and lack of sensitivity on patients’ emotional changesvariation of clinical picture

Paykel & Priest BMJ 1992 305:1198-1202

PatientsPatients’’ reluctance in seeking treatment reluctance in seeking treatment from family doctorfrom family doctor

Did not think anyone can help(28%)Did not think anyone can help(28%)A problem one should be able to cope with(28%)A problem one should be able to cope with(28%)Did not think it was necessary to contact a Did not think it was necessary to contact a doctor(17%)doctor(17%)Thought problems would get better by Thought problems would get better by itself(15%)itself(15%)Too embarrassed to discuss it with anyone(13%)Too embarrassed to discuss it with anyone(13%)Afraid of the consequences, e.g. treatment, Afraid of the consequences, e.g. treatment, hospitalisationhospitalisation (10%)(10%)

Meltzer et al 2000

58%

11%12%

19%

Minor tranquilizer only

Antidepressant* only

Antidepressant* andminor tranquilizer

No antidepressantor tranquilizer

UnderUnder--treatment of depressive treatment of depressive disordersdisorders

*39% of patients using antidepressants were receiving sub-therapeutic dosesData are rounded to nearest percentage

Wells KB et al. Am J Psychiatry 1994;151:694–700

Diagnostic features: DSM IV criteria for Major Depressive Episode

Depressed mood and/or loss of interest or pleasure in nearly all activities for at least 2 weeksAND, at least 4 of the following symptoms during the same 2-week period and represent a change from previous functioning:

Physical symptoms Psychological symptoms

Insomnia or hypersomnia Feel worthlessness or guilt

Change appetite/weightFatigue or loss of energy

Difficulty in thinking, concentrating or making decisions

Psychomotor agitation or retardation

Recurrent thoughts of death, suicidal ideation, plans or attempts

Depressive episode: ICD 10 criteria

2 weeks duration of at least 2 of the typical symptomsA. Depressed moodB. Lost of interest and enjoymentC. Reduced energy, increased fatiguability and diminished activity

AND at least 2 of the following;a. reduced concentration and attentionb. reduced self-esteem and self-confidencec. ideas of guilt and unworthinessd. bleak and pessimistic views of the futuree. ideas or acts of self-harm or suicidef. disturbed sleepg. diminished appetite

Symptoms common to major depression and anxiety Symptoms common to major depression and anxiety disordersdisorders

Major depression

Anxietydisorder

• Depressed mood

• Anhedonia• Weight gain/loss

• Loss of interest

• Hypervigilance• Agoraphobia• Compulsive rituals

• Fear• Panic• Apprehension• Panic attacks• Chronic pain• GI complaints• Excessive worry• Agitation• Difficulty concentrating

• Sleep disturbances

DSM-IVKeller MB. J Clin Psychiatry 1995;56:22–29

Clayton PJ et al. Am J Psychiatry 1991;148:1512–1517Coplan JD, Gorman JM. J Clin Psychiatry 1990;51:9–13

AetiologyAetiology of Depressionof Depression

Genetic causesGenetic causesLifetime prevalence Lifetime prevalence

women: 6women: 6--8.3%8.3%men: 2.7men: 2.7--4.6% 4.6% (Robins et al 1984; Surtees & (Robins et al 1984; Surtees & SashidharanSashidharan 1986)1986)

Parents, siblings and children of severely depressed patients: 1Parents, siblings and children of severely depressed patients: 100--15% 15% (Angst (Angst GershonGershon 1976)1976)

Adoption Studies: affective disorders more frequent in biologicaAdoption Studies: affective disorders more frequent in biological l relatives relatives ( ( CadoretCadoret 1978; 1978; MendlewiczMendlewicz & Rainer 1977; & Rainer 1977; WenderWender et al 1986)et al 1986)

MZ : DZ twins concordance rate for MDP: 68% : 23%MZ : DZ twins concordance rate for MDP: 68% : 23% (Price 1968; (Price 1968; BertelsenBertelsen 1977)1977)

Genetic studies: Chromosome 11, long arm of xGenetic studies: Chromosome 11, long arm of x--chromosome, HLA chromosome, HLA complescomples of chromosome 6, etc., polygenicof chromosome 6, etc., polygenic

BiochemicalBiochemicalNE and 5NE and 5--HT HT Lost of Lost of neuroplasticityneuroplasticity

PsychoPsycho--socialsocialmaternal deprivationmaternal deprivationrecent life eventsrecent life eventsPsychoanalytic and cognitive theoryPsychoanalytic and cognitive theory

Affective illness in the first degree relatives of Affective illness in the first degree relatives of unipolar(UPunipolar(UP) and ) and bipolar(BPbipolar(BP) ) probandsprobands(Data from studies reviewed by (Data from studies reviewed by McguffinMcguffin & Katz, 1986)& Katz, 1986)

RelativesRelativesProbandProbandtypetype

No. of No. of studiesstudies AgeAge--corrected**corrected**

n at riskn at riskMorbid risk* (range): %Morbid risk* (range): %

BP UPBP UPBPBP 1212 37103710 7.8 (1.57.8 (1.5--17.9)17.9) --

36483648 -- 11.4 (0.511.4 (0.5--22.4)22.4)

UPUP 77 23192319 0.6 (0.30.6 (0.3--2.1)2.1) 9.1 (5.99.1 (5.9--18.4)18.4)

*Weighted means

** Corrected denominator (“Bezugsiffer”) to allow for relatives who have not livedd through the period of risk

Peter McGuffin & Randy Katz, The genetics of Depression and Manic-depressive disorder, B J Psych (1989), 155, 294-304)

Frequency (%) of depression in the first degree relatives of Frequency (%) of depression in the first degree relatives of probandsprobandswith neurotic or endogenous depression (with neurotic or endogenous depression (McGuffinMcGuffin et al 1987)et al 1987)

ProbandProband typetypeNeurotic EndogenousNeurotic Endogenous

General General populationpopulation

Prevalence of current Prevalence of current ““casescases”” 23.523.5 12.712.7 11.1*11.1*

Morbid risk of moderate plus Morbid risk of moderate plus severe depressionsevere depression 23.723.7 25.725.7 8.9**8.9**

Morbid risk of severe Morbid risk of severe depressiondepression 7.97.9 14.714.7 2.6**2.6**

*From Bebbington et al (1981)

** From Sturt et al (1984)


Twin Concordance for major affective disorderTwin Concordance for major affective disorder

MonozygoticMonozygotic DizygoticDizygoticnn Concordance %Concordance % nn Concordance %Concordance %

GershonGershon et al (1975)*et al (1975)* 9191 6969 226226 1313

BertelsenBertelsen et al (1997)**et al (1997)** 6969 6767 5454 2020

TorgersenTorgersen et al (1986)**et al (1986)** 3737 5151 6565 2020

McguffinMcguffin & Katz (1989 & Katz (1989 priliminarypriliminary results) **results) ** 6262 5353 7979 2828

AuthorsAuthors


*Combined figure from 6 earlier studies reporting pair-wise concordance

** Systematic register-based studies reporting probanwise concordance

Monoamine hypothesisMonoamine hypothesis

Figure 5-13 & 14, Stephen M Stahl, Essential Psychopharmacology, 2nd edition

Figure 5-23, Stephen M Stahl, Essential Psychopharmacology, 2nd edition

Figure 5-51, Stephen M Stahl, Essential Psychopharmacology, 2nd edition

Figure 2.1, R. Shiloh, R. Stryjer, A Weizman, D. Nutt, Atlas of Psychiatric Pharmacology, 2nd ed.

Neuroplasticity theory

Management of depressionTreatment planning: primary care or specialist

in-patient or out-patientacute, continuation or maintenance

Mode of treatment: physical, psychological, social

Physical treatment: ECT, light therapyantidepressant medications

Psychological :cognitive behavioural psychotherapyinterpersonal psychotherapyDynamic psychotherapysupport and counseling to patients and relatives

Social

MxMx of MDD in primary care: the trendof MDD in primary care: the trend

Majority of depressive patients attempt to seek Majority of depressive patients attempt to seek initial treatment from primary careinitial treatment from primary careDiagnosis of depression is Diagnosis of depression is missed in 50% of missed in 50% of primary care casesprimary care casesless than 10% of the diagnosed received less than 10% of the diagnosed received appropriated treatmentappropriated treatment1 in 4 or 5 diagnosed to have MDD in primary 1 in 4 or 5 diagnosed to have MDD in primary care are referred to mental health servicescare are referred to mental health servicesVariation in GP skills and referralsVariation in GP skills and referrals

Montaro 1994, Goldberg 1994 &1998, Ustun & Sartorius 1995, Kisley et al 1995)

Strategies in managing depressionStrategies in managing depressionPublic mental health education campaignPublic mental health education campaign

Worldwide: WHO, Worldwide: WHO, RCPsychRCPsychLocal: CPHLocal: CPH--IMH Defeat Depression ProjectIMH Defeat Depression Project

Education & training of primary care providersEducation & training of primary care providersWHO training program for primary care workersWHO training program for primary care workersLocal: Training course and Diploma Program by Local: Training course and Diploma Program by universities and regular lectures conducted by CPHuniversities and regular lectures conducted by CPH--IMHIMH

Collaboration between primary care providers Collaboration between primary care providers and specialistsand specialistsTreatment by mental health specialist Treatment by mental health specialist Prevention and relapse preventionPrevention and relapse prevention

Public mental health education Public mental health education

Increase understanding and self recognitionIncrease understanding and self recognitionDo away stigma and Do away stigma and labellinglabellingIncrease motivation for treatmentIncrease motivation for treatmentSelfSelf--management skillsmanagement skillsAdherence to treatment regimenAdherence to treatment regimenPartnership with special groupsPartnership with special groups

Patient advocatePatient advocateMass mediaMass media

Enhance early recognition and treatmentEnhance early recognition and treatment

Specialist treatmentSpecialist treatmentSecondary referralSecondary referralMore severe or suicidal patientsMore severe or suicidal patientsResistant casesResistant casesOutpatientOutpatient--inpatientinpatient--day hospitalday hospital--homehome--community community Medications/ ECT/ Psychological treatmentMedications/ ECT/ Psychological treatmentCognitive behavioural therapy/ interpersonal Cognitive behavioural therapy/ interpersonal psychotherapy/ dynamic psychotherapypsychotherapy/ dynamic psychotherapyMultiMulti--disciplinary approachdisciplinary approach

Mechanism of action of Mechanism of action of TricyclicTricyclic antidepressantantidepressant

Shown here is an icon of a tricyclic antidepressant (TCA). These drugs are actually five drugs in one: (1) a serotonin reuptake inhibitor (SRI); (2) a norepinephrinereuptake inhibitor (NRI); (3) an anticholinergic/antimuscarinic drug (M1); (4) an alpha adrenergic antagonist (alpha); and (5) an antihistamine (H1).

Stephen M Stahl, Essential Psychopharmacology, 1st edition

Therapeutic actions of Therapeutic actions of TCAsTCAs

The serotonin reuptake inhibitor(SRI) portion of the TCA is inserted into the serotonin reuptake pump, blocking it and causing an antidepressant effect

Stephen M Stahl, Essential Psychopharmacology, 1st editionStephen M Stahl, Essential Psychopharmacology, 1st edition

Therapeutic actions of Therapeutic actions of TCAsTCAs

The norepinephrine portion of the TCA is inserted into the norepinephrinereuptake pump , blocking and causing an antidepressant effect


Side effects of the tricyclic antidepressants- part 1: the icon of the TCA is shown with its H1 (antihistamine) portion inserted into histamine receptors


Side effects of the tricyclic antidepressants - part 2: the icon of the TCA is shown with its M1 (anticholinergic/antimuscarinic) portion inserted into acetylcholine receptors


Side effects of the tricyclic antidepressants - part 3: the icon of the TCA is shown with its α (α adrenergic antagonist) portion inserted into α adrenergic receptors


Icon of a selective serotonin reuptake inhibitor (SSRI). In this case, 4 out of the 5 pharmacological properties of the TCAs were removed. Only the serotonin reuptake inhibitor (SRI) portion remains; thus the SRI action is selective, and thus named selective SRIs. Fluoxetine, Fluvoxamine, Citalopram, Paroxetine and Sertraline belongs to this group.


Mechanism of action:Mechanism of action: SRI (serotonin reuptake inhibitor) portion of the SSRImolecule is shown inserted in the serotonin reuptake pump, blocking it and causing an antidepressant effect. This is analogous to one of the dimensions of the tricyclicantidepressants (TCAs).


Fluoxetine Paroxetine

AmitriptylineMirtazapine

Paroxetine

escitalopram

Bupropion

Clomipramine

Venlafaxine

Fluvoxamine Moclobemide

Icon of a dual reuptake inhibitor which combines the actions of both a serotonin reuptake inhibitor (SRI) and a norepinephrine reuptake inhibitor (NRI). In this case, 3 out of the 5 pharmacological properties of the TCAs (tricyclic antidepressants) were removed. Both the SRI portion and the NRI portion of the TCA remain; however the alpha, antihistamine and anticholinergic portions are removed. These serotonin/norepinephrine reuptake inhibitorsare called SNRIs or dual inhibitors. A small amount of dopamine reuptake inhibition (DRI) is also present in some of these agents, especially at high doses.

venlafaxine (efexor)

Icons for two of the serotonin 2 antagonist/reuptake inhibitors (SARIs). These agents also have a dual action, but the two mechanisms are different from the dual actions of the SNRIs(serotonin norepinephrine reuptake inhibitors). The SARIs act by potent blockade both of serotonin 2 (5HT2) receptors, combined with SRI (serotonin reuptake inhibitor) actions. Nefazodone also has weak NRI (norepinephrine reuptake inhibition) as well as weak alpha adrenergic blocking properties. Trazodone also contains antihistamine properties and alpha antagonist properties, but lacks NRI (norepinephrine reuptake inhibition) properties.

Figure 7Figure 7--14 Stephen M Stahl, Essential Psychopharmacology, 2nd ed.14 Stephen M Stahl, Essential Psychopharmacology, 2nd ed.

Figure 7Figure 7--10 &11 Stephen M Stahl, Essential Psychopharmacology, 2nd ed.10 &11 Stephen M Stahl, Essential Psychopharmacology, 2nd ed.

Drugs used in major depressive disorderDrugs used in major depressive disorder

Cyclic Antidepresant

Starting dose (mg/day)

Usual adult dose (mg/day)

Usual serum level

Degree of Muscarinic blockade

Amitriptyline 25-50 50-175 - +++ Doxepin 25-50 50-175 - ++ Imipramine 25-50 50-175 - + Trimipramine 25-50 50-175 - + Desipramine 25-50 50-175 - + Nortriptyline 25 50-200 - + Clomipramine 25 50-175 _ +++ Trazodone 50 150-500 - 0 Prothiaden 25-50 50-175 - ++

Drugs used in major depressive disorderDrugs used in major depressive disorderSSRIs Starting dose

(mg/day) Usual adult dose

(mg/day) Usual

serum levelMuscarinic blockade

Fluoxetine 5-20 20-80 - 0 Sertraline 50-100 50-200 - 0 Paroxetine 10-20 20-50 - 0 Fluvoxamine 50-100 100-300 - 0 Citalopram 10-20 20-40 - 0 escitalopram 10 10-20 - 0 MAOIs Moclobemide 150X2 300-600 - 0

Others

Mianserin 10-20 20-80 - ? Venlafaxine SNRI 37.5 x 2 75-225 - ? Mirtazapine NaSSA 15 15-45 - ? Bupropion NDRI 225 in 3 dose 225-450 in 3 dose - ? Duloxetine SNRI 40-60 in 1-2 dose

Psychological treatment of DepressionPsychological treatment of Depression

Dynamic psychotherapyDynamic psychotherapyCognitive psychotherapyCognitive psychotherapyInterpersonal Interpersonal psychotherapy(IPTpsychotherapy(IPT))

IPTIPTAdolf Meyer: patientsAdolf Meyer: patients’’ relationship with his relationship with his environmentenvironmentSullivan: interpersonal relationship as a cause of Sullivan: interpersonal relationship as a cause of mental illnessmental illnessBowlbyBowlby: attachment and bonding: attachment and bondingstresses and life events associated with the onset of stresses and life events associated with the onset of depressiondepressionBrown & Harries(1978): intimacy and social support Brown & Harries(1978): intimacy and social support as a protection against depressionas a protection against depressionPearlinPearlin & Lieberman: the impact of chronic & Lieberman: the impact of chronic interpersonal stress on the onset of depressioninterpersonal stress on the onset of depressionKlermanKlerman & & WeissmanWeissman

Prevention of depressionPrevention of depression

Keep good social networkKeep good social networkKeep good family relationshipKeep good family relationshipGet a supportive partner/friendsGet a supportive partner/friendsAvoid alcohol and substances misuseAvoid alcohol and substances misuse

Relapse preventionRelapse prevention

Regular followRegular follow--upupMaintenance antidepressant Maintenance antidepressant treatment/psychotherapytreatment/psychotherapy

Definition of suicideDefinition of suicide

Stengel(1952) suicide & attempted suicideStengel(1952) suicide & attempted suicideKessel(1965) deliberate selfKessel(1965) deliberate self--poisoningpoisoning

deliberate selfdeliberate self--injuryinjuryKreitman(1977) parasuicideKreitman(1977) parasuicideMorgan(1979) deliberate self harm (DSH)Morgan(1979) deliberate self harm (DSH)

Suicide rates (per 100 000)Suicide rates (per 100 000)

Country Country 19691969--71 71 19861986--88 88 France France M/F M/F 21/821/8 36/11 36/11 Greece Greece M/F M/F 5/25/2 6/26/2ItalyItaly M/FM/F 7/37/3 10/310/3Netherlands M/FNetherlands M/F 8/68/6 15/915/9SpainSpain M/FM/F 5/25/2 6/26/2West GermanyWest Germany M/FM/F 31/1331/13 25/925/9UKUK M/FM/F 11/611/6 16/516/5USAUSA M/FM/F 20/1020/10 24/624/6FinlandFinland M/FM/F 49/1249/12 59/1359/13SwedenSweden M/FM/F 35/1635/16 31/1331/13Hong KongHong Kong M/F 11.7/9.4(1987)M/F 11.7/9.4(1987)TaiwanTaiwan M/FM/F 11.1/7.3(1987)11.1/7.3(1987)

BeijingBeijing M/FM/F 8.6/9.4(1987)8.6/9.4(1987)

Risk factors for suicideRisk factors for suicide

Severe psychiatric illness: 6Severe psychiatric illness: 6--11 times higher 11 times higher (Hirschfeld and Davision 1988; Garfinkel BD et (Hirschfeld and Davision 1988; Garfinkel BD et al 1982)al 1982)Dementia: 11% > 65 years yet contribute to Dementia: 11% > 65 years yet contribute to 25% completed suicide25% completed suicide(Margo & Finkel 1990)(Margo & Finkel 1990)Hopelessness Hopelessness (Prezant & Neimeyer 1988; Beck (Prezant & Neimeyer 1988; Beck AT 1985 & 1990; Schlebusch & Wessels 1988)AT 1985 & 1990; Schlebusch & Wessels 1988)Personality disorderPersonality disorderLethality of the attempt: the more violent and Lethality of the attempt: the more violent and painful the greater riskpainful the greater risk(Rich 1990)(Rich 1990)


Depression: 15% untreated major depression Depression: 15% untreated major depression died of suicidedied of suicide(Murphy 1983)(Murphy 1983)Repression: aggression turn inwardsRepression: aggression turn inwards(Goldberg (Goldberg & Sakinofsky 1988; Apter et al 1989)& Sakinofsky 1988; Apter et al 1989)Lack of obvious message/ secondary gainLack of obvious message/ secondary gainEarly loss or separation from parents Early loss or separation from parents (Wasserman & Cullberg 1989)(Wasserman & Cullberg 1989)Anxiety disorder: panic disorderAnxiety disorder: panic disorder(Weissman MM (Weissman MM 1989)1989)


AkathisiaAkathisia(Drake & Ehrlich 1985)(Drake & Ehrlich 1985)Accident pronenessAccident proneness(Black 1985)(Black 1985)Homicide: aggression and impulse control Homicide: aggression and impulse control (Virkkunen 1989; Griffith & Bell 1989; (Virkkunen 1989; Griffith & Bell 1989; Holinger 1980; Rosenbaum 1990)Holinger 1980; Rosenbaum 1990)Criminal behaviourCriminal behaviour(Alessi 1984)(Alessi 1984)Discontinuation of medication for BADDiscontinuation of medication for BAD (Schou (Schou & Weeke 1988)& Weeke 1988)StressStress (Kosky 1983; Cohen(Kosky 1983; Cohen--Sandler 1982)Sandler 1982)EpidemicsEpidemics(Lessler RC 1988; Rosen & Walsh (Lessler RC 1988; Rosen & Walsh 1989; Robbins & Kulbock 1988)1989; Robbins & Kulbock 1988)


Setting to avoid being foundSetting to avoid being foundLow selfLow self--esteemesteemFamily problemsFamily problems(Hawton 1982)(Hawton 1982)Child abuse and Hx of incestChild abuse and Hx of incestSpring & FallSpring & Fall(Hillard 1981)(Hillard 1981)Widowed, divorced and separated: single is Widowed, divorced and separated: single is twice rate as married; twice rate as married; MANBISMANBIS lowest lowest raterate(Roy 1983)(Roy 1983)Sex: woman more attempt but men succeed Sex: woman more attempt but men succeed moremoreAge: >65 for men, for women, peak at 65 Age: >65 for men, for women, peak at 65 then dropthen drop


Religion and cultural norms: low among Jews & Religion and cultural norms: low among Jews & Catholic, high among ProtestantsCatholic, high among ProtestantsCreative sensitive personCreative sensitive person(Clayton 1985; Slaby (Clayton 1985; Slaby 1991)1991)Socioeconomic status: highest among the Socioeconomic status: highest among the lowest and highest classeslowest and highest classesSevere InsomniaSevere InsomniaSubstance abuseSubstance abuseSchizophreniaSchizophreniaCommand hallucination & delusionsCommand hallucination & delusions


Being gay when young without social support Being gay when young without social support or being oldor being oldPhysical illnessPhysical illnessFamily Hx of suicideFamily Hx of suicidePrevious suicidal attempts Previous suicidal attempts (Goldacre & Hawton (Goldacre & Hawton 1985; Steer 1988; Lo & Leung 1985)1985; Steer 1988; Lo & Leung 1985)Living alone , contact with health care provider Living alone , contact with health care provider reduced riskreduced risk


HypochondriasisHypochondriasisRecent childbirth and operationRecent childbirth and operationunemployment and financial hardshipunemployment and financial hardshipeducation: higher among the educatededucation: higher among the educatedOccupation: higher among professionals Occupation: higher among professionals and least among artisans and farm and least among artisans and farm workersworkers

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

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

Warning ?!Warning ?!

Lo WH & Leung TM (1985)Lo WH & Leung TM (1985)40% communicated their suicidal intention to 40% communicated their suicidal intention to othersothers19% left a note 19% left a note 20% had previous attempts and 1/3 occurring 20% had previous attempts and 1/3 occurring within 6 months of their completed suicidewithin 6 months of their completed suicide

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

Suicidal noteSuicidal note

Shneidman 1976Shneidman 1976ask for forgivenessask for forgivenessaccusing or vindictiveaccusing or vindictivedrawing attention to failings in relatives drawing attention to failings in relatives or friendsor friends

Capstick 1960Capstick 1960express concern for those remain aliveexpress concern for those remain alive

Suicide following attempted suicideSuicide following attempted suicide

No. ofNo. of FUFU SuicideSuicideattempted suicideattempted suicide (years)(years) (%)(%)

Kessel & McCulloch (1966)Kessel & McCulloch (1966) 511511 11 1.61.6Buglass & Horton(1974)Buglass & Horton(1974) 28092809 11 0.80.8Greer & Bagley(1971)Greer & Bagley(1971) 204204 1.51.5 2.02.0Stengel & Cook(1958)Stengel & Cook(1958) 210210 2 2 -- 55 1.41.4Buglass & MuCulloch(70)Buglass & MuCulloch(70) 511511 33 3.33.3Hawton & Fagg(1987)Hawton & Fagg(1987) 13351335 88 2.82.8

A previous attempt in past one year will increase the A previous attempt in past one year will increase the risk by 100Xrisk by 100X

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 spouse,etcrecent life events e.g. loss, death of spouse,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

11to15

16to20

21to25

26to30

31to35

36to40

41to45

46to50

51to55

56to60

61to65

66to70

over70

Female

Male

Tsang FK 1997

Risk factors for attempted suicideRisk factors for attempted suicide

DemographicDemographicFemale, 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 for attempt and used the prescribed drugs for the attemptsthe attempts(Hawton & Blackstock 1976)(Hawton & Blackstock 1976)

Risk factors for attempted suicideRisk factors for attempted suicidePrecipitating factorsPrecipitating factors

recent threatening life eventsrecent threatening life eventsquarrel with spouse, girlfriend or boy friendquarrel with spouse, girlfriend or boy friend50% of the male attempters had employment 50% of the male attempters had employment problemproblemrejection 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


Predisposing factors Predisposing factors long term problems in marriage, children, long term problems in marriage, children, work and healthwork and health

Bancroft 1977Bancroft 19772/3 marital problem2/3 marital problem50% men involved in extramarital relationship50% men involved in extramarital relationship1/4 men c/o wives were unfaithful1/4 men c/o wives were unfaithfulor the unmarried, 50% had problems with the or the unmarried, 50% had problems with the sexual partnerssexual partners


Predisposing factorsPredisposing factorsMorgan 1975: 1/3 DSH men were unemployedMorgan 1975: 1/3 DSH men were unemployedHolding 1977: 50% were unemployedHolding 1977: 50% were unemployedlong term poor physical healthlong term poor physical healthepileptics 6x more DSH epileptics 6x more DSH (Hawton 1980)(Hawton 1980)early parental loss or parental neglected/abuseearly parental loss or parental neglected/abuse


Psychiatric disorderPsychiatric disorderaffective disorderaffective disorderpersonality disorderpersonality disorderschizophreniaschizophreniadependence on alcoholdependence on alcoholsubstances abusesubstances abuseBancroft 1977: 50% onsulted a GP, Bancroft 1977: 50% onsulted a GP, psychiatrists or social worker in the previous psychiatrists or social worker in the previous weekweek


Unemployment(Stephen Platt 1984)Unemployment(Stephen Platt 1984)parasuicide and suicide are always high parasuicide and suicide are always high among the unemployedamong the unemployedaggregate longitudinal analyses reveal a aggregate longitudinal analyses reveal a significant positive association between significant positive association between unemployment and suicide in US and unemployment and suicide in US and some European countries but not in UKsome European countries but not in UK

Motivation of DSHMotivation of DSH

Bancroft 1979Bancroft 1979few 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 intolerable seeking temporary escape from intolerable situationsituationattempt to influence someoneattempt to influence someoneto punish or to induce guilt feeling to someoneto punish or to induce guilt feeling to someone

Stengel & Cook 1958Stengel & Cook 1958a cry for helpa cry for help

Common methods used in suicidal attempt(Tsang FK 1997)

others 5%jump from height 3%

wrist cutting 17%

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 suicide

Overlap between the two groupsOverlap between the two groupsKreitman(1977): 1Kreitman(1977): 1--2% of attempters kill 2% of attempters kill themselves within one year; 1/3 to 1/2 of the themselves within one year; 1/3 to 1/2 of the completed suicide had a hx of DSH completed suicide had a hx of DSH Hawton 1985: 16Hawton 1985: 16--25% make further attempts 25% make further attempts within one yearwithin one yearhx of previous attempts and serious acts hx of previous attempts and serious acts increased further attemptsincreased further attemptsOvenstone 1973: attempted suicide: Ovenstone 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 GP, obtain independent information from GP, relatives and friendsrelatives and friendsarrange help for the patientsarrange help for the patients

Stages in the assessment interviewStages in the assessment interview

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

psychological and physical problemspsychological and physical problemsrelationship with partner and family, children relationship with partner and family, children and friendsand friendswork and studywork and studyconsumption of alcohol and substancesconsumption of alcohol and substances

BackgroundBackground

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

CopingCoping

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

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 with formulated together with the patientthe patient

Establishing what further help is required: Establishing what further help is required: what the patient wants and is prepared to acceptedwhat the patient wants and is prepared to acceptedwho 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 agreedassessor or other agencies made explicit and agreed

Psychiatric Diagnosis of suicidal attempters(Tsang FK 1997)

Acute stress reaction41%

Anxiety disorders9%

No Psychiatric Diagnosis11%

Depression20%

Substances abuse5%

Personaliy problems4%

Schizophrenia10%

Further disposal(Tsang FK 1997)

others

5%

Psychiatric Outpatient follow-up35%

admission to mental hospital10%

Home

50%

Beck suicidal intent scale Beck suicidal intent scale (1974a)(1974a)

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

each items score 0,1 or 2with a total each items score 0,1 or 2with a total score from 0 to 30score 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 scale

objective circumstances related to suicide objective circumstances related to suicide attemptattempt1. Isolation1. Isolation2. timing2. timing3. precautions against discovery/intervention3. precautions against discovery/intervention4. acting to get help during /after the attempt4. acting to get help during /after the attempt5. 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 the 8. Overt communication of intent before the

attemptattempt

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 rescuability14. Conception of medical rescuability15. Degree of premeditation15. Degree of premeditation

High risk factorsHigh risk factors(Tuckman & Youngman 1968)(Tuckman & Youngman 1968)

Man > 45Man > 45unemployed or retiredunemployed or retiredseparated, divorced or widowedseparated, divorced or widowedliving aloneliving alonepoor physical healthpoor physical healthreceived medical treatment within 6 monthsreceived medical treatment within 6 monthspsychiatric disorder including alcoholismpsychiatric disorder including alcoholismusing violent methodsusing violent methodspresence of a suicide notepresence of a suicide notehx of previous attempthx of previous attempt

Assessment of risk of repetitionAssessment of risk of repetition

Buglass & Horton (1974):Buglass & Horton (1974):problems in use of alcoholproblems in use of alcoholDx of sociopathyDx of sociopathyprevious psychiatric treatmentprevious psychiatric treatmentprevious outprevious out--patient psychiatric patient psychiatric treatmenttreatmentprevious DSHprevious DSHnot living with relativesnot living with relatives

Link between suicide and unemployment

Stephen Platt(1984)cross-sectional individual studies: parasuicideand suicide rates among the unemployed are always considerably higher than among the employedaggregate-cross-sectional studies: noevidence of a consistent association between unemployment and completed suicide , but a significant geographical association between unemployment and suicide were found

Parasuicide and unemployment

Platt & Kreitman (1985a) Edinburgh Studyin 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

Parasuicide and unemployment

Hawton & Rose (1986) Oxford Studyunemployment may exacerbate or

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

Parasuicide and unemploymentPlatt & Kreitman (1985a)

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

Parasuicide and unemploymentProlonged 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

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