Hayley Gorton
WELCOME to the first of three in this blog series that aims to raise awareness about suicide.
In June 2015, I was privileged to attend and present my work at the 28th International Association for Suicide Prevention (IASP) biennial congress, in Montréal, Canada. The six hundred delegates included psychiatrists, psychologists, epidemiologists and survivors of suicide; but I suspected that I was the only pharmacist there. This made me reflect on my own practice. Prior to starting my PhD project, what did I know about suicide risk? The answer is probably not a lot.
As first line healthcare professionals, pharmacists are public health advocates and suicide is a significant public health problem that we must be aware of. Alongside my research, I am therefore striving to improve suicide awareness amongst my peers. This first blog will focus on the epidemiology and risk factors for suicide. Subsequent blogs will focus on medication and suicide, and the role of the pharmacist in suicide prevention and awareness.
Impact
In 2013, 6,233 lives were lost in the UK to suicide [1] and worldwide, at least 800,000 people, probably more due to underreporting, die each year due to suicide. Some of this underreporting is attributable to the negative stigma that still surrounds suicide, particularly in countries where suicide remains illegal or is widely condemned by religions which dominate in that country.
The World Health Organization has issued suicide prevention guidance which is tailored to current levels of activity in different countries [2]. Futhermore, they commit in their Mental Health Action Plan, to reduce suicide death by 10% by the year 2020 [3].
Suicide is the most extreme of a spectrum of suicide behaviours including self-injurious behaviour with no suicide intent, suicidal ideation and suicide attempt [4]. Establishing whether a person intended to die by suicide is a complex process for even the most experienced psychiatrists and coroners.
Similarly, whether a self-harm episode had suicide intent is difficult to determine and the terminology used to accurately describe these behaviours provokes ongoing discussion in the suicide prevention research field. Regardless of these nuances in terminology, a previous suicide attempt is the single biggest predictor of death by suicide. For every one person who dies by suicide, 20 more attempt suicide [5].
Prevalence
Although there is some variation between countries, in most countries, suicide is between 1.5 – 3 times more common in men than it is women [2].
However, suicide attempts occur more frequently in women [6]. Some of this disparity is attributed to the selection of suicide method, with men often using more violent methods [7]. There is also a genetic component to risk of suicide. Heritability of 30%- 50% for suicidal behaviour has been suggested, some of which is accounted for by heritability of psychiatric illness [6].
Other factors which influence suicide risk have been identified by Gunnell and Lewis in their model of “Life Course Influences on Suicide”. Immediate influences at the time of suicide include method availability [8]. Restriction of potential means of suicide is advocated as a suicide prevention strategy by the World Health Organization [2]. In 1998, UK legislation restricted the over the counter availability of paracetamol. In the following 11 ¼ years, suicide deaths involving paracetamol reduced by 43% [9].
Unfortunately, however, deaths due to paracetamol poisoning still occur. In 2014, 200 deaths were attributed to paracetamol poisoning (suicide and accidental deaths combined) in England and Wales [10].
Risk factors
Proximal to suicide, risk factors include substance misuse, age and media influences [8]. Middle-aged and elderly men are the age groups with the highest suicide rates in most countries, but in 15-29 year olds, suicide is second most frequent cause of death.
Increased rates of suicides have been noted in 30 days of coverage of suicide by the media, particularly if the method is detailed or a celebrity is affected [6]. Factors distal to the suicide include environment influences on neurodevelopment (e.g. childhood abuse) and risk factors in adult, including relationship breakdown and socioeconomic conditions [11]. There have also been reports that an increased suicide rate coincided with the economic crisis of 2008 [12].
Psychiatric disorder has been identified in 90% of people who died by suicide [5] . Almost all mental illnesses are associated with an increased risk of suicide. Singhal et al (2014) compared people with no recorded diagnosis of mental illness to those with mental illness diagnoses. They found people with bipolar disorder to be at an 18-fold increased risk of suicide (Risk Ratio 17.9 (95% CI 16.00-20.00) and those with schizophrenia to be at over a 10-fold increased risk (Risk Ratio 10.6 (95%CI 9.8 – 11.4) [13].
Depression accounts for 4% of the world disease burden [3]. It is associated with a 13-fold increased risk of suicide (Risk Ratio 12.9 (95% CI 12.2-13.7) [13] therefore if not properly addressed, it will continue to be a major risk factor in the population.
The interplay between mental and physical illness is becoming increasingly acknowledged. The need for vigilance for depression in people with physical illness, is recognised in national guidance [14]. Albeit to a lesser extent than that associated with mental illness, physical illness has also been associated with risk of suicide. Comorbid depression explained much of the elevated risk in people with physical illness compared to those without, in a population-based study case-control study by Webb et al (2012).
However, cancer and coronary heart disease were associated with an increased risk, independent of depression [15]. When the effect of mental illness was adjusted for in the aforementioned study by Singhal et al (2014), they found that the physical illness with the greatest elevated risk of suicide was epilepsy (Risk Ratio 1.8 (95% CI 1.6-2.1)). Another study has suggested that hospitalisation for one or more physical illnesses has been associated with increased suicide risk, compared to no physical illness (Incidence Rate Ratio: 2.13 (95% CI 2.07-2.18)) [16].
Help and advice
There are a multitude of factors which contribute to increased suicide risk. Being aware of some of these risk factors might help us to help each other or someone else who is feeling suicidal. If you need to direct patients, customers, colleagues, friends or family for support; the following helplines are available:
- Samaritans: 116 123
- Mind: 0300 123 3393
- Childline: 0800 1111 (children)
- Papyrus: 0800 068 4141 (teenagers and adults)
- Hayley Gorton MRPharmS MPharm
The views expressed in this are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.
Hayley Gorton is a community pharmacist and a PhD student at Manchester Pharmacy School involved in suicide, medication safety, and pharmacoepidemiology research.
Follow Hayley @hayley_gorton
References
1. Office for NationalStatistics. Suicides in the United Kingdom, 2013 Registrations:. [Internet]. 2015 [cited 2015 Dec 06].
2. World Health Organization. Preventing suicide A global imperative. [Internet]. 2014 [cited 2015 Dec 06].
3. World Health Organization. Mental Health Action Plan 2013-2020. [Internet]. 2013 [cited 2015 06 Dec].
4. Posner K, Oquendo MA, Gould M, Stanley B, Davies M. Columbia Classification Algorithm of Suicide Assessment (C-CASA): Classification of Suicidal Events in the FDA’s Pediatric Suicidal Risk Analysis of Antidepressants. Am J Psychiatry. 2007;164:1035-43.
5. Hawton K, Van Heeringen K. Suicide. Lancet. 2009;373:1372-81.
6. Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet. 2015.
7. Denning DG, Conwell Y, King D, Cox C. Method choice, intent, and gender in completed suicide. Suicide Life Threat Behav. 2000; 3:282-8
8. Gunnell D, Lewis G. Studying suicide from the life course perspective: implications for prevention. Br J Psychiatry. 2005;187:206-08.
9. Hawton K, Bergen H, Simkin S, Dodd S, Pocock P, Bernal W, et al. Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses. BMJ. 2013;346:f403.
10. Statistics OfN. Deaths related to drug poisoning in England and Wales, 2014 registrations. Newport: Office for National Statistics, 2015.
11. Gunnell D, Bennewith O, Simkin S, Cooper J, Klineberg E, Rodway C, et al. Time trends in coroners’ use of different verdicts for possible suicides and their impact on officially reported incidence of suicide in England: 1990-2005. Psychological medicine. 2013;43(7):1415-22.
12. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. Lancet. 2011;378:124-5.
13. Singhal A, Ross J, Seminog O, Hawton K, Goldacre MJ. Risk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage. J R Soc Med. 2014;107(5):194-204
14. Depression in adults with a chronic physical health problem: Treatment and management (CG 91).[Internet] London: NICE. [2009; cited 2015 Dec 06].
15. Webb RT, Kontopantelis E, Doran T, Qin P, Creed F, Kapur N. Suicide Risk in Primary Care Patients with Major Physical Diseases. Arch Gen Psychiatry. 2012;69(3):256-64.
16. Qin P, Webb R, Kapur N, Sorensen HT. Hospitalization for physical illness and risk of subsequent suicide: a population study. J Intern Med. 2014;273:48-58.