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Online Essay Club No. 25: Suicide

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Describe the measures you would implement to improve the prevention of suicide and self-harm, in both the short and long term.

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start with the govt target to reduce the rates of suicide by at least a fifth by ?2020. is this going to be possible, how do we contribute towards the same as future consultant psychiatrists?

define suicide, parasuicide. RELIABILITY OF STATISTICS?

effect of abolition of suicide act in 1969

examples of what has helped in the past, especially Govt interventions, media intervention, etc.

consider the demographics in the various branches, child and adolescents, adult, old age, forensic, LD, etc.

what is the chance that reducing DSH will help with suicide as well?

to answer the Q proper,

measures to prevent suicide: BIO-PSYCHO-SOCIAL model including NATIONAL SUICIDE PREVENTION PROGRAMME, INTENSIVE CARE, OUTREACH, PROBLEM SOLVING THERAPY, CONTINUITY OF CARE, ANTIDEPRESSANTS, NEUROLEPTICS, ATYPICALS, EMERGENCY CARDS, FAMILY THERAPY, POPULATION STRATEGIES, HIGH RISK STRATEGIES

quote Gotland study for training GPs, defeat depression campaign, changing minds 'STIGMA CAMPAIGN', school based programmes, voluntary agencies, etc.

DSharm: WHO multicentre study into parasuicide, EURO study, BIO-PSYCHO-SOCIAL model, stress on psychotherapies, mention CBT, CAT, DBT,IPT, etc.

mention some work with PDs,

?biomedical concept, ? stress diathesis model

mention the relevance of MHAct 19833, the new guidance issued by the GMC regarding consent and capacity.would staff burn out be an issue?

i would conclude saying risk assessment is a dynamic process, with psychiatrists only playing a small role in assessing risk, but probably take the most stick for it. we would indeed try out best to help the society and the government in achieving its target....

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'A government has set itself a target to reduce the suicide rate in its country by at least 15% over a five year period. Discuss how psychiatrists may contribute to the realisation of this goal in terms of service organisation and provision of treatment'.

(Spring 1999 paper)

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Model answer:

INTRODUCTION

By way of an introduction the candidate might refer to epidemiological data, eg, variation in suicide rates between different countries and an increasing prevalence of suicide in young males. The candidate should also separate those suicide risk factors upon which psychiatrists have no influence (eg, male sex) from those on which the psychiatrist may exert an influence (eg, psychiatric disorder.

The evidence base for demographic and clinical variables associated with suicide is strong, but it is weak for the efficacy of interventions designed to reduce the suicide rate.

Comments from the Chief Examiner: There needs to be mention of diagnoses of suicide victims and this should be mentioned as either affective illness, alcoholism or schizophrenia in order for the candidate to pass.

Factors associated with suicide

In those who commit suicide a psychiatric disorder has been found in excess of 90% of cases. However, there might be a bias in the accuracy of suicide statistics, that those who have a psychiatric disorder are more likely to attract a coroner's verdict of suicide. Affective illness is the most prevalent psychiatric disorder; one estimate is that 15% of those with affective disorder end their lives by suicide which is a thirtyfold excess risk compared to the general population. About 15% of alcoholics eventually commit suicide and the majority of these individuals also suffer from depression. About 10% of schizophrenics die by suicide. There is an increased suicide risk in those with neurotic disorder, personality disorder, chronic physical disorder, comorbidity, a family history of suicide and a recent bereavement, particularly death of a spouse. There is an undoubted statistical association between unemployment and suicide, especially in men.

The Prevention of Suicide

Problems in identifying those at risk

A fundamental problem is the difficulty of predicting rare events. For example, if the risk of suicide during the year following a suicide attempt is about 1% then if our ability to detect those who kill themselves has a sensitivity of 80% and a specificity of 90%, of a 1000 attempters, 8 out of the 10 who might be expected to die by suicide within a year will be correctly identified. However, in doing so, a further 99 individuals will be incorrectly identified as being a suicide risk, ie, of 107 positive predictions there will be 99 false positives and 8 true positives identified. This false positive rate may be too high for predictions to be useful in targeting preventative efforts on such relatively high risk groups as young men, those who attempt suicide and those with a psychiatric disorder.

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Model answer continued

Methods for the prevention of suicide

Again, at least one of these methods should be selected by the candidate in order to achieve a pass mark.

The candidate should mention the possibility of rapid access to staff in mental health centres, the provision of community outreach teams and crisis telephone line availability, but there is a dearth of studies indicating any impact of these on suicide rates. With regard to suicide prevention organisations, in the UK there is uncertainty about the impact of the Samaritans on suicide rates.

Since the majority of people who kill themselves have visited doctors during the months before their death, it is natural to focus on those contacts to see whether patients at risk can be better identified and managed. In the well known study by Barraclough and colleagues, of a hundred suicides only a minority of patients with depressive disorders were receiving antidepressant drugs at the time of their deaths, in spite of being in contact with medical agencies. Of those receiving medication, some were receiving inappropriate classes of drugs, eg, anxiolytic sedatives, and subtherapeutic doses were often used.

While the older antidepressant drugs are undoubtedly more toxic in overdose, only a small minority (6% in one study) of suicide cases have toxic antidepressant blood levels and some recent studies have found that some of the newer antidepressants are associated with a significantly higher overall standardised mortality ratio for suicide when all causes of suicide (not just toxic overdose) are considered. Isacsson has commented that the problem in preventing suicide is not of choosing a particular class of antidepressant, but that some depressed patients receive no antidepressant, some receive it in too low a dose, and some stop it too soon. Continuation and maintenance drug treatments are of obvious importance and Barraclough has suggested that lithium may have an important prophylactic role with recurrent affective disorder in the prevention of suicide. The candidate must mention the use of hospital admission, if necessary under a section of the Mental Health Act, as a preventative measure; there should be mention of appropriate use of ECT and the need to treat psychotic depression with both antipsychotic and antidepressant drugs.

There is a considerable body of opinion that some suicides will be prevented if obvious methods of suicide cease to be available. Thus the introduction of non-toxic North Sea gas in the UK may be an example and it has been suggested that in the USA a reduction in gun ownership may achieve the same effect. The psychiatris might ensure that a relative would look after the supply of medication to remove the risk of an impulsive overdose; patients may be given small quantities of medication at a time, thus allowing therapeutic effects to occur in a safe environment. Ways of reducing the availability and toxicity of medicines such as the provision of blister packs, the idea of combining a small dose of an emetic with drugs commonly used for self poisoning and the keeping of minimum supplies of medication in the home, require testing in controlled studies.

Authors that the candidate might refer to include:

Bagley, Bancroft, Barraclough, Beck, Buglass, Catalan, Greer, Hawton, Holding, Isacsson, Isometsa, Jick, Kessel, Kreitman, Morgan, Robins (the famous American Study of 134 suicides), Roy, Sainsbury, Shepherd, and Weissman. An overview is provided by Hawton (1992) is his chapter 'Suicide and Attempted Suicide' in Handbook of Affective Disorders (Editor: E Paykel) Second Edition. Churchill Livingstone: London.

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