Suicide

Swedish data, here is the link

Insights §

Epidemiology §

• There are about 700 000 deaths by suicide in the world each year
  • India and China alone account for 42% of all suicide deaths
  • In Sweden there are approximately 1200 deaths annually, and another 300 where suicide is suspected but the intention has not been verified.
  • More than one in 100 deaths globally are the result of suicide
  • 20% of youth have experienced suicidal ideation, and 7% have made a suicide attempt
• It is unclear if the recent decrease in suicide mortality is due to suicide prevention activities or general improvements in population health
• Psychological autopsy studies estimate the rate of psychiatric disorders in suicides to be around 90%, but
  • Epidemiological data suggests mental illness is present in half of individuals who die by suicide
• An association between regional rates of bipolar diagnosis and suicide deaths in young males suggest that improved bipolar care for youth may reduce suicide mortality
• Patients recently discharged from psychiatric facilities have almost 200 times increased risk of suicide compared to the global rate
  • Negative aspects of in-patient psychiatric care might be involved in causing some suicides
• Patients that are referred to–but do not attend–psychiatric services after deliberate self-harm are at an increased risk of death by suicide
• Individuals who self-harm with fluctuating suicidal intent are at higher risk of subsequent suicide attempts
• There are approximately 20 suicide attempts for every death by suicide
• The life expectancy of self-harming individuals is reduced by 25 years
• Individuals who self-harm have 3.6 times increased all-cause mortality
  • Only 28% of those with self-harm at age 16 were free from mental health or substance use problems, and had adequate educational or employment status
• The interaction of reduced ideation, increased energy, and improved mood may put individuals within a high threshold of high risk of suicide during spring

Health care contacts before suicide §

• One month before suicide, 44% of individuals have contact with primary care
  • In the year prior to suicide, 80% of individuals have contact with primary care
  • A majority of individuals with suicidal thoughts or behaviors do not disclose them to other people, but
    • As many as 70% of individuals with suicidal thoughts or behaviors disclose their issues when the medium is online writing

Etiology §

• The increased risk of suicide within families of suicide decedents is primarly explained by a shared genetic etiology, but shared environment factors also play a role
  • The familial risk of suicide may be particularly high for female first-degree relatives of suicide probands
  • Losing a parent to suicide is a strong risk factor for suicidal behavior in children
• Identifying who will attempt suicide and when may not be necessary for effective prevention

Suicidal ideation and planning §

• Making a suicide attempt requires overcoming a predisposed tendency to avoid pain, injury and death
• The risk increase leading up to a suicide attempt can be very rapid
  • A majority of planning steps leading up to a suicide attempt take place within 12 hours prior to the attempt.
  • Preparation of personal affairs was the single strongest predictor of a suicide attempt in retrospective interviews
  • Over half of individuals report onset of suicidal ideation or planning on the same day as their suicide attempt

Costs and resource use §

• The majority of health-care costs in the year after self-harm are due to inpatient psychiatric care
• The probability of sickness absence, disability pension and psychiatric care is increased in the years following a suicide attempt
• DBT-A leads to long-term cost savings compared to treatment as usual due to fewer inpatient and emergency visits - haga2018
• The mean hospital cost per self-harm episode in Denmark is over 7000 USD - dyvesether2022

EMA findings §

• Suicidal ideation tends to be episodic, with quick onset and short duration
• Suicidal ideation varies dramatically even during short time-spans
  • Incorporating the dynamic short-term changes in suicidal ideation and intent improved prediciton of post-discharge suicide attempts - wang2021
  • Increased autocorrelation in suicidal ideation measures was an early warning sign for one individual in a proof-of-concept study
• The mean level and variability of suicidal ideation identified subgroups of individuals with a previous suicide attempt
  • Individuals with multiple suicide attempts have a tendency to ‘get stuck’ in states of more intense suicide ideation, whereas individuals with no or one attempt stabilize at a state of low risk (not EMA but weekly CBT session ratings)
• Being alone, at home, and passive leisure correlated with increased suicidal ideation in patients recently discharged from inpatient care after a suicide attempt
• K-means clustering of weekly suicidal ideation in adolescents identified a high-risk group which experienced more suicidal events compared to a medium and low-risk groups
• NSSI: Nonsuicidal self injury was often negatively reinforced and used as a method to escape anxeity, anger or sadness

Assessment §

• Meta-analysis by Runeson in 2017: Instruments for the assessment of suicide risk
  • Commonly used instruments in suicide risk do not have adequate sensitivity and specificity
• But the PHQ-9 looks decent: The PHQ-9 item on suicidality is predictive of suicide attempt or death - simon2013

Treatment §

• Fox 2020 review, some pessimistic findings:
  • Intervention efficacy for suicidal thoughts and behaviors has not improved over the last 50 years
  • Most interventions for suicidal thoughts and behaviors are not linked to common suicidality theories

Reviews & meta-analyses §

• NICE guidelines to reduce self-harm repetition: https://www.nice.org.uk/guidance/ng225
• Big meta-analysis of 50 years of research, 1125 RCTS fox2020
• Broad-scope review of the psychology of suicide oconnor2014
  • Good overview of psychological theories and psychological factors in suicidal ideation and behavior
• Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis hawton2016
• Strategies to prevent death by suicide: Meta-analysis of randomised controlled trials riblet2017
• Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: A meta-analysis inagaki2015
• Suicide prevention strategies revisited: 10-year systematic review zalsman2016
• Practitioner Review by Asarnow & Mehlum of the treatment of youth with NSSI and suicidal behavior. DBT is the only treatment with two independent RCTs asarnow2019

Brief suicide prevention interventions §

• Brief acute care suicide prevention interventions reduce the probability of subsequent suicide attempts
  • Typically done in one face-to-face session with optional telephone follow-up
  • Brief contact interventions (phased-out contact: 1D, 1W, 2W …)
  • Safety planning Intervention
    • stanley2012
  • Care coordination (handover to psychiatric care. scheduling appointment with clinic or mobile team)
  • Enhanced screening and safety planning reduced suicide-related events by 30% after visits to emergency departments

CBT-SP §

• stanley2009 is the first report with lots of details on the structure. However no efficacy results in there.

ICBT §

History §

• Computers have been used to provide one-to-one suicide prevention counselling since 1982
• As early as 1982, an online forum was used for suicide prevention through counselling in direct messages and referral to a local crisis center

Findings §

Reviews §

• Self-guided digital interventions have a small but significant effect on suicidal ideation - Review and meta-analysis torok2020
  • Only self-guided digital interventions that directly target suicidality reduce suicidal ideation
  • Psychotherapy for depression has a small effect on suicidal ideation
• Systematic review and meta-analysis buscher2022
  • Includes many of the trials below, k = 10, n = 2037
  • 41.5% treatment response, 28.2% in control conditions (≥50% reduction on BSS)
  • g = -0.31 (95% CI -0.40 to -0.22)
• Evidence for the use of mobile technologies as tools for suicide prevention are emerging, however there are only 4 published RCTs to date and the studies are generally small with inconsistent findings.

Primary studies §

• Living Under Control programme
  • Spijker2012 has cost-effectiveness too
  • ICBT for suicidal thoughts, n = 236. Between-group d = 0.28. Spijker2014 - Effectiveness of Online Self-Help for Suicidal Thoughts, Results of a Randomised Controlled Trial
  • ICBT for SI, n = 418. No significance compared to control. Spijker2018 - Effectiveness of a Web-Based Self-Help Program for Suicidal Thinking in an Australian Community Sample, Randomized Controlled Trial
  • Muhlmann2021 - Effectiveness of an Internet-Based Self-help Therapy Program for Suicidal Ideation With Follow-up at 6 Months, Results of a Randomized Controlled Trial
  • The same protocol but without mindfulness and more cognitive techniques instead. n = 724 and between-group d = 0.34 dejaegere2019
• Reframe-IT, ICBT for youth with suicidal ideation. n = 50, no significant between-group effects, 50% dropout at 3-month follow-up hetrick2017
• ICBT for depression, no additional effects on SI beyond helpline. Christensen2013 - The effect of a web-based depression intervention on suicide ideation, Secondary outcome from a randomised controlled trial in a helpline

Covid-19 §

• No increase in self-harm after COVID-19 infection - Erlangsen2023 - Associations between SARS-CoV-2 infection and self-harm, Danish nationwide register-based cohort study
• No impact of lockdowns on self-harm or suicide in Denmark - Danielsen2023 - Self-injury, suicidality and eating disorder symptoms in young adults following COVID-19 lockdowns in Denmark
• No increase in suicide in Sweden during the COVID-19 pandemic - Our study

Ethics §

• A zero-suicide vision is harmful because we have a poor understanding of who will commit suicide, and our prevention efforts risk harming individuals if we tolerate zero suicides sjostrand2023

Psychological theories of suicide §

Ideation-to-action §

The development of suicidal ideation and the transition from suicide ideation to attempts are distinct processes with distinct predictors and explanations klonsky2021

Suicide risk exists on a continuum from relatively low risk (desire for death) to higher risk (concrete plans).

• Beck’s hopelesness theory. Hopelessness is fairly stable over time and ultimately leads an individual to believe that suicide is a viable strategy to deal with untenable cicrumstances.
• Joiner’s interpersonal theory. Perceptions of burdensomeness and thwarted belongingness are fairly stable over time and ultimately lead an individual to consider suicide as a means of resolving their situation.

Klonsky & May’s Three-step theory §

In brief, the 3ST suggests that: a) suicidal ideation is caused by the combination of unbearable pain (usually psychological) and hopelessness, b) suicidal ideation is strong when one’s pain exceeds or overwhelms one’s connectedness (to valued people, communities, or sources of purpose and meaning), and c) transition from strong suicidal ideation to potentially lethal suicide attempts is facilitated by dispositional, acquired and practical contributors to capability for suicide. Thus, the 3ST is a concise theory that explains suicide in terms of just four variables: pain, hopelessness, connectedness, and suicide capability.

Multiple pathways, non-linear §

• Fluid Vulnerability Theory. Suicidal ideation fluctuates close to a baseline with episodic peaks representing suicidal crises.
• Baca-Garcia Multiple Pathways