1. ‘Suicide Awareness in Primary Care’ Dr Anne Doherty General Practitioner 10 October 2008

2. Understanding suicide “There is an idea that suicide is a mode of death that stands apart from others, but there are clear reasons why people die by suicide. Just like heart disease, if you understand it you can prevent it” Professor T Joiner, Harvard University Press, 2006

3. Causes of Death Suicide is the third largest cause of ‘years of lives lost’ 1. CVS Disease 2. Cancer 3. Suicide

4. Overview of presentation I will look at 3 studies Northern Ireland - population 1,685,267* Derry City - population 105,066* Inner city GP practice – population 10,000 *Source; Population Census 2001

5. Northern Ireland Study Suicide Rates/100,000 - 2004 MaleFemale Scotland Scotland30 10 Wales Wales22.4 6 N. Ireland N. Ireland18.3 5.6 R. of Ireland R. of Ireland17.7 4.97 England England16.7 5.4 Source; Professor Patricia R Casey

6. Derry City Study Suicide Rates 2000-2005 MaleFemale 83.33%16.67% Source; Dr A Burns, 2006

7. Inner City GP Practice Suicide Rates/10,000 Jan 06-Jun 08 Male Female 17% 83% Source; Dr A Doherty, 2008

8. Profiles Derry Study 2000-2005 Male 5:1 Over 1/3 of Males aged 21-30yrs Practice Study 2006- 2008 Female 5:1 Females aged 20- 30yrs Northern Ireland Study 2004 Men 3:1 60

9. Link with mental disorders? Current research evidence suggests that the strongest risk factors for youth suicide are mental disorders, in particular affective disorders, substance abuse disorders and anti-social behaviours. Priorities for intervening to reduce youth suicidal behaviours lie with interventions focused upon the improved recognition, treatment and management of young people with these.

10. Previous psychiatric disorder and suicide Derry Study 2000-2005 This highlights the importance of assessing mental health in our city

11. Previous psychiatric disorder and suicide Northern Ireland Study 2004 This highlights the importance of assessing mental health in Northern Ireland

12. Previous psychiatric disorder and suicide Practice Study 2006-2008 This highlights the importance of assessing mental health in the primary care context.

13. Risk Factors Derry Study 2000-2005 Apprentice painter 1 Foreman 1 Retired electrician 1 Area Manager 1 HM Forces 1 Schoolboy 1 Auxillary Nurse 1 Kitchen Assistant 1 Shop Assistant 3 Carpenter 1 Labourer 1 Social worker 1 Chef 1 Maintenance 1 Student3 Clerical worker 1 Mechanic 2 Theatre Nurse 1 Community worker 1 Painter 1 Unemployed 29 Electrician 1 Process operator 1 Voluntary worker 1 Employed 1 Retired civil servant 1 Waitress 1 Employment at time of death – this study indicates that 29 out of 60 were unemployed

14. Risk Factors Northern Ireland Study Personality problems Life events in previous year Unemployment History of deliberate self harm Problems with friend, neighbour etc Foster Study 1999

15. Risk Factors Inoue et al, Japan 1985-2002 This study showed a high correlation between male annual suicide rates and unemployment. Unemployment was the strongest correlate of suicide rates in Japan from 1985-2000

16. Risk Factors Practice Study 2008 This study showed that 50% of young suicide victims were unemployed 33.3% were third level education students 16.7% were employed in a profession

17. Research – What is clinical Autopsy? It is the cornerstone of much suicide research It involves detailed interviews with family and friends Interviews with GPs, psychiatrists and other mental health professionals It requires access to medical records

18. Northern Ireland psychological autopsy study Foster, Gillespie, McClelland 1997 British Journal of Psychiatry, 170, 447-452 Suicides under 30 less likely to have psychiatric diagnosis (68%) 96% of suicides had a current psychiatric diagnosis ; Axis I 86% Axis II 44%

19. Northern Ireland psychological autopsy study (continued) Principle axis I diagnosis Males %Females % _____________________________________________________________ Depressive disorders 28 60 Alcohol abuse/dependence 28 28 Other drug misuse/dependence 2 2 Schizophrenic disorders 13 4 Anxiety disorders 5 4 Adjustment disorders 3 4

20. Why Men? More violent means Less help seeking behaviour Changes to male role Women greater permission to leave Protective role of motherhood

21. Why Men? Increase in suicide rates in young males identified not only in Ireland and the UK, but in several European countries Most likely explanation for the increase in suicide rates in young males lies in social changes, particularly in terms of perceived or actual reduction in roles opportunities. Stress factors – unemployment, broken relationships, substance abuse, difficulty in seeking help High demands and responsibilities placed on them by society Changing gender roles Woman having better coping skills Relative stability of suicide rates in young females

22. Religious Beliefs Is suicide related to religious beliefs/practice? What is the mechanism by which religious beliefs reduce suicide – suicide intolerance or social cohesion provided by religion? Do the effects apply at an individual level as well as at a societal level? Neeleman et al 1997 Psychological Medicine 19 Western countries including USA Face to face interviews with 28,085 individuals

23. Religious Beliefs - continued Ecological findings: Higher rates among females associated with lower level of religious beliefs and less strongly religious attendance. Less strong among men Individual level: At an individual level stronger religious beliefs associated with lower tolerance of suicide. Personal religious beliefs for men and women and for men exposure to a religious environment also protects against suicide. Mediated by tolerance of suicide rather than social support of religious beliefs Confirms findings of other studies of association between religious beliefs rather than denominational affiliation (Stack USA) and of relationship to suicide tolerance

24. Why is suicide increasing? Is psychiatric disorder increasing? Is psychiatric disorder more incapacitating? Are there social changes driving the increase independent of psychiatric disorder? The identification and prevention of mental health problems is an important issue Many victims contact their GP in the months before providing obvious opportunities for intervention Rising unemployment rates, rising divorce rates, increasing alcohol abuse, increasing drug abuse

25. Reducing suicide Medical – adequate treatment of psychiatric disorder. Evidence that increased anti-depressant usage in NI has helped reduce suicide in the elderly but not the young (Kelly 2003 European Psychiatry) Personal – encourage help-seeking behaviour Voluntary sector- Samaritans Church/State – values certainty Media – responsible reporting

26. Be Aware of the Facts Suicide is preventable. Most suicide individuals desperately want to live. They are just unable to see alternatives to their problems Most give definite warnings of their suicidal intent Suicide is the 3 rd largest cause of “years of lives lost” following CVS and Cancer There has been an increase in the suicide rate in the 21-30yrs group. In the Derry study 2000-2005 the number of suicides doubled. The suicide rate is still higher among the elderly >65yrs Male to female ratio 4:1, overall and 6:1 in the young Suicide affects all age, economic, social and ethnic boundaries

27. Where do we start? ‘We are not merely some meaningless product of evolution…each of us is loved, each of us is willed, each of us is necessary..’ Pope Benedict XVI – Inauguration Mass 24.04.2005

28. Where do we start? As a GP It has been shown in the studies that many victims had contact with their GP in the preceding months 1. Time – Treat depression and suicidal intent with the same vigour as heart disease, diabetes or cancer 2. Access - Encourage young people to come back, give review appointment for 1 week. Provide open access and let receptionist know 3. Educate - Explain that depression is a disease. Put their symptoms into perspective, and tell them that like any other disease such as diabetes, treatment is available and with proper help they will get better.

29. Where do we start? ( continued) 4. Hope - It is important to keep things in proper procedure, the problems and deal with them one at a time. Many times patients will say they see no future, that they are facing a blank wall. It is up to us to enable them to see what might be around the corner. 5. Time to get better.Most depressive illness arises over a period of time often months or years. It is important at the outset to explain that recovery may take time whether the treatment is pharmacological or psychological. It is important to agree this at the outset so that false hope of an instant cure are not raised only to be dashed later with possible fatal consequences. The patient present in the surgery is the first step on the road to recovery if managed properly. It may have taken a lot of soul searching on the part of the patient to take this step and it should be acknowledged and praised.