Dr Ashutosh Suicide Prevention a Global Overview.ppt

Suicide Prevention

1. Suicide Prevention a Global
Overview
DR ASHUTOSH SRIVASTAVA
WWW.DRASHUTOSHSRIVASTAVA.COM

2. Incidence
~ 1 Million suicides/year worldwide*
>33,000 suicides/year in the U.S.**
Suicide attempts, U.S.(adults)***
1.1 M attempts
678,000 attempts requiring medical care
500,000 attempts resulting in an overnight hospital stay
Suicide ideation, U.S. (adults)***
8.3 M (3.7%) seriously considered suicide during past year
Epidemiology
Source: * World Health Organization. Suicide Prevention. Retrieved from
http://www.who.int/mental_health/prevention/en.
** National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (2009). Web-
based Injury Statistics Query and Reporting System (WISQARS). Available from:
www.cdc.gov/injury/wisqars/index.html.
***Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2009). The NSDUH
Report: Suicidal Thoughts and Behaviors among Adults. Rockville, MD.

3. Suicides:
Male:female= 4:1
Elderly white males --highest rate
Working aged males –60% of all suicides
American Indian/Alaskan Natives, youth and middle age
Attempts:
Female>>male
Rates peak in adolescence and decline with age
Young Latinas and LGBT
Demographics
National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
(2009).
Web-based Injury Statistics Query and Reporting System (WISQARS). Available from:
www.cdc.gov/injury/wisqars/index.html.

4. Prevalence of suicidal behaviors
Suicidal ideation at time of visit
Primary care: 2-4 percent (Olfson(1996, 2003))
Emergency departments: 8-12 percent*
Suicide attempts
Pts with major depression: 10% attempted during a past major
depressive episode**
Suicide
Pts with serious mental illness: lifetime suicide risk 4-8%
(1% lifetime suicide risk for general population)***
Epidemiology among Patients
* Claassen, C.A. & Larkin, G.L. (2005). Occult suicidalityin an emergency department population. The
British Journal of Psychiatry, 186, 352-353.
** Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2009). The
NSDUH Report: Suicidal Thoughts and Behaviors among Adults. Rockville, MD.
*** Litts, D. A., Radke, A. Q., & Silverman, M. M. (Eds.). (2008). Suicide Prevention Efforts for Individuals
with Serious Mental Illness: Roles for the State Mental Health Authority. Washington, D.C.:
NASMHPD/SPRC.

5. Real-time suicide surveillance in
the general population
Lockdown Lockdown
No risein the
number of
suspected suicides
This finding is
reflectedin ONS
findings
UK_SUICIDE (2009-201)
© National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.

6. ONS data on suicide (registrations)0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
200120022003200420052006200720082009201020112012201320142015201620172018201920202021
Q1 Q2 Q3Q4
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/quarterlysuici
dedeathregistrationsinengland/2001to2020registrationsandquarter1jantomartoquarter4octtodec2021provisionald
ata

7. Suicide in children
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/adhocs/
14550numberofsuicidesinchildrenagedunder18yearsinenglandoccurringbetween2015and2020
0
10
20
30
40
50
60
70
80
90
100
2015 2016 2017 2018 2019 2020
Persons Males Females

8. Self-harm (hospitalpresentations)

9. Young people
Cybulski L, Ashcroft DM, Carr MJ, Garg S, Chew‐Graham CA, Kapur N, Webb RT. Risk factors for nonfatal self‐harm and suicide among adolescents: two nested
case–control studies conducted in the UK Clinical Practice Research Datalink. Journal of child psychology and psychiatry. 2021 Dec 4.
•Most young people who had self-harmed
(75%) or died from suicide (85%) had seen
their GP in the previous year.
•Around 2/3 of young people who had died
from suicide had a history of previous self-
harm.
•Only one third of people had a recorded
psychiatric diagnosis before their death or
first self-harm event.

10. Young people
Cybulski L, Ashcroft DM, Carr MJ, Garg S, Chew-Graham CA, Kapur N, Webb RT. Temporal trends in annual incidence rates for psychiatric disorders and self-
harm among children and adolescents in the UK, 2003–2018. BMC psychiatry. 2021 Dec;21(1):1-2.

11. Online harms?
https://www.cambridge.org/core/journals/psychological-medicine/article/online-harms-suiciderelated-online-experience-a-ukwide-case-series-study-of-
young-people-who-die-by-suicide/BDF430691070BACDC1A14D12D66677E7

12. Ethnicity
Farooq B, Clements C, Hawton K, Geulayov G, Casey D, Waters K, Ness J, Patel A, Kelly S, Townsend E, Appleby L. Self-harm in children and adolescents by
ethnic group: an observational cohort study from the Multicentre Study of Self-Harm in England. The Lancet Child & Adolescent Health. 2021 Nov 1;5(11):782-91.
Young People from ethnic
minority groups:
•↑ Deprivation
•↓psychosocial assessment
•↓mental health care
•↑ no follow up
•↓repetition
•Similar incidence of suicide

13. Ethnicity
https://www.sciencedirect.com/science/article/pii/S2589537022001298
https://cpb-eu-w2.wpmucdn.com/blogs.bristol.ac.uk/dist/3/343/files/2022/06/Infographic_finalversion01_06_22.pdf

14. Suicide as a global issue
https://www.sciencedirect.com/science/article/pii/S0140673622001738

15. 3,345 (18%) patients with recent
economic adversity
Often middle-aged (45%) male (74%),
Over half were unemployed(55%) with alcohol (53%) or drug misuse
(41%)
Disengagementwith services was common, over a quarter (26%)
missed their last appointment, non-adherence with medication (15%)
Nearly half were living alone (49%), many were divorced (29%)

16. 149
deaths
per year
UK_SUICIDE (2009-2019)
© National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved.
Not to be reproduced in whole or part without the permission of the copyright holder.
Patients with a history of domestic violence
(2015-2019)
Notes: *2015 was the start of data collection and is therefore incomplete.
Male and female numbers in 2018 do not total the overall figure due to rounding.
Patient data unavailable in Northern Ireland in 2019.
10% of patient
suicides

17. Understanding Risk Factors
Society
Community Individual
Relationship

18. Previous suicide attempt
Majority die on first attempt
Suicidal ideation, plan, intent
Major mood or anxiety disorder
Substance abuse disorder
Other mental illnesses
Co morbidity (psych/SA)
Physical illness, chronic pain
CNS disorders/traumatic brain injury
Insomnia
Clinically Salient Suicide Risk Factors
Suicidality
Generally:
Risk ↑’d with
1) severity of
symptoms,
2) # of
conditions
3) recent onset

19. Suicide Assessment & Prevention
for Older Adults: Warning Signs
Q:What are the warning signs that
someone is at risk for suicide?

20. Warning Signs
Increasing alcohol or drug use
Withdrawing from friends,
family or society
Anxiety, agitation, unable to
sleep, or sleeping all the time
Dramatic mood changes
No reason for living; no sense
of purpose in life
Hopelessness
Rage, anger, seeking revenge
Acting reckless or engaging in
risky activities, seemingly
without thinking
Feeling trapped—like there's
no way out
Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., Van
Orden, K., & Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical
applications. Suicide and Life-Threatening Behavior, 36(3), 255-262.

21. Suicide Assessment & Prevention
Warning Signs
Remember “IS PATH WARM?”
I Ideation
SSubstance Use
PPurposelessness
AAnxiety/Agitation
TTrapped
H Hopelessness/Helplessness
W Withdrawal
AAnger
R Recklessness
M Mood Changes
From the American Association of Suicidology (AAS) website
(www.suicidology.org).

22. Suicide Assessment & Prevention
Risk Factors
Q:What are the risk factors
for suicide?

23. Suicide Assessment & Prevention
Risk Factors
1. Suicidal Ideation and / or Behaviour
Prior suicidal behaviour (including suicide attempt), prior self-harm
behaviour, previous expression of suicide ideation
Feels tired of living and/or wishes to die
Thinks about suicide, has suicidal wishes and / or desires
Has a suicide plan / note
2. Family History
Family history of suicide, suicide ideation, mental illness

24. Suicide Assessment & Prevention
Risk Factors
3. Mental Illness (can include)
Any mental disorder, co-morbidity
Major depressive disorder
Any mood disorder
Psychotic disorder
Substance misuse disorder / addictions
4. Personality Factors
Personality disorders
Emotional instability
Rigid personality
Poor coping skills, introversion

25. Suicide Assessment & Prevention
Risk Factors
5. Medical Illness
Pain, chronic illness
Sensory impairment
Perceived or anticipated / feared illness
6. Negative Life Events and Transitions
Family discord, separation, death or other losses
Financial or legal difficulties
Employment/retirement difficulties
Relocation stresses
7. Functional Impairment
Loss of independence
Problems with activities of daily living

26. Suicide Assessment & Prevention
Resiliency Factors
Q:What are some of the resiliency
(protective) factors?

27. Suicide Assessment & Prevention
Resiliency Factors
1.Sense of meaning and purpose in life.
2.Sense of hope.
3.Sense of optimism.
4.Religious (or spiritual) practice.
5.Active social networks and support from family and friends.
6.Good health care practices.
7.Positive help-seeking behaviours.
8.Engagement in activities of personal interest.

28. Suicide Assessment & Prevention
Assessment Process
Q:How do I tell if someone is at
risk of suicide?

29. Suicide Assessment & Prevention
Assessment Process
1.Establish rapport and assess for suicide risk in a sensitive and
respectful fashion.
2.Respect the dignity of older adults. Acknowledge their
experiences and validate their feelings.
3.Assess for suicide risk factors.
4.Assess for psychological resiliency.
5.Assess for suicide warning signs IS PATH WARM.

30. Suicide Assessment & Prevention
Assessment Process
6.Where appropriate, access collateral information
(medical chart, family members, other providers).
7.Be mindful of ambivalent wishes to live and to die.
8.Develop a risk management/action plan.
9.Seek consultation and/or assistance if you do not have
specialized training in mental health or in suicide prevention.

31. Suicide Assessment & Prevention
Key Questions
Q:What questions do I ask?

32. Suicide Assessment & Prevention
Key Questions
1. Ask about their feelings
Do you feel tired of living?
Have you been thinking about harming yourself
and/or ending your life?
Have you been thinking about suicide?

33. Suicide Assessment & Prevention
Key Questions
2. Ask about a suicide plan
Have you thought of specific ways of hurting yourself or ending
your life?
Have you made any specific plans or preparations (giving away
possessions, tying up 'loose ends')?
Have you asked someone to help you end your life or join you in
death?
Do you have access to lethal means like a gun or other
implements?
Have you collected pills in order to take an overdose?
Have you started to put a suicide plan into action?

34. Suicide Assessment & Prevention
Key Questions
3. Ask about their reasons to live
What has kept you from harming yourself?
Who or what makes life so worth living that you
would not harm yourself?
What other questions could you ask?…

35. Suicide Assessment & Prevention
Q:What are some strategies for
intervening and managing risk?

36. Suicide Assessment & Prevention
Risk Management
RISK MANAGEMENT STRATEGIES:
Help the older adult connect with a team of
supports:
other medical and/or mental health care
providers,
social service providers, clergy, family
members, friends, and/or other community
members.

37. Suicide Assessment & Prevention
Risk Management
Immediate Risk Management
1. Do not leave the person alone until you have arranged for the
involvement of another appropriate care provider or source of
protection.
2. Establish an immediate safety plan that includes:
family support
homecare support
24-hour (or in-home) care providers
police intervention (if needed)

38. Suicide Assessment & Prevention
Risk Management
Immediate Risk Management (Cont.):
3. Consider care needs:
emergency services
telephone and / or in-person crisis / distress / support services
mental health services
medical services
social service providers, community supports
4. Ensure that follow-up care is arranged.
5. Where possible, restrict access to lethal means.

39. Suicide Assessment & Prevention
Risk Management
Ongoing Risk Management
1. Address underlying issues:
medical illness
mental health problems
social problems, concerns, transitions
environmental factors
2. Continually re-assess suicide risk, resiliency, and warning signs.
3. Continue to build and sustain the therapeutic relationship.
4. Look for ways to foster hope and enhance a sense of meaning in life.

40. Suicide Assessment & Prevention
Risk Management
Ongoing Risk Management (Cont.)
5. Develop a safety plan that includes after-hours support.
6. Read and continually review Guidelines and other appropriate
treatment guidelines.
7. Work within a culturally competent model of care.
8. Work within an inter-disciplinary care model where possible:
Develop relationships with mental health teams for support and
ongoing follow-up.
Be aware of community resources and referral sites / processes.

41. Suicide Assessment & Prevention
Treatment & Management
Treatment and Management: Suicidal Seniors
Foster hope in clients who are suicidal
Assist in finding and maintaining meaning and purpose in life
Attend to the therapeutic relationship
Work in a team setting -don’t work alone (collaborative care)
Consult colleagues, keep detailed notes, use crisis services
Restrict access to lethal means
Mental health outreach

42. Suicide Assessment & Prevention
Treatment & Management
Recommendation: Treatment and Management
Health care providers working with suicidal older adults
should ensure that their clients are appropriately assessed and
treated for depression.

43. Suicide Assessment & Prevention
Treatment & Management
SYMPTOMS OF DEPRESSION: REMEMBER SIG E CAPS
(Source: Michael Jenike, 1989)
S Sleep is disturbed
I Interest is decreased
G Guilt (feelings of guilt or regret)
E Energy is less than usual
C Concentration is poor
A Appetite is disturbed
P Psychomotor agitation or retardation
S Suicidal Ideation, including passive wish to die

44. Suicide Assessment & Prevention
Treatment & Management
SYMPTOMS OF DEPRESSION:
Depressed people often experience sadness, despair, and low
energy. However, many depressed older adults do not appear
obviously sad. It is important to assess for "hidden depression".

45. Insufficient Treatment
“A recognition is needed that effective
prevention of suicide attempts might
require substantially more intensive
treatment than is currently provided to the
majority of people in outpatient treatment
for mental disorders.”
1
1
Kessler, R.C., Berglund, P., Borges, G., Nock, M., & Wang, P.S. (2005). Trends in suicide ideation,
plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. JAMA, 293(20),
2487-2495.