Suicide

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61 Suicide

Chris O’Loughlin

	T	F
1. The term ‘Deliberate self-harm’ was coined by Morgan.
2. ‘Anomie’ explains suicide bombing.
3. A British household survey found 1% of adults had suicidal ideation in the preceding week.
4. Living with spouse is a risk factor for repeated deliberate self-harm (DSH).
5. Risk of repeated DSH is high in the first 3 months after an episode of DSH.
6. Repetition of self-harm is more likely in antisocial personality disorder.
7. A history of criminal conviction is a risk factor for repeated deliberate self-harm.
8. The rate of repetition of DSH is 50% within the first year.
9. Attempted suicide in the elderly is more common in men than in women.
10. Deliberate self-harm in the elderly is less common in comparison with teenagers.
11. In old age self-harm is rarely a failed suicide attempt.
12. The suicide rate in pathological gambling is around 15%.
13. Depressed women are more likely to commit suicide than depressed men.
14. Identical twins are more prone to committing suicide.
15. Having a child aged below 2 years reduces the risk of suicide in women.
16. Suicide in the elderly is commonly associated with alcoholism.
17. 25% of suicides are committed by those aged above 65 years.
18. Suicide is less common in the elderly when compared to the general population.
19. In the elderly, suicide is not usually due to mental health disorders.
20. Suicide is commonly associated with physical illness in old age.
21. Suicide in the elderly is more common in women than in men.
22. A 65-year-old depressed man is more likely to kill himself than a 30-year-old depressed man.
23. Adolescent girls with intentional self-harm have usually experienced parental criticism immediately preceding the episode.
24. When considering a suicide attempt in a 15-year-old, parental criticism is usually the cause.
25. Reducing the availability of means of suicide does not reduce suicides in the long term.

ANSWERS

1. The term ‘Deliberate self-harm’ was coined by Morgan.

True: Before the 1950s little distinction was made between those who killed themselves and those who survived after an apparent suicidal act. In 1952 Stengel differentiated between suicide and attempted suicide. The terms evolved further:

• Stengel (1952) Attempted suicide

• Kessel (1965) Deliberate self-poisoning and Deliberate self-injury

• Morgan (1975) Deliberate self-harm

• Kreitman (1977) Parasuicide.

More recently, patient groups have advocated dropping the word ‘deliberate’ as it is felt by some to be pejorative and stigmatizing (Gelder et al 2006, p. 418; Johnstone et al 2004, p. 670).

2. ‘Anomie’ explains suicide bombing.

False: Emile Durkheim in 1897 described four basic types of suicide:

1. Anomic: The individual is out of step with society because of changes in life circumstances and the weakness of the society, e.g. an alcoholic who has lost his job, is rejected by his family and falls between services.

2. Altruistic: The individual dies for a cause where society exerts a strong influence on him to take his own life, e.g. suicide bombing.

3. Egoistic: Lonely, withdrawn individuals, who are not integrated into or dependent on society, e.g. arranging an assisted suicide.

4. Fatalistic: Result of strict rules in society which are decisive for the individual, e.g. suicide of a slave, or a widow in certain cultures (Gelder et al 2000, p. 1035; Sadock & Sadock 2005, p. 2442).

3. A British household survey found 1% of adults had suicidal ideation in the preceding week.

True: The British psychiatric morbidity survey found that 10% had depressive symptoms and amongst them 1 in 10 had suicidal ideation (Jenkins et al 1998).

4. Living with spouse is a risk factor for repeated deliberate self-harm.

False: Living alone and being single, divorced, separated or widowed are associated with increased risk (Gelder et al 2000, p. 1043; Gelder et al 2006, p. 420; Johnstone et al 2004, p. 661).

5. Risk of repeated DSH is high in the first 3 months after an episode of DSH.

True: The risk of repetition of DSH is highest in the 3 months after an episode of DSH. Amongst those admitted to hospitals for DSH, one-half are first-timers and the others are repeaters. The rates of repetition after DSH are:

• Within 3 months = 10%

• Within 1 year = 15% (12–26%)

• Within 4 years = 21% (12–30%)

• Long-term = 23% (12–32%).

Bancroft & Marsack in 1997 proposed three patterns of repetition: chronic repetition due to recurrent crisis, bursts of repetition during periods of stress and one-off repetition during severe crisis. Repeaters with >20 admissions account for 4% of DSH patients (Gelder et al 2000, p. 1043; Johnstone et al 2004, p. 677).

6. Repetition of self-harm is more likely in antisocial personality disorder.

True: DSH and repetition of DSH are associated with personality disorders, especially antisocial personality disorder. DSH is also associated with impulsivity, criminal record, history of violence, history of traumatic events (including a ‘broken home’), family violence, physical and mental maltreatment by partners and unstable living conditions (Gelder et al 2000, p. 1043; Gelder et al 2006, p. 421; Sadock & Sadock 2005, p. 2448).

7. A history of criminal conviction is a risk factor for repeated deliberate self-harm.

True: Features that predict repetition of DSH include unemployment, lower social class, criminal record, history of violence, high suicidal intent, hopelessness, past psychiatric history, history of traumatic events including broken homes, family violence, physical and mental maltreatment by partners, unstable living conditions, substance misuse and non-compliance.

There is a high incidence of self-harm amongst prisoners, particularly female prisoners. The lifetime prevalence of deliberate self-harm among sentenced prisoners is 32% in women and 17% in men (Gelder et al 2000, p. 1043; Gelder et al 2006, p. 420; Johnstone et al 2004, p. 675).

8. The rate of repetition of DSH is 50% within the first year.

False: Among those who present with their first episode of DSH, 12–26% (mean = 15%) repeat within a year. Approximately half of those presenting to the hospital with DSH are first-timers, the other half are repeaters, 30% having self-harmed at least twice (Gelder et al 2000, p. 1043; Johnstone et al 2004, p. 677).

9. Attempted suicide in the elderly is more common in men than in women.

False: Deliberate self-harm is more common in women than men at all ages but the ratio decreases in the elderly. The absolute number of DSH episodes in women is higher with a 3:2 ratio. However, the rates are more similar because there are fewer elderly men than elderly women. DSH in the elderly accounts for 5% of all cases of DSH. Among elderly DSH patients, 90% have depression, 60% have physical illness, 50% are admitted to a psychiatric facility and 8% commit suicide within the next 3 years. DSH in the elderly is often precipitated by bereavement, up to 44% in one series (Jacoby & Oppenheimer 2002, p. 677; Johnstone et al 2004, p. 648).

10. Deliberate self-harm in the elderly is less common in comparison with teenagers.

True: DSH declines with age (Gelder et al 2000, p. 1041).

11. In old age self-harm is rarely a failed suicide attempt.

False: DSH in older people is more likely to represent suicide attempts failed due to confusion from physical illnesses, polypharmacy and alcohol misuse. DSH is relatively uncommon in older age groups, contributing only 5–15% of the total number of episodes of DSH. Compared with younger subjects, repetition of DSH is less common, but completed suicides are more common in the elderly (Gelder et al 2000, p. 1659; Johnstone et al 2004, p. 648).

12. The suicide rate in pathological gambling is around 15%.

False: The rates of suicidal ideation, suicide attempts and suicide are higher in pathological gamblers. This may be related to their high impulsivity, high rates of co-morbid psychiatric conditions as well as social disruptions. The incidence of attempted suicide among pathological gamblers is approximately 8 times that of the general population. Even though there is little specific information on suicide rates in pathological gambling, the rates are unlikely to be as high as 15% (Gelder et al 2000, p. 992).

13. Depressed women are more likely to commit suicide than depressed men.

False: Suicide is 3 times more common in men than in women (Gelder et al 2006, p. 410; Johnstone et al 2004, p. 662).

14. Identical twins are more prone to committing suicide.

False: Twins have a reduced risk of suicide (Tomassini et al 2003).

15. Having a child aged below 2 years reduces the risk of suicide in women.

True: Having a child aged below 2 years is significantly protective for women (Johnstone et al 2004, p. 662).

16. Suicide in the elderly is commonly associated with alcoholism.

False: Substance misuse is a risk factor for suicide in the elderly. However, primary substance use disorders account for a smaller proportion of suicides than in younger age groups (Gelder et al 2006, p. 410; Jacoby & Oppenheimer 2002, p. 679).

17. 25% of suicides are committed by those aged above 65 years.

False: Around 20% of all suicides are committed by those aged above 65 years. They form only 15% of the population. The rates declined in the 1960s following detoxification of the gas supply. The rates are three times higher in men than in women. The rates in men increase with advancing age, while the female rates gradually fall. The main predictive factors in old age are age, male gender, physical illness (in 35–85% of cases), social isolation, widowed or separated status, alcohol abuse and current depression or a history of depression (80%). Up to 15% have no psychiatric illnesses (Johnstone et al 2004, p. 648; www.Samaritans.org).

18. Suicide is less common in the elderly when compared to the general population.

False: Around 20% of all suicides are committed by those aged above 65 years, who form only 15% of the population. In most countries, the highest suicide rates are in those aged over 75 years (Gelder et al 2000, p. 1658; Gelder et al 2006, p. 412; Johnstone et al 2004, p. 648).

19. In the elderly, suicide is not usually due to mental health disorders.

False: Current or past history of depression, social isolation and physical health problems are the most important risk factors for suicide in the elderly. 70–80% of elderly suicides are associated with mental illness, most commonly depression. Up to 15% may have no psychiatric illness (Gelder et al 2000, p. 1660; Gelder et al 2006, p. 412; Johnstone et al 2004, p. 648).

20. Suicide is commonly associated with physical illness in old age.

True: Suicide in the elderly is associated with physical illness (20–85%), mental illness (70–80%), especially depression and/or substance abuse, separated or widowed status, and social isolation, increasing age and male gender (3 times). Terminal illness is under-represented in suicide victims (Jacoby & Oppenheimer 2002, p. 679; Johnstone et al 2004, p. 648).

21. Suicide in the elderly is more common in women than in men.

False: Suicide is more common in men than women at all ages, showing a ratio of approximately 3:1 (Jacoby & Oppenheimer 2002, p. 678; Johnstone et al 2004, p. 648).

22. A 65-year-old depressed man is more likely to kill himself than a 30-year-old depressed man.

False: Suicide rates used to be higher in older people and depression used to be more frequently associated with suicide in the elderly than in the young. However, in the past decade there has been a marked shift in suicide epidemiology. The suicide rates in young men have increased dramatically, though in the past couple of years the rates have been falling. The rates in the elderly have come down. Currently, in the UK, the rate of suicide for young men is higher than for older adults.

23. Adolescent girls with intentional self-harm have usually experienced parental criticism immediately preceding the episode.

True: Deliberate self-harm behaviour in adolescent girls is usually impulsive and occurs in the context of a dispute within the family or a significant relationship (Gelder et al 2000, p. 1805).

24. When considering a suicide attempt in a 15-year-old, parental criticism is usually the cause.

False: The large Oxford study of under 16s who had attempted suicide showed that arguments with parents were usually the most common problem for the young people. This may include parental criticism. However, it cannot be concluded that the cause for the suicide attempt is usually parental criticism.

25. Reducing the availability of means of suicide does not reduce suicides in the long term.

False: A proportion of people who attempt to kill themselves are ambivalent about their plan. Hence, restricting the availability of methods is likely to decrease the likelihood of suicides. One-third of individuals who fail to commit suicide with one method will not switch to an alternative. Population-based measures basically aim at decreasing the availability of the means to kill oneself. In Britain, during 1948–50, domestic coal gas accounted for 40% of suicides in men and 60% in women. The introduction of non-toxic North Sea gas reduced suicides by a third. Erecting a physical barrier on the Clifton suspension bridge in Bristol reduced suicides by jumping from the bridge. The results of reducing the toxicity of car exhausts (7% reduction in male suicides expected) and substituting tricyclics with SSRIs are awaited. Adding methionine to paracetamol has been predicted to reduce female suicides by 5% (Gelder et al 2006, p. 418; Johnstone et al 2004, p. 670).

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