Reference: Kaplan & - PowerPoint Presentation

Slide1

Reference:Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition (2007)

SUICIDESlide2

Suicide – taking one’s own lifea primary emergency for the mental health professionalalmost always the result of a mental illness, usually depression, and is amenable to psychological and pharmacological treatmentSlide3

STATISTICS ON SUICIDE 90 % have depression or another diagnosable mental or substance abuse disorder.Up to 15% who are clinically depressed die by suicide. Slide4

More than four times as many men than women die by suicide Women report attempting suicide about twice as often as men through overdose on medications Women usually use means from which they may be rescued

, such as a drug overdose

Men

tend to use

firearms or automobiles

.

hanging, or jumping from high places. Slide5

Suicide by firearms -most common method for completed suicide for both men and women. suicide rate in young people has increased dramatically. Slide6

adolescents aged 15 to 19, the gender ratio was 5:1 (males: females). Among young people aged 20 to 24, the gender ratio in this age group was 7:1 (males: females). Slide7

Men commit suicide more than four times as often as women Women, however, are four times more likely to attempt suicide than men. Men's higher rate of completed suicide is related to: use of firearms, hanging, or jumping from high places. Women commonly take an overdose of psychoactive substances or a poisonSlide8

Globally, the most common method of suicide is hangingSlide9

FIGURE 34.1-2 Venn diagram summarizing suicide data and its relation to mood disorder and suicide attempts. (Courtesy of Alec Roy, M.D.)Slide10
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CAUSES OF DEPRESSIONThe causes of depression are often multi-factorial and may include:Genetic predispositionStress at home, work or schoolSlide12

Loss of a parent or loved oneAlcohol or substance abuseBreakup of a romantic relationshipMedications Slide13

Low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF) were associated with suicidal behavior. Studies support the hypothesis that reduced central serotonin is associated with suicideSlide14

Table 34.1-2 Evaluation of Suicide Risk(From Adam K. Attempted suicide. Psychiatr

Clin

North Am. 1985;8:183, with permission.)Slide15
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Factors that may be related to suicide are as follows:Bullying and discrimination Mental illness and disability Poverty

Substance abuseSlide19

Crime — Criminals may commit suicide before they're caught, or before they get on trial. They would rather die than face the legal and social consequences of their actions. StressReligious reasons (e.g. many suicide bombings in the Middle East have been based on Islamic fundamentalism)Slide20

Misery due to one's location AnxietyHopelessness Altruism (e.g. self-sacrifice to save someone else) Physical Agony (eg. physical agony that just is not correctable) Slide21

Suicide rates increase with age. Evaluation for suicide potential: a complete psychiatric history examination of the patient's mental stateinquiry about depressive symptoms suicidal thoughts, intents, plans, and attempts. Slide22

A lack of future plans, giving away personal property, making a will, and having recently experienced a loss all imply increased risk of suicide. The absence of a strong social support system, a history of impulsive behavior, and a suicidal plan of action are indications for hospitalization—treated as an emergencySlide23

Vigorous treatment with antidepressant or antipsychotic medication should be initiatedSome medications (e.g., risperidone [Risperdal]) have both antipsychotic and antidepressant effects and are useful when the patient has signs and symptoms of both psychosis and depression.Slide24

Table 34.1-1 Variables Enhancing Risk of Suicide among Vulnerable GroupAdolescence and late lifeBisexual or homosexual gender identityCriminal behaviorCultural sanctions for suicideDelusions

Disposition

of personal

property

Divorced

, separated, or single marital

status

Early

loss or separation from

parents

Family

history of

suicide

Hallucinations

Homicide

Hopelessness

HypochondriasisSlide25

ImpulsivityIncreasing agitationIncreasing stressInsomniaLack of future plansLack of sleepLethality of previous attemptLiving aloneLow self-esteem

Male sex

Physical illness or impairment

Previous attempts that could have resulted in death

Protestant or nonreligious status

Recent childbirthSlide26

Recent lossRepression as a defenseSecondary gainSevere family pathologySevere psychiatric illnessSexual abuseSignals of intent to dieSuicide epidemicsUnemployment

White raceSlide27

Parasuicidal Behaviordescribe patients who injure themselves by self-mutilation (e.g., cutting the skin), but who usually do not wish to die. about 4 percent of all patients in psychiatric hospitals have cut themselves; the female-to-male ratio is almost 3 to 1.Slide28

Warning signs of SuicidePrevious suicide attemptsRecent suicide of a friend or relativeThreats to suicideDepression

Changes in personality or behaviorSlide29

Warning signs of Suicide6. Increased use of drugs and/or alcoholBehavioral disturbancesPsychiatric illnessPreparation for deathSudden lift in spiritSlide30

SUBSTANCE ABUSESubstance abuse is a risk factor for suicide. Substance abuse refers to the overindulgence in and dependence on a stimulant, depressant, chemical substance, herb (plant) or = effects that are detrimental to the individual's physical health or mental health, or the welfare of others.Slide31

Substance abuse is sometimes used as a synonym for drug abuse, drug addiction, and chemical dependency, but actually refers to the use of substances in a manner outside sociocultural conventions Addiction, or dependence - a cluster of 3 or more symptoms occurring at any time in the same 12-month period" (American Psychiatric Association)Slide32

SYMPTOMS OF SUBSTANCE ABUSEtolerance, or needing more and more of a substance to achieve the same effect; withdrawal, which involves unpleasant symptoms when the body is deprived of the substance, resulting in more frequent use to alleviate the negative symptoms; Slide33

taking the substance for a longer period of time or in larger amounts than originally intended; unsuccessful desire to minimize use of the substance;much time spent to obtain, use, or recover from the effects of the substance; Slide34

social, occupational, or recreational activities are missed because of substance abuse; and substance use is continued despite knowledge of causing a problem. If neither tolerance nor withdrawal are present, then at least three of the remaining symptoms must be presentSlide35

COMPLETED SUICIDES SHOWED THE FOLLOWING COMMON CHARACTERISTICS:IdeationSuicidal intent Plan

MeansSlide36

Table 34.1-3 Questions about Suicidal Feelings and Behaviors*Begin with questions that address the patient's feeling about livingHave you ever felt that life was not worth living?Did you ever wish you could go to sleep and just not wake up?

Follow

on with specific questions that ask about thoughts of death, self-harm, or

suicide

Is

death something you have thought about

recently?

Have

things ever reached the point that you have thought of harming

yourself?

For

individuals who have thoughts of self-harm or suicide

When did you first notice such thoughts?Slide37

What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)?How often have those thoughts occurred, including frequency, obsessional quality, controllability?How close have you come to acting on those thoughts?How likely do you think it is that you will act on them in the future?Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)?Slide38

What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)?Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)Do you have guns or other weapons available to you?Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?Have you spoken to anyone about your plans?How does the future look to you?Slide39

What things would lead you to feel more (or less) hopeful about the future (e.g., treatment, reconciliation of relationship, resolution of stressors)?What things would make it more (or less) likely that you would try to kill yourself?What things in your life would lead you to want to escape from life or be dead?What things in your life make you want to go on living?If you began to have thoughts of harming or killing yourself again, what would you do?For individuals who have attempted suicide or engaged in self-damaging action(s), parallel questions to those in the previous section can address the prior attempt(s). Slide40

Additional questions can be asked in general terms or can refer to the specific method used and may include:Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)?What thoughts were you having beforehand that led up to the attempt?What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)?Were other people present at the time?Did you seek help afterward yourself, or did someone get help for you?Slide41

Had you planned to be discovered, or were you found accidentally?How did you feel afterward (e.g., relief versus regret at being alive)?Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)?Has your view of things changed, or is anything different for you since the attempt?Are there other times in the past when you have tried to harm (or kill) yourself?For individuals with repeated suicidal thoughts or attemptsAbout how often have you tried to harm (or kill) yourself?Slide42

When was the most recent time?Can you describe your thoughts at the time that you were thinking most seriously about suicide?When was your most serious attempt at harming or killing yourself?What led up to it, and what happened afterward?For individuals with psychosis, ask specifically about hallucinations and delusionsCan you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus nonrecognizable)?Slide43

What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples.)How do you cope with (or respond to) the voices?Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?)Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?)Are you worried about having a serious illness or that your body is rotting?Are you concerned about your financial situation even when others tell you there's nothing to worry about?Slide44

Are there things that you've been feeling guilty about or blaming yourself for?Consider assessing the patient's potential to harm others in addition to him- or herselfAre there others who you think may be responsible for what you are experiencing (e.g., persecutory ideas, passivity experiences)?Are you having any thoughts of harming them?Are there other people you would want to die with you?Are there others who you think would be unable to go on without you?Slide45

THE END