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Suicide: Overview
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There are around 4000 suicides per year in the UK, it being amongst the 10 commonest causes of death, and the fourth commonest for young adults. In addition, due to the strict legal criteria required for a verdict of suicide, it is estimated that it is under-reported by 30% to 50%. It is often classed by Coroners as ‘accidental death’, or ‘open verdict’, since for a verdict of suicide to be given it must be proven beyond reasonable doubt. When it comes to the actual suicidal act 2/3 of women and 1/3 of men who commit suicide take overdoses, although with increasing numbers of men taking overdoses these figures are converging. Men are more likely to use violent means (hanging, shooting, jumping, cutting) or car exhaust than women. 1 in 6 people who kill themselves leaves a note.
Such is the importance of suicide in epidemiological terms that there is currently a government funded research project looking at both suicide and homicide in psychiatric patients (a summary of the study is available on the web) with the aim of making recommendations to reduce the incidence of both in this population group.
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Suicide: Epidemiology
There have been few dramatic changes in the crude rate of suicide over the years, the exceptions being:
- falls during the two world wars
- a rise during the depression in the 1930’s
- a fall after 1960 when carbon monoxide was removed from domestic gas.
Since the 1960’s the rates have been increasing.
Season
Suicides peak in April, May and June and are at their lowest in December. This variation is most marked in women.
Age & Sex
Men are more likely to kill themselves than women for all age groups. Rates increase with age to peak at 60-75. However, in recent years there has been a large and steady increase in the incidence in younger age groups and some decline in the elderly, so the rates are now more evenly distributed with age.
Marital Status
The greatest incidence is in divorcees, widows, and widowers the lowest in those that are married.
Social Class
Highest rates are in socio-economic classes 1 and 5, the lowest in 2 and 3.
Employment
Rates are higher in the unemployed. Some employment groups have high rates, including university students, doctors, lawyers, farmers, policemen and insurance agents.
Psychiatric Illness
Up to 90% of suicides have a psychiatric illness. Around 70% of people committing suicide have some depressive symptoms if not a clear depressive illness. Patients treated for an affective disorder have 30 times the risk of suicide than the general population, and overall 15% of depressives will commit suicide. Also note that suicide in depression often occurs during early recovery when energy and motivation have returned, but hopelessness continues. Other important psychiatric diagnoses include alcoholism (around 15% of suicides), antisocial personality disorder, drug misuse, early dementia, and schizophrenia. Schizophrenics make up a small number of suicides, although their lifetime risk is around 10%. Most schizophrenic suicides are young men early in the course of their illness, particularly if there are depressive symptoms. Note that only in a small minority suicide was a ‘rational’ or ‘existential’ act.
Other Correlates
These include immigrant status, social isolation, previous episodes of DSH, family history of psychiatric illness, recent loss (bereavement, separation, redundancy), chronic physical illness.
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Suicide: Assessment
To do this direct but tactful questions need to be asked (these do not increase the risk of suicide) with reference to epidemiological risk factors. In particular consider:
- A direct statement of intent.
- Presence of psychiatric illness, particularly depression.
- Previous suicidal attempts.
- Feelings of hopelessness.
Also beware social isolation, elderly, males, chronic painful illnesses, misuse of alcohol, and bereavement.
Find out not only reasons why suicide is being considered, but also reasons to hold back (e.g. religion, family). If suicidal thoughts are expressed, have plans been made, and if so what are they?
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Suicide: Prevention and Management
There is an "urban myth" that people who are seriously considering suicide do not talk about there feelings or intentions. Nothing could be further from the truth suicidal ideas are expressed by 68% before they act and 67% visit their GP in previous month, 40% in the previous week. Also remember that 25% are currently psychiatric out-patients.
The most important aspect of management is recognition of suicidal risk.
Any psychiatric illness present needs to be adequately treated. This might entail admission to hospital, perhaps under the terms of the Mental Health Act, with high levels of observation by hospital staff .
Effective follow-up with social and psychological support is essential for patients who have had contact with psychiatric services.
In addition to the psychiatric services, voluntary organisations, such as the Samaritans, may also help to prevent suicide.
N.B. Despite all efforts suicides do occur, and in these circumstances support for relatives, and staff, is vital.
This work is licenced under a Creative Commons Licence.