Angus H Thompson Dept of Public Health, Flinders University Adelaide, Australia

1. PREDICTING SUICIDESpecificity Of Parasuicidal Behaviour, Communication Of Intent, And Proximal Vs Distal Precursors Angus H Thompson Dept of Public Health, Flinders University Adelaide, Australia IFPE 11th International CongressGöteborg, May 5, 2007

2. PREDICTION OF SUICIDE “Too Rare to be Usefully Predicted” 11 per 100,000 Australia & Canada (< one-ninetieth of one percent)

3. ATTEMPTS vs COMPLETIONS DUAL ENTITY MODEL • Many Attempters do not wish to die • Very few attempters take their own lives • Differences between the two groups

4. SINGLE DIMENSION MODEL • Attempts signify higher risk • Escalation in lethality if no resolution • Observed differences between the two may be due to differences in escalated intensity

5. SUICIDAL PROGRESSION MODEL Thoughts of Death Suicidal Thoughts Plans/Serious Ideation Suicide Attempts Completed Suicide

6. CAN WE PREDICT SUICIDE?

7. MORTALITY DUE TO SUICIDE(% of All Deaths) Versus 0.011% (11 per 100,000 annual rates) Additional dimension – Lifetime

8. PREDICTING SUICIDESTUDY 1 Canadian University Students N = 227 65% Female

9. QUESTIONS Q1 Has there ever been a period when you felt like you wanted to die? Q2 Have you felt so low you thought of committing suicide? Q3 Have you ever made definite plans to commit suicide (even though you did not actually make an attempt)? Q4 Have you ever attempted suicide?

10. RESULTS

11. RESULTS

12. STUDY ONE OBSERVATIONS • This Apparently Mundane Dimension, Isn’t! • Orderly Decline in Frequency From Lower to Higher Levels of Suicidality • Virtually All Cases of Any Level Are Captured by the Next Lowest Level • Presumably These Are Chronologically Ordered

13. PREMISE If an attempt is a communication, then attempts could be grouped with other forms of expression of suicidal intent for the purposes of prediction.

14. STUDY 2 • Expression of Intent/Attempts • Review: Psychological Autopsy Studies • Suicides with Prior Communication and/or Attempts

15. EXPRESSED INTENT INCLUDES: • Direct Statements • Dire Predictions, Allusions to Being Better off Dead, Expressing a Wish to be Dead

16. PSYCHOLOGICAL AUTOPSY STUDIES

17. On “average” 75% of suicides were preceded by a communication of intent (Range: 63%-97%) Not a predictive value (how many communicators complete?)

18. PROPORTION OF ATTEMPTORS WHO COMPLETE

19. ESTIMATING THE PROPORTION OF COMMUNICATORS WHO COMPLETE Among Completed Suicides: Expressers + Attempters = 1.69 Attempters Only

21. Communicated Intent Death 1st-Yr. Death Lifetime BOTH SEXES 5% 29% FEMALES 3% 14% MALES 8% 43% CONSIDERING GENDER (Male:Female Completion Ratio = 3:1)

22. OBSERVATIONS • Suicide is predictable (with minimal data) • Minimal Data  Potential for Improvement • Interventions: Proximal & distal predictions • Meaningful commonality with Social problems / Injury / Mental illness

23. FUTURE RESEARCH • Replicate with longitudinal data • Test the intensity-chronology hypothesis • Determine precursors to 1st death wish • Add risk-factors to prediction equation • Discover why most life trajectories move away from suicide

24. Many Thanks For More Information: Angus H Thompson, Ph.D. Dept of Public Health, Flinders University angus.thompson@flinders.edu.au www.socialproblemindex. ualberta.ca

26. COMMONALITY

27. THE ASSOCIATION BETWEEN SOCIAL PROBLEMS AND PSYCHIATRIC DIAGNOSES IN THE EDMONTON AREA EPIDEMIOLOGICAL STUDY OF PSYCHIATRIC DISORDERS Source: Thompson A & Bland RC (1995). Social dysfunction and mental illness in a community sample. Canadian Journal of Psychiatry 40, 15 – 20.

28. THE CANADIAN SOCIAL PROBLEM INDEX COMPONENTSMurder Attempted Murder Assault Sexual assault Robbery Suicide Divorce Alcoholism Source: Thompson AH, Howard AW, Yin J (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51.

29. Source: Thompson AH, Howard AW, Yin J (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51.

30. (r = 0.81) Source: Thompson AH, Borden K, Belton KL. (2004). Intentional & unintentional injuries across health regions in Alberta, Canada: An implication for policy. Crisis 25(4) 156-160.

31. TO DO LIST Improve Prediction • Add MI, PTSD, Risk factors, … • Match Proximal/Distal & Intervention Type • Predictability should include associated mental and social problems • Note that children with a death wish are likely already in trouble

32. TO DO LIST Discover Precursors to Thoughts of Death • Sub-optimal Brain Development • Childhood Trauma / PTSD • Disrupted Attachment • Oppositional / Avoidant Temperament

33. TO DO LIST Discover Precursors to Thoughts of Death • Sub-optimal Brain Development • Childhood Trauma • Child Abuse & Neglect

34. TO DO LIST Discover Why Life Trajectories Move Away From Suicide • Addition of Other Coping Strategies • Social Support • Formal Attention to Transitions • Treatment

35. TO DO LIST Discover Causes in Common With Other Social Problems, Injury & Mental Illness • Social Structure • Genetic Vulnerability • Cultural Stance / Social Inclusion • Healthy public policy approach to alcohol use, gambling, media, education

36. THREE IMPORTANT SLIDES • Serotonin Polymorphism & Abuse • Increases in Childhood Trauma • Cultural Continuity

37. Figure 3 THE PREVALENCE OF TWO OR MORE TRAUMATIC CHILDHOOD EVENTS BY “COHORT YEAR” AND SEX “Cohort Year” = Date when the youngest person in each group would have been about 15 years of age Source: Thompson AH, Cui X (2000). Increasing Childhood Trauma in Canada: Findings From the National Population Health Survey, 1994/95. Canadian Journal of Public Health, 91(3), 197-200.

38. Serotonin Transporter Gene, Early Life Experience, & Depression at Age 26 Depression Risk .70 SS S = Short Allele L = Long Allele .50 SL LL .30 NoAbuse ModerateAbuse SevereAbuse Founders Network A. Caspi, Science, 18 July 2003, Vol 301.

39. CULTURAL CONTINUITY