Surviving Psychiatric Illness: Suicide Risk Assessment and Prevention

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1 Surviving Psychiatric Illness: Suicide Risk Assessment and Prevention J. John Mann, MD New York State Psychiatric Institute Paul Janssen Professor of Translational Neuroscience in Psychiatry and Radiology College of Physicians and Surgeons of Columbia University

2 Disclosures Royalties from Research Foundation for Mental Hygiene for commercial use of C-SSRS Stock options from Qualitas Health, a start-up developing an omega-3 polyunsaturated fatty acid nutritional supplement.

3 Relationship to Psychiatric Illness Psychological autopsies in suicides confirm that over 90% have a diagnosable psychiatric illness. Most are untreated. Life-time mortality due to suicide in previously hospitalized patients is high: unipolar depression (15%); bipolar disorder (15-20%); alcoholics (18%); schizophrenics (10-15%); and borderline and antisocial personality disorders (5-10%). Combinations of psychiatric illnesses increases risk.

4 Vulnerability or Diathesis for Suicidal Behavior Most patients with psychiatric disorders including mood disorders do not attempt suicide. What determines whether a patient with major depression will attempt or complete suicide? At risk patients have a vulnerability or predisposition to suicidal behavior under circumstances of a psychiatric illness. What is this vulnerability or diathesis?

5 Vulnerability or Diathesis for Suicidal Behavior Impulsive/aggressive traits indicating a tendency to act on powerful feelings. More severe subjective depression combined with more hopelessness, recall fewer reasons for living and more severe suicidal thoughts. Earlier onset depressive illness. Impaired problem-solving or cognitive rigidity enhancing feeling of being trapped with no other option or alternatives.

6 A Stress Diathesis Model Stressors include an acute psychiatric illness such as a major depressive episode or psychosocial crisis. The stressor is not enough. There must be a diathesis or predisposition. The best clinical clue to the presence of a diathesis is personal or family history of a suicide attempt. This is not a perfect screening tool since two thirds of all suicides die at the first attempt.

7 Stress Diathesis Model of Suicidal Behavior Mann, Nature Neuroscience Reviews, 2003

8 Suicide Prevention Strategies: A 2005 Systematic Review Circled letters refer to relevant prevention interventions listed on right. Mann JJ, et al. JAMA. 2005;294(16):

9 Who Dies by Suicide? In Western nations 90% or more suicides are during a psychiatric illness 60% have a mood disorder About 13% are adequately treated based on older studies and more recent studies suggest more depressions are treated prior to suicide but most are not. Henriksson MM, et al. Am J Psychiatry. 1993;150(6): Isometsa ET, et al. Am J Psychiatry. 1994;151(4):

10 Primary Care In developed nations GPs treat most adult depression and in developing nations often a health care worker is only source of treatment. High level of contact with primary care practitioners prior to suicide up to 83% within a year and 66% within a month of death. (Luoma et al. 2002, Andersen et al. 2000, Suominen et al. 2002). Educating general practitioners on recognition and treatment of depression is the most successful single suicide prevention method.

11 The Major Strategies for Suicide Prevention and the Role of the GP and Internist Improve awareness and education for public, doctors and gatekeepers: role of psychiatric illness and treatment. Improved chain of care. Treatment: Medication and psychotherapy for psychiatric disorders, especially major depression. Means restriction: reduce availability of commonest methods: guns and pills in the home. Media reporting about suicide: stop encouragement of suicide

12 Nuremberg Alliance Against Depression 1. Cooperation with GPs: eg, advanced training 4. Help offers for patients and relatives (self-help, high-risk groups) Aim: To optimize care for depressed patients and to prevent suicidality 2. Public relations; information for the broad public 3. Cooperation with multipliers: eg, priests, teachers, police, media GP = general practitioner. Hegerl U, et al. Psychol Med. 2006;36(9):

13 Nuremberg: Main Outcome Criteria Number of Suicides Main outcome criterion: number of suicidal acts in comparison to the baseline and a control-region Number of Suicide Attempts Hegerl U, et al. Psychol Med. 2006;36(9):

14 Suicidal Acts Suicidal Acts in Nuremberg and Wuerzburg % % % 420 Chi² (one-tailed): 2000 vs 2001; P < vs 2002; P < vs 2003; P < % % % Nuremberg 2001 Wuerzburg Hegerl U, et al. Psychol Med. 2006;36(9): Hegerl U, et al. Eur Arch Psychiatry Clin Neurosci. 2010;260(5):

15 Changes in Rates of Attempted Suicides (%) Impact was Greater on More Lethal Suicide Attempts Baseline (2000) vs Intervention (mean: 2001/2002) High-Risk Methods 72 vs 34 ASs (-53%) Low-Risk Methods 400 vs 340 ASs (-15%) -60 chi² = 7.23 (P <.01; 2-tailed) AS = attempted suicide. Hegerl U, et al. Psychol Med. 2006;36(9): Hegerl U, et al. Eur Arch Psychiatry Clin Neurosci. 2010;260(5):

16 Principles of Management of the Suicidal Patient Evaluation of suicide risk and psychiatric diagnosis. Treatment of the psychiatric disorder. Resolution of psychosocial crisis. Elevation of the threshold for suicidal behavior by medication and/or psychotherapy. Remove the means for suicide. Calibrate supervision of the patient during the acute suicide risk crisis period.

17 Evaluation of Suicide Risk Past history of suicide attempt or family history of suicide attempt. Get details of planning, method and medical damage because lethality tends to escalate. Current ideation is best short-term predictor. A plan with a specific method is more serious. Most severe ideation in last two weeks is more important than day to day fluctuations. Look for consistent improvement. For longer-term risk assess worst lifetime ideation and attempt lethality.

18 Where Does Neurobiology Fit In? Psychiatric illnesses involve brain biology. The diathesis or vulnerability to suicidal behavior involves different brain biology. Parts of the brain biology related to components of diathesis such as aggression/impulsivity, suicide intent or hopelessness have been identified.

19 Stress Diathesis Model of Suicidal Behavior Mann, Nature Neuroscience Reviews, 2003

20 Serotonergic Activity is Related to Decision-Making, Major Depressive Episodes and thereby Suicidal Behavior There is a trait deficiency of serotonin function proportional to seriousness of past and future suicidal acts such that it predicts future suicide. Low serotonin is proportional to seriousness of externally directed aggression and can predict future aggression. Low serotonin function modulates the intent and impulsive aspects of both suicidal and aggressive behavior predisposition via decision-making. Low serotonin trait affects suicide risk because it is also associated with major depressive episodes.

21 Low Norepinephrine Predicts Risk of Future Suicide Attempts Hopelessness predicts future suicide. Suicide attempters feel more hopeless and perceive fewer reasons for living than other patients in the face of equivalent psychiatric illness or adverse life events. Inescapable restraint in rats depletes norepinephrine and can generate despair and giving up. Suicide victims have evidence of marked stress responses in the brain norepinephrine system. Low NE turnover predicts risk and lethality of future suicide attempts

22 Hypothalamic Pituitary Adrenal (HPA) Axis Higher cortisol levels after suppression by dexamethasone in major depression conveys 4+ greater fold increase in risk for suicide. May be related to stress sensitivity and mood regulation and thereby results in unstable or treatment resistant mood disorder. Cortisol also affects cognition and thereby problem solving.

23 Mapping the Pathobiology of Major Depression and Suicide Diathesis in the Brain This approach tells us what parts of the brain is involved in the pathobiology of depression and the predisposition for suicide.

24 Serotonin System Dysfunction: independent correlations with suicidal behavior and depression Deficient serotonergic neurotransmission has been hypothesized as a cause of major depression for 30 years. Depression is a complex disorder and involves many brain regions. Deficient serotonergic function is also associated with suicidal behavior. Suicidal behavior involves a basic decision regarding life or death, likely involving a small part of the brain.

25 Serotonin transporter binding in postmortem prefrontal cortex is an index of serotonin activity

26 Postmortem Serotonin Transporter Binding in Suicide and Depression Suicide (n=45) 9 8 Major Depression (n=33) Decreases Arango et al., Progress Brain Res., 2002

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28 Low Serotonin Transporter Binding in MDD Suicide Attempters controls MDD nonattempters MDD nonattempters MDD attempters Miller et al (2013)

29 The Future Better prediction of risk. Treat more people with psychiatric illness. Develop medication and psychotherapeutic interventions to reduce predisposition to suicidal behavior. Prevention by reducing familial transmission of predisposition to suicidal behavior.