Suicide : Facts and Myths

1. Suicide: Facts and Myths JON EDWARD JURILLA., MD Makati Medical Center Asian Hospital and Medical Center Medical City

2. Suicide: Definition • “The conscious act of self-induced annihilation, best understood as a multi-dimensional malaise in a needful individual who defines an issue for which the act is perceived as the best action.” • Edwin Edgardo Juan L. Tolentino, Jr,MD

3. Why Talk of Suicide? • The mortality from suicide is about 1 in 10,000 of the adult population. Over 90% of suicide are associated with psychiatric illness and in 70% of cases this is DEPRESSION • Suicide risk is greatest among the untreated depressed patients • Studies suggest that more than 50% of suicides saw a physician during the month before death • Thus, death from suicide can be minimized, if not prevented. Edgardo Juan L. Tolentino, Jr,MD

4. Breaking Myths on Suicide • When a person threatens suicide, he/she is merely attention-getting • Once a person has tried suicide before, he/she won’t do it again • A deeply religious person will never commit suicide. • Only crazy people commit suicide • Asking a depressed person, if he/she is thinking of committing suicide only precipitates the act. Edgardo Juan L. Tolentino, Jr,MD

5. Calculating Suicidal Risk • The risk is greater if: • The person is depressed • The person has attempted suicide before • He/she has been recently bereaved or suffered some other stressful event • The person talks about ending his/her own life • He/she suddenly makes a will • The person starts to write suicide notes. Edgardo Juan L. Tolentino, Jr,MD

6. Epidemiology of Suicide

7. Incidence and Prevalence • Completed suicides: 30,000 (U.S.) • Attempted suicides: 240,000-300,000 cases (U.S.) Edgardo Juan L. Tolentino, Jr,MD

8. Previous Suicidal Behavior • A past suicide attempt is perhaps the best predictor that a patient is at increased risk to commit suicide • 40% of people who commit suicide have made a previous attempt Edgardo Juan L. Tolentino, Jr,MD

9. Sex • Men commit suicide 3x more often than women • Women attempt suicide 4x more often than men Edgardo Juan L. Tolentino, Jr,MD

10. Methods • Men use firearms, hanging or jumping from high places • Women are more likely to take an overdose of drugs or poison Edgardo Juan L. Tolentino, Jr,MD

11. Age • Suicide rates increase with age: • Among men, suicide rates peak and continue to rise after age 45 • Among women, the greatest no. of completed suicides occurs after age 55 • The elderly account for 25% of suicides • Among the 15-24 year old age group, suicide is the 2nd leading cause of death Edgardo Juan L. Tolentino, Jr,MD

12. Race (U.S.) • The rates of suicide among whites is nearly twice than among non-whites (2 out of 3 suicides are white males). • Suicide among immigrants is higher than in the native-born population Edgardo Juan L. Tolentino, Jr,MD

13. Religion • Suicide rates among Catholic populations have been lower than rates among Protestants and Jews. Edgardo Juan L. Tolentino, Jr,MD

14. Marital Status • Marriage reinforced by children seems to lessen significantly the risk of suicide • Suicide rates: • 11 per 100,000 among married persons • 22 per 100,000 among single, never-married persons • 24 per 100,000 among the widowed • 40 per 100,000 among the divorced: • >69 per 100,000 among divorced men • >18 per 100,000 among divorced women Edgardo Juan L. Tolentino, Jr,MD

15. Occupation • The higher a person’s status is, the greater the suicide risk; but fall in social status also increases the risk. • Professionals, particularly physicians, have traditionally been considered to be at higher risk for suicide. • Among physicians, psychiatrists are considered to be at greatest risk, followed by ophthalmologists and anaesthsiologists. Edgardo Juan L. Tolentino, Jr,MD

16. Physical Health • Prior medical care appears to be positively correlated risk indicator of suicide: • 2% of suicides had medical attention within 6 mos. Of death • 25% - 75% of all suicide victims on postmortem studies showed physical illness. Edgardo Juan L. Tolentino, Jr,MD

17. Evaluation of Risk Source: K. Adam, Self-Destructive Behavior; Psychiatric Clinic of N. America 8; 183;1995 Edgardo Juan L. Tolentino, Jr,MD

18. Dealing with Suicide • Suspicion that someone may be about to harm him/herself must be taken very seriously. • Every effort should be made to get him/her to see a doctor/psychiatrist. • Seek help immediately from a member of the care team. • Depression can be effectively treated Edgardo Juan L. Tolentino, Jr,MD

19. Program of Care for Depressed Patients • Day Programs and Rehabilitation – where people can meet and learn social and vocational skills. • Psychoeducation – to inc. understanding of the illness and its treatment, and to encourage the person to take more responsibility for his/her symptoms • Social skills training – to improve the person’s ability in terms of self-care, self-confidence, coping skills and relationships Edgardo Juan L. Tolentino, Jr,MD

20. Program of Care for Depressed Patients • Cognitive behavioral therapy – education, advice and training on coping skills to help manage stress and overcome particular problems of living w/ depression • Psychotherapy/Counseling • Group therapy/Support groups – based on principle of identification • Continuing medication Edgardo Juan L. Tolentino, Jr,MD

21. Communicating with the Depressed Patient • Giving honest, positive feedback is very important. • Try to include person who is ill in family matters; their views on and feelings about family matters relevant to them should be elicited. • Work towards encouraging your loved one to regain independence • However, when in the depressed state, discourage patient from making major decisions until fairly stable. Edgardo Juan L. Tolentino, Jr,MD

22. Communicating with the Depressed Patient • Avoid making judgmental comments. If you need to express dissatisfaction or criticism, do it in a loving and constructive way- your tone of voice is important. • Communicate clearly, concisely, and consistently • Stay calm and relaxed. Working in a family environment that is safe, supportive, tolerant, and accepting will give the person who is ill their best chance of recovery. BUT, don’t put too much pressure on yourself to achieve perfection Edgardo Juan L. Tolentino, Jr,MD

23. Reducing Stress at Home • Look after your own personal needs: • Have a good laugh, or a good cry w/ friends • It may help to find someone outside the family you can talk to re your worries and concerns • Networking w/ other families who are in the same position may be particularly useful • Start keeping your own stress diary: • Take note of your stressors, how you feel, and how you cope • Look at your stress diary after a week and try to identify patterns • Are there situations that make you particularly anxious? Is there anything you can do to reduce stress or change your behavior so that you are reacting more calmly? Edgardo Juan L. Tolentino, Jr,MD

24. Stress Diary • TIME Monday night • STRESSOR Kris would not sleep and has been bugging me to listen to her • MY FEELINGS Why won’t she sleep? Doesn’t she understand I had too much to do at work today? • MY RESPONSE Lost my cool! Raised my voice. Really felt guilty after. • MY PLAN/ MY GOAL Will avoid making a critical comment. Will praise her for her next good deed. Edgardo Juan L. Tolentino, Jr,MD

25. Hospital Admissions and Difficult Situations • Situations when the symptoms of depression are best treated in the hospital: • Initial phase of illness. This is done so they can be given the tx needed in a place where progress can be monitored closely. • When symptoms have come back again or if they are at risk of suicide. • If the symptoms of depression have been complicated by psychosis and/or substance abuse and out patient management compromises safety of patient or others • When patient has been deemed treatment resistant and other interventions or combinations are contemplated. Edgardo Juan L. Tolentino, Jr,MD

26. Hospital Admissions and Difficult Situations • When is hospital admissions necessary? • When a patient is considered a danger to himself or others the patient may be given treatment against his will • When a patient may not believe he/she is ill and refuses treatment, supervised treatment may become necessary Edgardo Juan L. Tolentino, Jr,MD

27. Hospital Admissions and Difficult Situations • How do we become prepared for hospital admission? • Draw up an emergency plan, even if you never need it. • Make a note of emergency nos., including police, psychiatrist, doctors, ambulance service, and an emergency center for psychiatric admission • Find out from your psychiatrist which hospital you should take your relative to in an emergency • Make arrangements for other family members to care for children or pets, ensure that the home is secure and deal w/ bills in case a relative needs to be hospitalized. • Draw up a ‘contract’/contingency plan with the patient for what to do if he/she becomes too ill to understand the need for help. Patient may wish to have a copy of the plan or to carry the name of a friend or relative to be contacted in an emergency. Edgardo Juan L. Tolentino, Jr,MD

28. What To Ask the Care Team • When a relative is admitted to hospital, you may feel anxious, upset and confused esp. it is the 1st time. When a person is admitted, they will be given a thorough psychiatric and physical exam to determine the appropriate tx and whether it should be given in hospital. • Ask questions so you know what’s happening but try to be cooperative. Develop good relationship w/ the hospital staff. It might help to write down everything you’ve been told before you forget them. • Make a note of all the questions you want to ask and any responses you are given • Ask for info about the signs and symptoms of the illness and the proposed tx methods. Use the space on flip side to record the names and telephone nos. of the care team assigned to your relative. Edgardo Juan L. Tolentino, Jr,MD

29. Dealing with Difficult Behavior • When a depressed relative or friend has gone into psychotic behavior (losing touch w/ reality), you can help this person by staying calm and maintaining his/her trust in you. • The person may be frightened and feel as if he/she is losing control Edgardo Juan L. Tolentino, Jr,MD

30. DO’s: Remember the person may be frightened Try to stay as calm as possible Dec. other distractions Sit down w/ the person Talk slowly Avoid touching the person Avoid direct eye contact Ask the person what’s bothering him or her Allow the person personal space DON’T’s: Try to reason with the person Shout or get angry Patronize or criticize Argue with other people about what to do Block a doorway or exit route Guidelines for Coping withDifficult Behavior Edgardo Juan L. Tolentino, Jr,MD

31. Realizing You Have Done Your Best…. • Sometimes it is necessary to accept that you have done the best you can in a situation, even if things don’t work out as planned. • If this happens try not to blame yourself. Talk to others about how you feel. • Try to learn from the experience. • Sometimes it may be necessary to step back from a situation. It will not help to get overly involved in the needs of the person with the illness or let family life revolve around him/her. Edgardo Juan L. Tolentino, Jr,MD

32. Avoiding Future Difficulties • Three key strategies: • Be vigilant for sings of relapse • Try to maintain a calm family environment • Encourage you relative to take their medication and continue with other non-drug treatments, as well as follow up with their doctor • There is always HOPE. Take comfort from the strength you and your family have shown in coping so far. Share experience with a support group. People who have been through similar things with their own relatives or friends may be able to give you practical tips on how to deal with difficult behavior. Edgardo Juan L. Tolentino, Jr,MD

33. Thank you! “Knowing is not enough; we must apply.Willing is not enough, we must do. -Goethe Edgardo Juan L. Tolentino, Jr,MD