Suicide Prevention and Suicide Postvention

1. Suicide Prevention and Suicide Postvention Dr Peter M HerriotSenior Visiting Medical Specialist, Pain Management Unit, Royal Adelaide Hospital&Consultant Psychiatrist, Eastwood House, 29 Hauteville Tce, Eastwood, 5063

2. Outline of today’s presentation • Recent events • Epidemiology of suicide • Physician suicide • Suicide prevention • Suicide postvention • How bereavement from suicide may differ from other forms of bereavement • Conclusion

3. Background & context: recent events • October 2013: beyondblue’s National Mental Health Survey of Doctors and Medical Students • February 2015: sudden deaths of three psychiatry registrars in Melbourne and one intern at Geelong Hospital within a few weeks of each other •  Dr Kimberley Ivory’s blog for crikey.com.au in response to the above deaths: “A call for medicine to stop devouring its young” • Debate surrounding the mandatory reporting of doctors

4. beyondblue National Mental Health Survey of Doctors and Medical Students 2013 • Conducted with the aims of (1) understanding issues associated with the mental health of Australian medical students and doctors, (2) increasing awareness across the medical profession and community of these issues and (3) informing the development of mental health services and supports for the medical profession • Anonymous, self-completed survey • Sample size = 42,942 doctors and 6,658 medical students • Final response rate was approximately 27% for both groups

5. beyondblue National Mental Health Survey of Doctors and Medical Students 2013 – key findings • Doctors reported substantially higher rates of psychological distress and attempted suicide compared to both the Australian population and other Australian professionals • Young doctors and female doctors appeared to have higher levels of general and specific mental health problems and reported greater work stress • The general work experience for Australian doctors is stressful and demanding • Stigmatising attitudes regarding the performance of doctors with mental health conditions persist • Doctors appear to have a greater degree of resilience to the negative impacts of poor mental health

8. Dr Kimberley Ivory’s blog for crikey.com.au in response to the above deaths: “A call for medicine to stop devouring its young” • Suicides are the tip of an iceberg buoyed by many who tried and failed/thought about it and changed their minds/numbed their pain with drugs and alcohol/walked away from the profession completely to keep body and soul together • Discussions about lack of mental health support is “victim-shaming” • “Why didn’t they get help” and “Why wasn’t help provided?” ignores the determinants of psychological distress in the community and the barriers to accessing care. • The medical culture & overcoming stigma

9. “A call for medicine to stop devouring its young” Examining the medical culture • The beyondblue survey suggests an “intense work environment may contribute to the high levels of general and specific mental distress … in comparison to the general population” and describes the work environment of doctors and medical students as “challenging” • Do we “walk the talk” of ethics, professionalism, compassion and empathy? • A recent meta-analysis of 51 studies on harassment and discrimination in medical training showed high rates of harassment and discrimination as well as “teaching by humiliation” (Fnais et al 2014) • Under-reporting - implications for career advancement - necessary part of professional development • ADF has acknowledged the “dark side” of their institutional culture. Is it time for medicine to do the same?

10. “A call for medicine to stop devouring its young” The role of stigma • Beyondblue survey found that 40% of doctors think their colleagues with mental health issues are less competent and that 59% think being a patient is embarrassing for doctors • Beyondblue survey also highlights that most doctors experiencing psychological distress do seek care and that the impact on their work and life is relatively modest • Teaching ethics, professionalism and resilience to students and trainees targets the victims and ignores the deeply entrenched cultural factors perpetuating the distress • “Until the profession at large, the medical educators, the trainee selection committees, the professional colleges, fellow trainees and workplace managers are prepared to own the “dark side”, there will be no solution and talented young people will continue to die”

11. Is the stigma compounded by mandatory reporting requirements? Support or report? • Doctors should be encouraged to seek professional help if they experience symptoms of psychological distress • Since 2010, unusually far reaching laws in all Australian states and territories require health practitioners to report all “notifiable conduct” to AHPRA • Does it facilitate identification of dangerous practitioners or create a culture of fear? Does it in fact deter helps-seeking and fuel professional rivalries and vexatious reporting? • Some of the forecast adverse effects and manifest benefits have not materialised. Bismark et al (2014)

12. Epidemiology of suicide • According to the World Health Organization, each year approximately one million individuals suicide worldwide - one death every 40 seconds (WHO 2012). • The number of lives lost each year through suicide exceeds the number of deaths due to homicide and war combined.

13. Epidemiology of suicide

14. Epidemiology of suicide - Australia At some point in their lives, 13.3% of Australians aged 16-85 years have experienced suicidal ideation, 4.0% have made suicide plans and 3.3% have attempted suicide. This is equivalent to: • Over 2.1 million Australians having thought about taking their own life. • Over 600,000 making a suicide plan. • Some 500,000 individuals making a suicide attempt during their lifetime. • Approximately 65,000 attempts a year. (Slade et al 2009)

15. Epidemiology of suicide - Australia • In 2012, 2,535 deaths were reported as a result of suicide in Australia (the equivalent of 6 deaths per day), which is significantly higher than the 1479 deaths resulting from transport accident (Australian Bureau of Statistics (ABS) 2014). • In 2012 men accounted for 75% of deaths by suicide. • It is likely the number of deaths from suicide are higher than ABS figures. • This was the largest number of suicides in the past 10 years.

16. Epidemiology of suicide - Australia

17. Epidemiology of suicide – Australia:Proportion with suicidal ideation by sexSA Monitoring & Surveillance System (SAMSS)

18. Epidemiology of suicide - Australia

19. Physician suicide • Several studies indicate an elevated risk of suicide for medical occupations such as physicians, dentists, veterinarians and nurses compared to the general population and to other academic occupations • A meta-analysis showed that male physicians had a 1.41-times and female physicians a 2.27-times higher risk of suicide compared to the general population (Schernhammer and Colditz, 2004) • High suicide rates among physicians have been present for generations and noted as far back as 1881 however recent studies suggest the suicide gap between physicians and the population is closing

20. Physician suicide • The findings are however not consistent • A recent study from Taiwan showed a significantly lower risk of suicide in doctors compared to the general population (Shang et al 2011) • Some studies have found elevated suicide rates only in female doctors. Hawton et al (2001) found an increased risk of suicide in female doctors, but male doctors seem to be at less risk than men in the general population • There were significant differences between specialties (p=0.0001), with anaesthetists, community health doctors, general practitioners and psychiatrists having significantly increased rates compared with doctors in general hospital medicine (Hawton et al 2001)

21. Physician suicide – method* • Self‐poisoning with drugs was more common in the doctors than in general population suicides • The finding that the greater proportion of suicide deaths in doctors were by self‐poisoning may reflect the fact that doctors have ready access to drugs, and have knowledge of which drugs and doses are likely to cause death • The specific finding that a large proportion of suicides in anaesthetists involved anaesthetic agents supports this explanation • Availability of method may be a factor contributing to the relatively high suicide rate of doctors. This fact might influence clinical management of doctors who are known to be depressed or suicidal *Hawton et al (2000) Doctors who kill themselves: a study of the methods used for suicide

22. Physician suicide – work problems • Study by Gold et al (2012) reviewed 203 US physician suicides and used multivariable logistic regression. They found that • Having a known mental health disorder • Job problem which contributed to the suicide significantly predicted being a physician – in other words, the physician is much more likely to have a job problem contribute to the suicide • For someone whose work helps to define his/her personal and professional identity, a crisis in a work situation might feel more threatening than for someone whose personal identity was less reliant on work satisfaction • Kolves and De Leo (2013) in an analysis of the QSR similarly found work-related problems were most prevalent in suicide in medical doctors

23. Suicide – risk factors Psychiatric disorders Psychological autopsy studies done in various countries over almost 50 years have consistently reported: • 90% of those who died by suicide were suffering from one or more psychiatric disorders at the time of death: • Major Depressive Disorder* - about 2/3 of those who die by suicide have symptoms consistent with major depression at the time of death • Bipolar Disorder, Depressive phase* • Alcohol or Substance Abuse • Schizophrenia – 30 – 40 x risk of suicide v general population & 5% lifetime risk of dying by suicide • Personality Disorders such as Borderline PD *Especially when combined with alcohol and drug abuse

24. Suicide – risk factors Past suicide attempts • A previous suicide attempt is the strongest known predictor of completed suicide • The risk of suicide after an unsuccessful attempt is around 10% over follow-up of 5-35 years1 • Use of methods other than poisoning and cutting, particularly hanging, for attempted suicide are moderately to strongly related to subsequent successful suicide. • suicide was particularly common during the first year after the index attempt, perhaps because of a distressing life situation or intense symptom rich phases of coexisting psychiatric disorder • 69% of those who attempted suicide by hanging and had a psychotic disorder died from suicide within one year. • Crossing a threshold? Suicidal mode – less stress to activate? 1: Runeson et al 2010

26. Suicide – clinical features associated with suicide (Fawcett et al Am J Psychiatry 1990) Associated with suicide within one year Panic attacks Severe psychic anxiety Diminished concentration Global insomnia Moderate alcohol abuse Severe loss of interest or pleasure (anhedonia) Associated with suicide occurring after one year Severe hopelessness Suicidal ideation History of previous suicide attempts 954 psychiatric patients with major affective disorders

27. Suicide – risk factors Symptom risk factors • Major physical illness, especially recent • Chronic physical pain • History of childhood trauma or abuse, or of being bullied • Family history of death by suicide • Alcohol and substance use

28. Suicide – risk factors Sociodemographic risk factors • Male • Increasing age • White • Separated, widowed or divorced – marriage reinforced by children appears to lessen the risk significantly • Living alone or socially isolated • Being unemployed or retired – work, in general, protects against suicide • Occupation: health-related occupations higher (Dentists, Doctors, Nurses, Social Workers and especially high in women physicians) Environmental risk factors • Easy access to lethal means (e.g. rural environment) or imitative suicide (unequivocal association between publicity about suicide and a subsequent increases in suicidal acts)

29. Suicide prevention – broader approaches • Education • Primary risk factor for suicide is psychiatric illness • Depression is treatable • Destigmatize the illness • Destigmatize treatment • Encourage help-seeking behaviors and continuation of treatment • National programmes and more focused community interventions • Australian National Suicide Prevention Programme (NSPP) • Restriction to access of means of suicide • Legislative measures to restrict access to means of suicide are effective • Media Guidelines • Indiscriminate reporting of suicidal behavior is associated with increases in suicide  guidelines for responsible reporting about suicide

30. Definitions - Postvention • Postvention is really a form of tertiary prevention and may be defined as prevention strategies that target individuals after (post) an event. • In the case of suicide, postvention services target those individuals recently bereaved by the death of a loved one. • The intention of postvention programming is to (1) aid the grieving process and (2) reduce the incidence of suicide contagion through bereavement counseling and education among “survivors”, encompassing family, friends, classmates, etc. who are affected by the death. Szumilas 2011

31. Definitions – Suicide Survivor • A suicide survivor is someone who experiences a high level of self-perceived psychological, physical and/or social distress for a considerable length of time after exposure to the suicide of another person (Jordan & McIntosh 2011) • Requires a personal and close relationship with the deceased • Distinguish from “exposure to suicide” where the person did not know the deceased personally but who knows about the death through reports of others or media reports or who has personally witnessed the death of a stranger (eg train drivers and police)

32. Postvention – systematic review • A systematic review by Szumilas & Kutcher found that the literature does not provide support for any evidence-based suicide postvention program that reduces the incidence of suicide or suicide attempts and/or reduces suicide contagion and no studies described the cost effectiveness of support programs targeted at individuals bereaved by suicide. • Provision of outreach at the time of suicide to family member survivors resulted in increased use of services designed to assist in the grieving process (compared to no outreach), and bereavement support group interventions conducted by trained facilitators resulted in some positive short-term reduction in emotional distress. Szumilas M & Kutcher S. Post-suicide intervention programs: a systematic review Can J Public Health. 2011 Jan-Feb;102(1):18-29.

33. Is bereavement from suicide different? • It is claimed/estimated that for every death by suicide, approximately six people will suffer intense grief (Clark and Goldney 2000) • Recent studies generally suggest bereavement after suicide not necessarily more severe than other types of bereavement but certain features or themes may be more prominent. These factors may make coping with the loss particularly difficult (Hawton & Simkin 2003) • In suicide bereavement one can recognise reactions present in bereavement after all types of death, reactions characteristic for bereavement after unexpected deaths and elements of bereavement after violent death (Andriessen & Krysinska 2012)

34. Experiences common in people bereaved by suicide • Stigmatisation • Awareness of generally negative reaction of the community to suicide compared with other types of death may compound sense of stigma • Undermines social support, increases isolation of the bereaved person and may make help seeking more difficult • Shame and guilt • Particularly where suicide of a son or daughter has occurred • May blame self for contributing to the death or failure to recognise mental illness or its severity • Sense of rejection • Features that seem to be unique to suicide bereavement include anger at the deceased for “choosing” death over life and the feeling of abandonment2 • Bereavement after suicide likely to be influenced by the age of the deceased, the quality of the relationship, attitude of bereaved to the loss and cultural beliefs • Accumulating clinical and empirical evidence of subgroups of suicide survivors. E.g. reactions may differ as a consequence of previous history of suicidality of the deceased and the expectation of death2 Hawton & Simkin 2003 ; 2: Andriessen & Krysinska 2012

35. Grief themes in bereavement through suicide (Goldney 2008)

36. Comments on issues unique to us as clinicians –suicide of a patient • Hospital authorities react very differently to death by suicide as compared with other deaths • Acceptance of the inevitable mortality associated with chronic physical illness v the undercurrent of blame when a patient with a psychiatric illness takes their own life • Depression is not a cause of death to be determined by the Coroner but rather suicide is grouped with the other stigmatised “-cides” • Hard to accept we can be so helpless in the face of forces over which we appear to have so little control – must be someone or something to blame • The banalities of official enquiries – “poor communication” and “failure of adequate risk assessment” – gloss over the negative consequences of changes in psychiatry over past decades (fragmented care, short-termism etc) Holmes J “Personal experience: Suicide and Psychiatric care – a lament” BJPsych Bulletin (2015) 39 45 - 47

37. Conclusion • High rates of psychological distress and attempted suicide amongst doctors • Do we need to confront a “dark side” within the medical workplace as well as the stigma of mental illness and barriers to accessing care? • Physicians may have higher suicide rates than other professional and non-professional groups. What is required? • Good management of mental imbalance and psychiatric disorders • Reduce workplace and work-home balance stressors • Restrict access to means for physicians who are in situations in which the two other factors are acute • Improved access to treatment

38. Conclusion • Despite research conclusively demonstrating the importance of a number of mental disorders, psycho-social factors and physical illnesses, none of these factors are sufficient to explain suicidal behavior per se. The individual’s perception of his or her environment and interpersonal stressors and relationships is still of critical importance in precipitating suicide1 • Prevention may be a matter of a caring person with the right knowledge being available in the right place at the right time2 1Goldney (2008) 2American Foundation for suicide prevention