Suicide

=Reading= Andreason =Goals=

4. List several additional clinical risk factors, including serious phyiscal illness and social isolation/interpersonal loss
==5. List and discuss at least five principles of clinical decision-making and intervention when working witha  suicidal patient

Demographics: white male worst, black female best male, white risk factors very high among old people white men rises in old age black men have peak in 20s, then rise again in old age women more of a plateu, or drops off in older age group

Prevalence: Age: older Gender: Men (women attempt more) race: whites highest, hispanics, asians lowest Region: Highest rates in mountain states > Colorado, western california, montana, washington....50% higher than midwest, which has lowest rate no one knows why!

Mehtods
Firearms most common method for men and somen in the US (57%) Hanging second most common for men; gtoxic ingestion second most common for women Firearms approximately 80% lethal lots of attempts stop just short of pulling trigger hanging 60% lethal jumping 50-60% drug overdose 10% lethal cutting: most common method self-injury...usually non-lethal peripheral vasculature tends to clamp down...

recent trends and their publichealth implications Increases among young and elderly increases in firearms

usually not a philosophical conclusion that time to end lives Usually stress, major depression usually begins with fantasy... if truck pulled in front of me hit me...going a little faster...I'd have been killed then wish that had died then obsessional thought thought of tall building...toxic cleanser At first, intrusive image if can tap into what that image is, and block it from occurring, a large percentage are not going to be creative about thinking about other mechanisms remarkably effective e.g., someone fixates on shooting, get firearms out of house should ask if individual has access to firearms US has moderate rate of suicide risk.... High: Hungary, finland, dnemark, austria, switzerland, france, japan, norway up to 2x higher italy, ireland, england, portugal, spain israel, greece, enezuela have lower rates. NO one really knows why when move to US, end up with suicide rates midway between native country & US In terms of intervention:
 * 30-40% of completers have attempted suicide before
 * nearly 2/3 of suicide completers communicated their suicidal intentions to others....including health care providers
 * Most suicide attempters are able to experience a reduction in suicidality and a return to fll function

too difficult to predict human behavior like weather...meaningful, but limited 2 kinds of predictions... overall pattern: Next summer, moderately hot, humid, rain a lot clearly not describing los angeles can make broad predictions over long haul

other type: specific predictions... going to rain, going to slow, not going to get over 60 degrees can be meaningful

where get in trouble is on scale of weeks just can't predict weather for several weeks intermediate

many give clue to health care provider not true that those who talk about suicide not true that true suiciders keep quiet a handful make determination, don't talk about it small minority majority of cases, deeply ambivalent about suicide fantasy about death gradually shifts over time to more acceptable idea active thoughts of doing something during most of time, would welcome intervention

"Are you having thoghts of harming yourself? Are you having thoughts of suicide?"

most feel relief that their distress is being recognized, that people are offering to intervene in meaningful way.

if can force to accept treatment...majority will experience reduction or elimination of thoughts of suicide majority go on to full function majority who make atttempt do not go on to suicide

in 1980s...golden gate bridge #1 suicide spot 10% of people who jump do survive at time, 2200 suicides...now 3500 tracked down about 1/2 of the survivors interviewed 2 things striking from interviews every one said stood on edge of bridge for long, long time debating whether wanted to jump All the way down, thought most on my mind...I really wish I were back on that ledge, rethinking this decision... Not one had gone on to complete suicide... good chance that intervention will be successful

Comorbditiy... Depression > Bipolar also Alchohol/Drug Abuse Schizophrenia > especially early stages, higher function Other psych disorders

of those who complete suicide >50% meet criteria for major depression at time of suicide 15% of person with significant mood disorder will commit suicide link etwen depression and suicide suicide can occur in all phases of depressive episode, but risk is highest during early recovery phase right after started treatment not because of antidepressants...same thing happens with psychotherapy no matter what intervention, time when have to be most careful as inpatient...most likely to kill selves when about to discharge

1/3 f suicides in chronic alcoholics 2-4% of chronic alcoholics commit suicides 30-40% of suicides have positive blood alcohol levels

5-10% schizophrenics commit suicide schizophernia accounts for 5% of suicides also look for commnad hallucincations... voices saying 'you must kill yourself' also delusions

parking structure jumpers...believe world going to end unless end life...

Social factors: social isolation... more common amongst divorced widowed, and single/never married than among married

50% have loss of social loss in last year

among young adults..interpersonal conflict and disciplinary//legla problems often precipitate suicide

hopelessness regarding a dilemma, especially with the prospect of public humiliation ( failing calss, but don't dare drop out, xexual impropriety about to come to light) both demographics and immediate factors should eb considered demograhics is threshold for intervention hopelessness is biggest risk factor

can look trivial to the outside... I have this class for my major, no way for me to get decent grade, too late to drop, there's no way out "Going to be humiliated...in front of all friends" friend in law school....guy came to class contemplateing suicide because had failed everything he'd ever done... I've never been #1 let's get a little perspective...you can go to Yale and get C's and become president! not rational...

humiliation is a big deal

other indices: History of attempts: method, intent, lethality current suiidal thoughts/intent//plan Final arrangements/will/suicide notes/giving away possessions

passive: "I wish I were dead, I wish I'd never been born, I wish I could go to sleep and never wake up" active: "I have to do something to end it all. I just keep thinking about the parking structure" more dangerous Final arrangements: giving away pets, leaving notes...have to act

Current ental status: Hopelessness Acute agitation Intoxiation Psychosis: ewith comnd hallucinations or delusions

Really edgy, bouncing all over.....at high risk for suicide

Be familiar with stuff on list.... Summary of risk factors

assess availability and lethality f the means

General principles of intervention recognize 'cry for help' or the expressed suicidal ideation/intent ask questions objectively in a straightforward manner, convey an unemotional willingness t respond i.e., don't flip out!

Don't alienate patient with sarcasm, ridicule, disbelief, or minimization of their perceived problems

don't apologize for it, just ask

know what to do.

coney a sense of hope; counteract hopelessness Maintain continuity of care with other treatment providers Talk calmly and openly about problems; assess depression, drug abuse, alcoholism, availability of firearms

major risk times: transition in care one place outpatient to another inpatient to antoher service don't become preoccupied wth speicifcs of the suicide attempt; work to understand its function; treat patient as a whole. Most health provders fail to respond with proper objectivity and support; many fail to diagnose and treat depression Ask questions to elicit feelings and thoughts about death and suicide-do not refrain from asking the tough questions that need to be asked

call police, 'I'm doctor so-and-so, I am concerned about so-and-so, could you do a welfare check. police...'reason to be concerned about welfare'... people will confide to police...

Clincial decisions: If attempt is clinically serious or risk factors suggest high risk, paitent may needhospitalization

If suciide is a ethod of repeated 'communication' and if risk is relatively low, hospitalization may not be treatment of choice

judge risk

check in wth patietn as discuss suicide

estblish mitis on self-destrucive behavior... will curse in moment, but most will live to thank you reasons for living....identity, family, friends, involve family and friends coney knowledge that depression is treatable

Myths about suicide: talkers don't follow through suidicde happens without any warning All suicidal eprsonas are 'insane' suicide stems from single disease asking about suicide 'plants' the idea in mind

What to do with pt w/ suicidal thought ask questions listen calmly consult as needed treat mental disorders remove the means.