Tues May 13/2008
Tues May 13/2008 |
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Depression and Suicide - Preventing Suicidal AttemptsTYPES OF SUICIDAL BEHAVIOURThe concept of suicide is relatively straightforward, as it is defined by a legal judgement where there is clear evidence that the person intended to take his or her own life. Cases where clear evidence is lacking but the suspicion is of suicide are usually recorded as undetermined deaths and are often included in the suicide statistics. Non-fatal suicidal behaviour is more complicated because of the range of behaviours encompassed and the variety of terms used. The terms usually imply something about the level of intent to die; for example, ‘attempted suicide’ implies a strong intention to die, whereas ‘deliberate self-harm’ does not. It is tempting to make judgements about the level of intent, but this is difficult to do in practice. People are often unaware of the medical lethality of the overdose they have taken (by far the most common type of self-harm), thus rendering this a poor criterion. Moreover, when asked, most commonly, people simply say they wanted to escape; they may not be clear about whether they wanted to die or not. Finally, individuals with more than one episode of self-harm are quite likely to have a mixture of levels of intent across different episodes. One solution suggested by Kreitman (1977) was to use the term ‘parasuicide’ as a descriptive term to cover all deliberate but non-fatal acts of self-harm, thus, remaining neutral about level of intent to die. Factors associated with increased suicide risk after acts of deliberate self-harm include:
Two particular groups of patients are at significantly increased risk of suicide: those with a history of suicide attempts; and those recently discharged from psychiatric inpatient care. About 1% of all deliberate self-harm patients commit suicide within 12 months of a suicide attempt, and up to 10% may eventually die by suicide4. In addition 10–15% of patients in contact with health services following a suicide attempt will eventually die by suicide, this risk being greatest during the first year after an attempt. Up to 41% of suicide victims have received psychiatric inpatient care in the year prior to death, and up to 9% of suicide victims kill themselves within 1 day of discharge. Depression and Suicidal AttemptsThose with depression have a greater risk of deliberate self-harm and suicide. A recent meta-analysis estimated the standardized mortality ratio for completed suicide of those who had previously attempted suicide to be over 4000, higher than the risk attached to any particular psychiatric disorder, including major depression or alcoholism. Other risk factors for suicide include:
SUICIDE AND BEREAVEMENT (loss of something or someone that one loves)There is an increased risk of suicidal gestures, completed suicide and death from accidents following the death of a spouse or a parent. The suicide risk for those widowed was first observed over a century ago by Durkheim who found that suicide was higher amongst those widowed compared to those married. When compared to the general population Mergenhagen and colleagues found the mortality ratio for suicide in young widowers (45–64 years of age) was about four and a half times the rate for married men of similar age. Most studies have found a gender bias with younger men being at the greatest risk of suicide, although Heikkinen and coworkers found evidence of an association between widowhood and women aged 60–69 years.
Several longitudinal studies have found that the risk
of suicide is greatest for the period immediately following
the loss. The risk of suicide
among the widowed population was generally higher in
the first 4 years after the death of the spouse, the risk of
suicide in the first year was 2.5 times higher, and in the Relation between depression and suicideThere is a strong link between depression and suicidal behaviour, but there is also high divergence, as shown especially by the fact that the vast majority of depressed people do not commit or attempt suicide. The presence or absence of other factors might help explain this divergence. Factors such as other psychiatric diagnoses, especially personality disorder; protective factors; and other psychological factors, such as personality and affective traits, and problem-solving skills, have all been shown to distinguish suicidal from non-suicidal depressed individuals. The relationship between depression and suicide is mainly dependent on one particular facet of depression—hopelessness about the future. Hopelessness appears to consist mainly of a lack of positive thoughts about the future rather than preoccupation with a negative future. Risk assessment and intervention in suicidal behaviour are difficult because of the relatively low base rate of suicidal behaviour and the heterogeneity of those who engage in it. Predictive models, whether using depressive hopelessness or a range of factors, are able to identify those at risk only through incorrectly classifing unacceptably high numbers of people as at risk. Because of predictive inaccuracy, the emphasis has shifted to assessment of relative risk rather than absolute risk. Treatments of depression are themselves never likely to be effective treatments for suicidal behaviour per se. The majority of studies testing specific interventions for suicidal behaviour have shown no benefit over treatment as usual, though a number of studies have shown positive results. There is no obvious pattern to the successful interventions in terms of their content, though they do seem either to target a specific subgroup of parasuicides or to involve a brief, flexible treatment delivered at home. Both these strategies potentially limit the problem of heterogeneity. A modular approach provides a framework for incorporating a range of treatment strategies derived from the interface between basic and applied research. Developing strategies to tackle depressive hopelessness, particularly lack of positivity about the future, is one of the most needed and promising lines for future research.
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