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Suicide Risk: Comprehensive Assessment and Clinical Management. David A. Brent, M.D. Western Psychiatric Institute and Clinic March 28, 2006. Objectives. Review descriptive epidemiology of suicidal ideation, attempts, and completion
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David A. Brent, M.D.
Western Psychiatric Institute and Clinic
March 28, 2006
Suicidal ideation 20%
Suicide attempts 1.3-3.8% males 1.5-10% females
Risk for recurrent attempts 15-30%/year
Risk for completed suicide 0.5-1.0%/year
Increased risk of suicideamong attempters 10-60-fold increased
Lifetime ideation 13.5%
Ideation with a plan 3.9%
Attempt 4.6%
*Kessler et al., 1999
Hazard Functions of First Onset of Suicide Ideation, Plan, and Attempt (N=5877)*
*Kessler et al., 1999
Data are from Center for Disease Control and Prevention
Data from the Center for Disease Control and Prevention
Ideation to plan 34%
Ideation to attempt 26% (90% in 1 yr)
Plan to attempt 72% (60% in 1 yr)
*Kessler et al., 1999
*Kessler et al., 1999
*95% CI excludes 1.0
Rates of Suicide by Firearm During the Six Years After Purchase Among Persons Who Purchased Handguns inCalifornia in 1991
The horizontal line indicates the age- and sex-adjusted average annual rate of suicide by firearm in California in 1991 through 1996 (10.7 per 100,000 persons per year).
Abstracted from Wintemute et al., New England Journal of Medicine, 341:1583-1589
Kapur et al., 1992
Agitation - Anxiety, agitation, EPS, insomnia
Ideation - Active ideation with a plan
Depression - Depression and decline, hopelessness
Instability - Substance use, affective lability, mixed state or rapid cycling, brain injury
Loss - Of relationship, work, health, or function
Lethal agent- Availability of a gun
Suicidal history - Personal or in family
Aggression and impulsivity
Difficult course - Poor treatment response, comorbid, severe
Difficult patient - Non-adherent
Abuse and trauma history
Disconnection from support, work, relationships
Substance or alcohol abuse
*Powell et al. 2000
*Meehan et al., 2006
*Meehan et al., 2006
*Hunt et al., 2006
Hospitalized for suicidality 8.6%
Hospitalized 4.0%
Outpatient 2.2%
Non-affectively ill 0.5%
Tends to occur relatively early in the course of illness
*Fawcett et al., 1990
*Hawton et.al., 2005a
*Hawton et al., 2005a
*Hawton et al., 2005b
*Hawton et al., 2005b
*Murphy, 1992; Conner et al., 2003, 2004
*Murphy, 1992; Conner et al., 2003, 2004
Short Term
Long Term
Suicide Rate %
Suicide Rate %0
Placebo
Placebo
Response % SuicidalityIndication N Drug Placebo NNT Drug Placebo NNH
MDD 2,750 59.5 47.9 9 45/1,708 21/1,433 125
OCD 705 51.5 32.2 6 4/362 1/339 200
ANX 1,143 68.9 38.8 3 6/573 1/582 143
*Bridge et al., in preparation
Drug % Placebo % Pooled Pooled
Risk Difference* Relative Risk*
(95% CI) (95% CI)
MDD 2.6 1.5 0.8% 1.7
(-0.2%-1.8%) (0.97-2.8)
OCD 1.1 0.3 0.5% 1.8
(-0.1%-2.2%) (0.4-8.5)
ANX 0.4 0.2 0.7% 3.1
(-0.0%-1.8%) (0.6-16.8)
*Using random effects models
Rates of Suicide Attempts During the 3 Months Before and the 6 Months After Initial Antidepressant Prescriptiona
aBars indicate 95% confidence intervals
Simon et al., 2006
Hawton et al., 1998
Brown et al., 2005
Survival Curves of Time to Repeat Suicide Attempt*
*Brown, G. K. et al. JAMA 2005;294:563-570.
Harrington et al. (1998) – Home-based family intervention no better than TAU for adolescent overdose attempts. In non-depressed group family treatment reduced ideation
Wood et al (2001) – 6-session group treatment >TAU for reducing single (OR=.6) and recurrent attempts (OR=.16), anger, and conduct disorder, but not depression. More of experimental treatment better, more of TAU worse.
*Motto & Bostrom, 2001
*Carter et al., 2005
Forest Plot Showing Meta-Analysis of Suicides Plus
Deliberate Self-Harm in Randomized Trials Comparing
Lithium with Placebo or Active Comparators
Cipriani et al., 2005
*Baldessarini, 2003 †Coppen, 2000 ‡Goodwin, 2003
*Meltzer et al., 2003
Management of “External Factors” in Treatment of Attempters
Family
Discord
Availability of Lethal Agents
School Problems
Attempt
Social Skills
Training
Interpersonal Difficulties
Restrict Access to Means
Case Management
Adjust Expectation
Family Therapy , Education
Treatment of Parents
Management of “Internal Factors” inTreatment of Attempters
Negative Affect and other Disorders
Hopelessness
Emotional Lability
Attempt
Problem-solving
Positive Health Habits
Impulsivity
Cognitive Restructuring
Emotion Regulation
Distress, Tolerance, Treatment Disorder