Psychiatry & Psychotherapy Podcast - Suicide Epidemiology, Risk Factors, and Treatments

Episode Date: August 3, 2019

On this week's episode of the podcast, I interview Jaeger Ackerman, 4th year medical student about suicide risk factors and treatments. As a therapist, attempt to closely approximate their reality of feeling suicidal with words. When I first hear their thoughts and feelings, I try to clarify with the patient to make sure I'm understanding their feelings. I usually try to put it into other words, and echo back to them. I'll say something like, "I hear that you feel like there's no other way out, that you feel lost and like it's a very dark time for you." I ask myself continually how to be present with them in their feelings, in the moment. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel

Hello and welcome to the psychiatry and psychotherapy podcast with over 32,000 mental health professionals listening in every episode. Why? Because we need to stick together to survive the mental health field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. Welcome back to the podcast. Before I bring in Jagger Ackerman, who is a fourth-year medical student, who did a really good job digging into a ton of studies for this episode on suicide. I'd like to say a little bit about treating people with suicide. You know, as a psychiatrist, as a therapist, I attempt to closely approximate the reality of someone's experience. And I try to put that into words as closely as I can.

When you first hear someone's suicidal thoughts and feelings, I like to clarify and make sure I'm understanding them and make sure that they're feeling understood. I usually try to put it into words, echo back to them, try to say something like, hey, I hear you feel that there's no way out, that you feel lost, and that it's like a very dark time for you. And I just want you to know that I hear that you feel like there's a desperation in how you feel. And I ask myself continually, how can I be present with them in the midst of their despair?

I often hear some people say they feel uncomfortable putting it so strongly. They want to soften it. They want to initially say to someone like, oh, there's so much life to live for, you shouldn't feel suicidal, you know, and that's really like the opposite of empathy. So it's not going to, it's not going to worsen their suicidality to empathize with them. In reality, feeling heard, feeling understood, can meet them where they're at. So although we may be hesitant to use words that would communicate how dark their desire is, we are not agreeing with them by empathizing with them. And instead, they'll feel like someone at least understands them and maybe can tolerate being with them in that dark place. It creates an empathic connection. And we know that empathy will always

lead to better outcomes. The therapeutic lines, empathy, by and large, cross the board will lead to better outcomes. So if we want to help them, sometimes we have to start with empathy. You know, I also try to move into eventually a place of hope. You know, a little hope. I try to give them a little hope.

I might say something like, hey, I know you feel like you've exhausted all, you know, a lot of things that you've tried. I feel like as a psychiatrist in my perspective, we might not have exhausted all the opportunities to make you feel better. And there's a path that I've seen other people take who are in this dark place. And then I watch, see how they react. If they react with a little bit of like, oh, okay, maybe there's a little confidence that I can have in this professional, you know, to help guide me.

maybe there's some things that we haven't tried, that can be helpful. If they feel less heard, you know, I might come back to more empathy and just sit with them in that place. In reality, I have seen people come back from places that I didn't think possible. I've seen people who, you know, the first or second time I met with them or maybe even the fifth time, I would go home and I would have nightmares. I would think, how is this person not going to kill themselves? And as I stuck with it with that person, I was able to see them do the work necessary to overcome incredible amounts of trauma, incredible amounts of genetic loading that would have predicted

suicide. I've seen people overcome incredible stresses and hardships and struggles. And sometimes, you know, the journey is a couple year journey. You know, sometimes it takes a couple years. Sometimes it takes like a partial or a day treatment program. Sometimes it takes treatments like ECT or like the higher level treatments that are more like for the severe, severe cases. So in this podcast, we are going to start a series on suicide. And I thought it would be really important to go through the epidemiology of suicide, the different risk factors and the different diseases and the rates of suicide.

and I want it to also give providers a sense of meaning and purpose in what they do. You know, I always kind of joking around, tell my staff, hey, saving lives today. You know, they're just answering phone calls. They don't get it. And then I'll say, no, I want you to know that really, I think the work that you are doing is saving lives. And that's what we're in the business of in psychiatry, a psychotherapy. We're in the business of saving lives using the best evidence that we know.

know how, you know, and remember, one of the best evidence is empathy, therapeutic alliance, connecting. And so, no matter what treatment we're doing, that's going to be the foundation. So in this, in this episode, we're going to do a deep dive into the epidemiology and the risk factors. And, you know, we're going to talk a lot about statistics and things we know, things that we have learned from the literature. We're going to go through about 20 plus studies. And in the blog and in the resource library, I'll have all. those citations if you want to dig deeper into it. And so my hope would be twofold. One is that through this, you would have increased empathy and increased knowledge, increased wisdom, but also I would

hope that you would have increased meaning, you know, in that what we're really doing, even if it seems like just your average Joe, you know, OCD or depression, what we are really doing is we're trying to prevent as many deaths as possible and improve the quality of life and help people come to a place of thriving, you know? With some patients, like, I just had a patient today. He's like, he's out of his depression. He's no longer having nightmares. He's no longer waking in a panic. But it's like, okay, now it's time to do the hard work of building a life worth living, right? Building a life where he's going on dates with his wife, where he's connecting well with his kids, where he's enjoying deep friendships, you know, all of these things that were sort of not there, the positive things.

And through therapy, we're starting to sort of build that foundation of creating a life with living. And I think it's so important as mental health professionals to remind ourselves of why we show up to work every day. And part of the reason is because we want to see people improve and move not only out of depression, not only out of suicide, but into thriving. into finding meaningful, meaningful work, meaningful relationships, meaningful hobbies, and maybe even generativity, you know. So, all right, let's begin. So let's talk about the epidemiology of suicide.

It is the 10th most common cause of death in adults. And who is that the biggest risk factor for this? So it's especially concerning in people between the age of 15 and 24. It's actually the second leading cause of death in this age range. In the United States in particular, it accounts for over 45,000 suicides per year, which comes out to about 11 per 100,000 individuals. And it's actually a geographic preference, too. Suicide rates tend to be higher in the Western United States than they do in the Mid-Atlantic states. Internationally, there's a higher prevalence in central and eastern European countries, particularly Scandinavian Hungary.

And it's lower in countries with Catholic or Muslim populations. So you actually see much lower rates in countries in Latin America in the Middle East. Yeah, so it's 11 per 100,000 per year in the United States. In the European countries, it's 27 per 100,000. And in the lower countries, the Catholic countries, the Muslim countries, it's 6.5 per 100,000. Does it peak seasonally? There is a seasonal peak. it's somewhat bimodal with a peak that's greatest in the late spring, but there's also a secondary

peak in the fall as well. Economic factors play into this. We actually saw the highest rates during the Great Depression and tend to see lower rates during times of war. So when there's economic crises, when there's poverty, that plays into the suicidality. Yeah, and we find that people who are younger than 30 are more likely to have substance use disorder and antisocial personality disorder and people greater than 30 who commit suicide are more likely to have a mood disorder. Let's go through some of the risk factors, especially like the sad person. Yeah, so there's this really great mnemonic to help remember some of the most significant risk factors. Sad persons, it stands for sex, age, depression, a prior history, ethanol abuse, rational abuse, rational

thinking loss, support system loss, organized plan, meaning they have a plan in place for how they would carry out the attempt, no significant other sickness, and then as one last caveat that we added in access to guns, and we'll go through each of those as well. Okay. So with sex, males are actually four times more successful than women at completing suicide, and women make three times more attempts. So about two-thirds of completers are actually male. Right. And there's there's a couple of different thoughts that go into that of why are the completers more often male, whereas the attemptors are more often female. Yeah, what did you find? One one big thought behind it is impulsivity. Studies have showed higher levels of impulsivity in males, and women on the other hand

are more punishment sensitive. So that kind of plays into this concept of who's going to be the higher risk for a completer. Men also showed higher sensation seeking on questionnaire measures and on behavioral risk-taking tasks, which implies a higher level of impulsivity, which could lead to further completion rates. Substance abuse is another factor that plays into this gender difference. Men are much more likely to have drunk alcohol in the hours prior to suicide. And there's even a difference in methodology. Firearms are the most common method used for suicide completion, both in males and females, but the rate is much higher in males. It's actually a 56% firearm use in males.

This difference is equatable internationally. Similar rates of firearm use in males in the United States. In the United Kingdom, there's high rates of violent methodology, hanging, strangulation, suffocation, whereas females are more likely to use poisoning as an attempt. And even when firearms are used, there's actually a different in methodology of where the gunshot is located. Women are actually less likely to shoot themselves in the head compared to men.

And there's this thought out there that there's more of a concern in females for avoidance of facial disfiguration. Yeah, and so sad, that was the sex. So the next one is age. So what do we know about age and suicide? With age and suicide, there's a bimodal distribution as well. The highest frequency is among 15 to 24-year-olds, but there's another peak in individuals over the age of 75, and this is especially significant in males. So S-A-D, sad, so D for depression, for people who are depressed, how much of a greater risk do they have than the general population? It's actually quite significant, up to 20 times greater risk than the general population.

and this risk is beyond just depression, all the different mood disorders, bipolar, schizophrenia, I think we'll get into those rates later, but each of those have a higher rates of suicidality as well. So sad person. So P is for prior history. P is a prior history. This is one of the highest risk groups. If they've made an attempt before, actually 80% of completed suicide attempts were preceded by a prior attempt that was non-lethal. Yeah. And person P.E., so ethanol abuse. Ethanol abuse. I think we'll get into those statistics a little bit more later, but the alcohol use, other drug use, really plays a significant factor into suicidality. Yeah, I think it really decreases the sort of inhibitions.

Absolutely. And increases impulsivity as well. Increases depression, increases irrational thinking. And that leads us to rational thinking. So sad person, P-E-R, so rational thinking loss. Yeah, and this part of it can be related to substances. Part of it can be related to delirium or decreasing censorium in the elderly, and even episodes of depression,

episodes of physical illness all contributing to decreased rational thinking. Person P-E-R-S, so S is for social support system. So what are the types of social support system issues that people who commit to? people who commit suicide have. Yeah, and this is a huge topic, and I think one we'll get into on a later podcast, but you think of your romantic relationships, or when individuals go through divorce or become widowed, having the death of a relative or a spouse,

and just isolation in general. These are all concepts of how our support system kind of being eroded in a way that's maladaptive. Yeah, and we'll get into this a little bit, but there's perceived isolation and then there's actual isolation. So a lot of people are depressed who have mental illness, they perceive that they're a whole lot more isolated than they actually are. But then also people who are very depressed and the final common pathway, I think, is to isolate actually and to sort of withdraw from people.

Anything else you want to say on that right now? Not for now. It really is a lot to unpack. There's so much data out there about isolation, connection, and its relationship to suicide. But I think that would be for another day. Okay, we'll see if we can get to it later in the show. So the sad person, P-E-R-S-O, so organized plan.

Tell me a little bit about that. So organized plan. There can be conceptualized two different categories of suicide attemptors. Think on one extreme is the individual who goes to a motel, doesn't tell anybody how they get. got there, Uber's there, has a loaded gun, and has a suicide note already written. That's somebody who really has an organized plan in place. Compare that to the individual who, on a whim, goes into their parents' cabinet,

takes out whatever medications are on the shelf and attempts to overdose on pills after getting into an argument with their mom or dad. So on one end, you have somebody who is very organized and methodical in the plan of how they're going to complete suicide, and the other is a little bit more sporadic and on a whim. The individual has a plan in place is much more likely to complete it. Yeah. The organized plan is something I always ask when I ask someone about suicide.

It doesn't hurt to ask. It's actually good. And you want to know, like, how much thought have they put into this? Have they been researching? Have they been writing letters, giving things away? Those are really strong indicators that this person needs intervention quickly. So sad person, P-R-S-O-N. So N, no significant other.

Tell me about this one. This one is somewhat similar to the support system loss. But again, significant others consider your spouse, parents, children, really anyone in your life who is a relational anchor. without that significant other, we find that people who are more isolated, socially isolated from a familial connection have much higher rates of suicide.

Yeah. And, you know, this is why I think therapy is partially so important. It's because therapy can provide a person that they connect with on a regular basis that's a bridge to developing other connections outside of therapy. So sad persons, persons, S, being sickness. So tell me, a little bit about what you found about people who suffer from chronic medical issues.

Yeah, so serious physical illness is, it does play a significant role in suicidality. About 5% of suicide completers have physical illness at the time of suicide. Some of the big contributors that we need to be on the lookout for as professionals is traumatic brain injury, epilepsy, MS, multiple sclerosis, Huntington's, Parkinson's, and really big categories of cancer and AIDS. These two chronic illnesses are very debilitating. A lot of patients become depressed and are at a higher suicide risk.

And then the one that we kind of added was access to guns. And that's a question I always ask every patient, do you have guns at home? Are they locked up? Do you have access to them? What have we found about that in the U.S.? Yeah, the reason why we wanted to include this is more than half of completed suicides in the U.S. are by firearms.

This is different internationally, I believe, in other countries just because there's lower access. The most common cause is by hanging. But in the United States, we have such a prevalence of easy access to firearms that that is actually such a huge percentage of how suicides are completed here. Especially by men. Especially by men. And coming back to that statistic. which I think it's pretty stark. You know, two-thirds of suicide completers are male

and a large majority of those by guns. Okay, let's get into some of the different psychiatric illnesses. We're going to do a deep dive into risk factors for suicide and such. So let's talk about mood disorders, specifically, you know, what percentage of suicide completers had a major psychological disorder at the time of suicide. So this is, I don't know if this is surprising or unsurprising, but it's actually 90%. And at the time of suicide itself, over half of individuals who complete suicide were clinically

depressed. Yeah. So it's quite staggering. Depression accounts for, so about 10 to 15% of patients who have been hospitalized for depression will commit suicide. Again, going back to that, that 1% of individual. in the United States will commit suicide. In depressed individuals, it jumps up to 10 to 15%.

So we talked about kind of looking at two different types of depression, melancholic and catatonic. What did you find with the melancholic depression? So just to give a definition of melancholic depression from the DSM-5, it's considered either loss of pleasure in all or almost all activities or lack of reactivity to usually pleasurable stimuli, plus three or more of the following, either a distinct quality of depressed mood characterized by profound despondency or despair, depression that is regularly worse in the morning, early morning awakening, marked psychomotor, agitation,

or retardation, significant anorexia or weight loss, and excessive or inappropriate guilt. So this subtype of depression, melancholic, it's more common in the inpatient setting. and actually this clustering of symptoms, it can actually be predictive of a good response to antidepressants or to electroconvulsive therapy. So if you see this melancholic depression, there's good evidence that they'll respond to treatment. Yeah, so this is lack of pleasure, early morning awakenings,

and then sometimes they have this pretty significant anxiety in the early morning awakenings, and they also have the weight loss. And you want to kind of differentiate this in your mind from someone who's chronically suicidal, like someone who struggles with maybe borderline personality disorder. So the two big categories is the melancholics and the people with a lot of trauma, borderline personality disorder that are in the hospital. Those are the main two categories that I kind of differentiate in my mind.

And this melancholic type, they won't snap out of it as quickly. And there'll be a little bit more guarded about a plan. And you kind of, you know, see the writing on the wall, especially if they've had like 50 pounds of weight loss. You know, always roll out other medical causes, of course, because that can be making it a lot worse, like pancreatic cancer or some type of cancer. Sure.

But yeah, I always think melancholics, especially the severe melancholics, you know, are they still super anxious on the day of discharge? They should not be discharged, even if the insurance company is trying to push them out. if they're still waking up with that severe, severe anxiety, it's a huge risk factor. We'll get more to that.

Okay, the second type is the catatonic. So tell me a little bit about the catatonic depressed patient. So catatonia, I saw this once on the inpatient setting, and when you see it, it's a little unsettling. I see one catatonic every time I round on a weekend. So when I go in on a weekend, I'll see 30 to 40 patients, which is not ideal, but that's how busy we are. And I have a team, by the way, that I'm seeing those patients with.

So I have like three or four residents. And I'll usually catch one. So think about like out of a big psychiatric hospital, you probably have one or two that have catatonia. Sure. Okay, so what are the symptoms that are common with this type of person? So in the DSM-5, this subtype is defined by the presence of three or more of 12 specific psychomotor features.

And these features include stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, stereotypy, agitation, grimacing, ecolalia, echopraxia. And the waxy flexibility, it's this kind of idea

where you can actually place the individual's limb in a position and it'll just stay there. The echolalia and echopraxia can be quite unusual as well. They will repeat words that you say or repeat actions that you use, but it's entirely taken out of context

and it's just this repetitive pattern that persists. Yeah, so you'd be like, how are you doing today? And they'll be like, how are you doing today? And then you ask another question, and they say, how are you doing today? So sometimes they'll even repeat themselves like after you've asked another question, and that's kind of the big eye opener to me.

I often feel like they have a lot of anxiety. So deep down inside, I've talked about that before. These patients definitely have increased mortality. And they also have risk factors for malnutrition, exhaustion. I've had patients with catatonia who stopped drinking. So they just lose the drive to drink water. Yeah. So then their blood pressure, this one patient outpatient,

he came into my outpatient with a blood pressure of like 80 over 50. And I was like, what the heck is going on in this guy? And his wife, like, I just can't get him to drink anything. And that's what I knew I needed to get this guy into ECT because he had lost like 50 pounds. He was severely, he had a lot of stupor. And he had this just kind of like vacant look in his face. Yeah. And it's difficult to work with because I remember the reason we had the patient, inpatient in the hospital,

this was not on a psychiatric unit was because they're often so medically unstable that they can't often go to psychiatric units before they're medically cleared, but the catatonia itself needs to be addressed psychiatrically. So it's almost this catch-22. Yeah, and so sometimes you see these patients first in the C&L team where they're like,

okay, like this guy came in, you know, he hadn't been eating, he has been drinking, he's lost a lot of weight, and he's not really interacting. he's not with the world like what the heck is going on you know um so that sometimes we'll see this guy in like a cnl team and then you know from their eCT or like high doses of adivan is the way to go and sometimes that you know we give like two milligrams of iam adivan and instead of like making this person sedated it'll like bring them out of the catatonia for a little bit

so that's that's kind of the um diagnostic features for my myself when I'm seeing them. And something I always try to like, okay, let's get the medical students to see him before. Let's check muscle tone because it's rigid. And then let's give the ad of end and let's see what happens after. And it's like, it's a stark difference. It's a lot of fun to see that sort of come back to reality type of thing real quick. Okay.

So the third sort of feature that we wanted to touch base on is the anxious distress. Yeah. So anxious distress is. is often found in patients with depression. It's associated with a higher suicide risk, longer duration of illness, and greater likelihood of non-responsive treatment as well. One study that I looked at in particularly was assessing anxiety sensitivity. This is really the fear of anxiety, even the fear of having anxiety-related symptoms.

And this was associated with a small to moderate increase in suicide ideation and suicide risk for attempt with significant P values. Yeah, so anxiety is something that we can actually change quickly. So if someone comes into the psychiatric hospital, sometimes on the day of discharge, they still are having passive suicidal thoughts, they're still having maybe fleeting suicidal thoughts,

but we don't want them to leave with anxiety. So if on the day of discharge in your note, it says patient has high anxiety, very worried, pacing the hall, that's where if this person, person commits suicide, there may be a malpractice claim that comes up afterwards. And so we always want to address the anxiety in the acute setting and fight for days to get that under control. Definitely. Okay, the last type is atypical features. Yeah, just to round out the different

subtypes of depression. Atypical features, you see weight gain rather than weight loss, hypersominy, where they're actually sleeping more rather than sleeping less. And they still have mood reactivity. So mood reactivity meaning that if a positive event happens, they can respond to that with joy. They can respond to a child's birthday party and recall that it made them happy. There's also this leaden paralysis

where it's just feeling like you're like a lead pipe, really, stiff, non-flexible, really just a decreased movement overall. And while they have mood reactivity, they also have strong rejection sensitivity. And this is the other side of the emotional spectrum where they respond to slights very acutely. They'll respond as if one small slight is the biggest personal attack that has ever happened to them. Good.

Yeah. And so thinking about the different features of the depression, thinking about, you know, all of these different types have. of risks for suicide and how do we get the most effective treatment possible. So let's move into bipolar. So I think the couple really significant suicide attempts that I've seen where it didn't end up in completion, a couple of these patients that come to my mind immediately had a manic episode and sometimes a first manic episode.

And one in particular, it's like we didn't even know it until she was in my treatment program. And a couple months in, she got manic, hyperverbal, talkative, was making cookies every night to like two in the morning. And I was like, oh my gosh, we didn't catch it because she had shot herself in the head. And she had, it didn't go through her brain, luckily. but she was sedated after with propofal, with she was on a ventilator for days. And so that allowed us to not see a clear picture of this person having a manic episode.

Wow. Because it actually was the treatment for the manic episode, the heavy mood stabilizers that led to her being a sedation. So we didn't see the manic episode until months later. Yeah. And when she had attempted the suicide, was that during a manic or a depressive episode? During a manic.

So one of my statements for true bipolar is that they end in a hospitalization, a jail, or a suicide attempt. And so tell me a little bit about the rates of suicide and what you found for this population. Right. So rates for suicide and major depression are higher than general population, but they're even higher, actually, in bipolar patients. One study found that bipolar rates were up to close to 30% for attempts and just under 20% for actual completed suicide in patients with bipolar. Not uncommonly, episodes of mania are followed by episodes of depression. So there's really two times of risk where the suicide attempt can happen, either during the episode of acute mania itself or even following the mania when a patient becomes remorsefully aware of the inappropriate behavior and the fallout from that. that patients who have gone on these big binges or who have become hypersexual,

maybe did something they regret. Or just think about it like this. Like when your brain is elevated like that for days, weeks, they crash. And it's a sensorium issue as well as what looks like depression. And yeah, there's incredible guilt. There's incredible sadness, despair, you know, wanting to stay in bed all day.

and you know, I see this. And so they're at risk both for when they're manic and for when they're in this sort of depression. So, yeah, anything else you found about bipolar you wanted to mention? A couple of thoughts. There is bipolar type 1 and there's bipolar type 2. There have been found to be a greater number of attempts and suicide completion, especially the violent subtype

in type 1, biopolar type 1, bipolar. Rapid cycling actually is a greater risk factor for suicide attempts as well. This is when patients are identified to have at least four major depressive manic, hypomanic, or mixed episodes in a 12-month period. So they're cycling back and forth quite rapidly. Yeah. And sometimes I think we, sometimes, you know, rapid cycling, it's hard to differentiate. Is it really rapid cycling bipolar or is this someone with like borderline personality disorder with chronic suicidality dating back to their adolescence history of binging purging, you know, self-harm? And some people with borderline personality disorder will have these sort of rapid cycles of mood as well. And you know, they'll do

self-harm and I think we're going to get to borderline personality disorder in a little bit. Yeah, definitely. Let's jump to schizophrenia. So how often will someone with schizophrenia attempt and how often will they commit suicide? It's actually up to 50% will attempt suicide. So half of all schizophrenics at some time in their life will attempt suicide, with 10% actually committing the act and leading to death. What are some of the risk factors for someone with schizophrenia? Being male, young males, less than 30, unemployment,

having a chronic course of disease that's unrelenting, unremitting, history of prior depression, substance abuse, and especially high-risk state is in being recently discharged from the hospital. Yeah. And it's so important when they're discharged to get connected to an outpatient team. Often when people with schizophrenia are discharged, they stop their meds. They don't follow up, and they sort of regress back into the second. and so that's an issue.

I also wanted you to look at acesia, specifically with risk of suicide. What did you find with acesia? Yeah, so acethesia, I know it's something that is very important to you. It's something that you've seen and tried to address in many of your patients. It's been identified as an independent risk factor in patients, and it's often secondary to actually the antipsychotic treatment that professionals are prescribing. So it's this restlessness, this agitation, this need to move and just feeling incredible unrest.

And looking through the literature, there have been multiple case reports of impulsive suicide attempts associated with acesia that resolve when the acesia is treated. So it was really quite incredible to see there were these patients who had, they were schizophrenic, but had never had any suicide attempt in their life. were treated with antipsychotics, the schizophrenia was reduced, but they developed this acesia and became suicidal secondary to that. Yeah. And this is why I'm so passionate about it

because I feel like if, I feel like if I can convince everyone to continually assess, if they're doing inpatient psychiatry, especially, you know, does this person have aceshesia? If they're doing outpatient psychiatry, you know, there's got to be some way for the patient to reach you if,

and you have to warn them that, hey, we're trying this new med, if it makes you more anxious, if you feel incredibly restless, like feel free to get a hold of me that day and have some way of doing that. Because it's another thing that actually is a risk factor for a malpractice case. Like if you're putting in your last note

on the day of discharge, like, or if the nurses have documented like this person's restless, they're pacing the hallway, you know, they're saying they're internally restless, externally restless, and you didn't address the accusation. like that and then they commit suicide, that puts you at huge risk.

So it's something that we wanna continually monitor when we're starting antipsychotics. It is horrible, horrible feeling. And we'll talk more about that in the future and I have talked about in the past. So just remember if they have aceshesia, one, can you reduce the dose? Can you try a different medication?

Propanelol, remoron, you know, mertazepine, and clonopin are the three treatments, if you have to have them on that medication in particular. All right, let's go into OCD. So what did you find about suicidality and someone with obsessive-compulsive disorder? So there was this really nice med analysis done in 2018. Large sample size, good evidence,

showed a mean rate of lifetime suicide attempts close to 14.25% and suicide ideation close to 44% Yeah, and honestly, someone with just pure OCD, they're less likely to be the one that comes into the hospital. They're less likely to seek treatment early on. And yet, look, these people do commit suicide. They're at higher risk. So, you know, being able to develop a strong therapeutic alliance is so crucial, especially people with schizophrenia and OCD,

because they will be more likely to actually follow through with treatment. for some reason I I find that in general people with OCD and schizophrenia have a harder time like especially early on getting on board with treatment both psychotherapy

and good psychopharm so with OCD you know I'm thinking clomopramine it's it's the best you know in terms of the number needed to treat it's better than Prozac probably number two I'm thinking prozac

and you start low and go slow and get them onto a higher dose for the antidepressing since it's, you know, SSRIs, usually the dose is higher than what you normally give. So with Prozac, it's not just 40, it's 60 or 80. But that being said, you know, if you bring them up too fast, it can make them even more anxious. And so it's like when you're getting a history of someone with really bad OCD and what

they've tried before, a lot of times they've tried things, but it was brought up too fast, or they didn't understand it would make things worse. And so there's a lot of nuance in getting someone to the right. dose and keeping them there for long enough for them to actually have their OCD reduced because it does take six or more weeks for the treatment to actually work. So you have to get them onto a dose and hold them there. So episode coming up on OCD, look forward to it. Okay, next up, we'll start with some personality disorders, borderline personality disorder. This is the most frequent personality disorder. There's a saying that inpatient psychiatry, borderline personality disorder

until proven otherwise with 15 to 50% of psychiatric patients in the inpatient setting having borderline personality disorder, about 11% meeting outpatient, 11% of outpatients having this disorder. So what are some of the common things that we see in this disorder and how much of a risk factor is suicide? Right. So specifically pertaining to suicide, self-mutilating behavior is a very common phenomenon in borderline personality disorder. It occurs in about 50 to 80% of cases and it's frequently repetitive. In fact, more than 41% of borderlines will have more than 50 self-mutilations in their lifetime. These are actions such as cutting, bruising, burning, and biting themselves. The suicide rate in borderline personality disorder is between 5 and 10% percent. percent of borderlines. And the relationship between self-mutilating behavior and suicide risk is somewhat contentious. Some will suggest that this self-mutilation is actually a protective factor against suicide insofar as the cutting, for example, produces a relief, escape, or

sensation of living again. However, in general, most authors will still consider self-mutilating behavior to be a risk factor for eventual completed suicide. And one study by Umay and Friedman in 2008 noted that borderline patients with a history of self-mutilation have about twice the rate of suicide as those without. Yeah. And it's possible that sometimes, you know, you hit a big artery. You may not have planned to kill yourself. Sure. But, you know, things happen. So I think it's always, my mind a risk factor for suicide because, you know, people don't know what's going to happen after they cut themselves. So let's go into primary psychopathy. So what you mentioned earlier, or we mentioned earlier, that if you're younger than 30, you're at increased risk of suicide,

if you have antisocial personality disorder especially and drugs. So what do we know about primary psychopathy and then what do we know about antisocial personality disorder? So as far as primary psychopathy to begin with, there was a study done that assessed kind of the relationship between, it's called the PCLR, it's the psychopathy checklist revised, and it's this checklist that's used for assessing psychopathy antisocial personality disorder. They found that there was a significant positive relationship between total PCR scores and a history of suicide attempts in this study by Veronica. and Patrick done in 2001. Now, the correlation is only, like, 0.11. It is 0.11, but it does have statistic significance. So there's, I would call it a statistically significant, moderate increased risk.

Okay. And then the odds ratio is, what, 2.12? Yeah, so this was specifically, they looked at one subset of the PCLR scores. It's subcomponent F2, looking specifically at antisocial deviance behavior. and when you're just assessing that component of the score, there's a significant odds ratio of 2.12. Okay, now, you know, primary psychopathy, low affective empathy, normal cognitive empathy.

And, you know, they, in the previous episode, Dr. Cummings, we go through some of the neurological differences, they have different issues with BDNF. But it's a little bit different, as a construct than antisocial personality disorder. So what have you found about antisocial personality disorder specifically? Specifically to risk for suicide, the DSM-5 goes out of its way to make the point that individuals with antisocial personality disorder are more likely than members of the general population to die by violent means, and that's including both homicide and suicide as far as violent means.

specifically the suicide rate in antisocial personality disorder is found to be had an attempt rate of around 11% and a completion rate of close to 5%. There was a study that was conducted specifically on inmates. This is actually the same study we referenced for primary psychopathy, but inmates with antisocial personality disorder diagnosis were found to be more likely to have a history of suicidal behavior than inmates without. And this was with a Chai squared score of 5.93 and a p value of less than 0.05 in that study. Okay, let's move on to substance use disorder. So lifetime risk of a suicide attempt in alcohol dependence is estimated at 7%. And if they have current substance use disorder, it increases the suicidal risk, especially among women. Tell me about that a little bit.

So I think there's a couple studies we'll get into a little later. I can reference down to a veteran study that was done in 2005, really highlighting the significance of this suicide risk and substance use in women. So in 2005, there was this massive study that was done using the Veterans Health Administration data. They had a cohort of 9,087 individuals who committed suicide. And they were looking at specific hazard ratios and risk risk. ratios of substance use between males and females. So it's important to note that in this cohort, there was a suicide rate of 75.6 per 100,000 among substance users. Going back, remember, the general population that we referenced at the beginning of the episode, only 11 and 100,000. So this is about seven times greater. Yeah, that's really significant. Now, it's also important to note that in this study, there was also about a rate of 34.7 suicides. per 100,000 among veterans in general. So just being in that population of a veteran places you had an increased risk.

But having that substance use on board is significantly higher risk. Yeah, so just think about like all veterans have about three times the risk as the general population and seven times the risk if they're using substances. So one of the big things to think about whenever you are treating this population is, okay, number one, how do I help them get off of substances? and then treat underlying PTSD or depression or anxiety, that kind of stuff as well. So tell me about this Quebec study that we looked at. So in the Quebec study, this was a cohort of over 6,500 patients in Quebec, Canada.

They were entering treatment programs for addiction at the time. What they found was that there were rates for suicidal ideation up to 3,000, 3.3% in actual suicide attempts in close to 6% of these individuals entering treatment within the past 30 days of starting the program. So this is an important study just to recognize that that acute phase when patients are entering treatment either of their own accord or being forced into treatment by enforcement, by family, whatever situation is bringing them in. This is an incredibly high-risk group. The highest rates seen in this study were a combination of alcohol with any other drug, be it benzos, be barbiturates, opiates. It didn't matter what the second drug was. What was

most significant from the study was that a combination of alcohol with anything else seemed to be the highest risk group. Yeah. Sometimes this is because the alcohol, you know, decreases the frontal load function, makes people more impulsive, makes them not themselves, do things that are, you know, decreases the inhibitions there. And then you have like cocaine or methamphetamines or some sort of stimulant that maybe, you know, moves them into action in a way that they wouldn't have otherwise as well. So that's why that can be a really bad combo.

Also, I know from my own digging, and I'm going to have an episode coming out soon on this, is fentanyl has actually been one of the biggest culprits for accidental overdoses in this population. and it has been increasing very rapidly, and I'll get into that in a future episode. So in another study we looked at specifically, how much does substance abuse increase risk of completed suicide in general?

And the answer is like about two and a half times more than they would have otherwise. And the risk actually is quite a bit larger, for females. It's like 6.6 times more, like the hazard ratio is 6.6 compared to men, which is like 2.27. So there's something about women who are using substances where that really increases the risk, even more than men. Yeah. And going back to that veteran study, we talked about just a couple minutes ago. Specifically in women, they found that use of opiates and sedative hypnotics or anxiolytic, so benzodiazepines, barbiturates, were significant.

greater at risk for committing suicide. There was a hazard ratio of 8.2 for opiate use in women and 11.35 for hypnotic and anxiolytic use in women, which is really incredible. Yeah, and also cannabis. So marijuana for men gave them like two times the rate of suicide. And for women, it was about four times the rate of suicide. And of course, there were other drugs that they looked at as well.

For men, you know, alcohol 2.2 times more likely has a ratio. Opiates 2.3, amphetamines, 2.6. So, you know, all drugs, but especially those sedative, hypnotic, anzeoletics, like the benzodiazepines, the barbiturates, those decrease, those inhibitions and increase the depression. Well, another one of my interest is medical education, and so I've looked at this question of substance abuse and physicians, physician suicides. So tell me a little bit about what we looked at there. Yeah, so the study we're going to be talking about, this was done in 2013. They looked at over 31,000 suicide victims, of whom 203 were identified as physicians.

and they found that 27% of all suicides and physicians had one or more illicit drug or alcohol levels above 0.8%. Comparing the physician suicide rates and levels of different drug use compared to the general population was suicide, physicians were at significantly higher odds than non-physicians of having antipsychotics, benzodiazepines, or barbiturates present on toxicology. testing. I don't think they had a very big difference in terms of alcohol. No, there was actually no statistical difference relative to, for alcohol. Yeah, so this is very interesting, the antipsychotic. Physicians were even less likely to have blood alcohol levels above 0.08 in their system.

Yeah, it's, it's curious to me to look at the antipsychotic, the odds ratio was so much higher. is 28 times higher in physicians to have antipsychotics on board. And it makes me wonder, you know, where a lot of those physicians having manic episodes or whatnot or, you know, what was going on there. So we'll have to explore that in a future episode. It's difficult from this study alone to try to determine what the reason for those drugs being on board were.

You may infer whether or not it's the use of these medications, was intended to be toxic versus therapeutic. I know as physicians were better trained and educated about the toxic effects and doses for specific medications, so a strong argument could be made that the reason for these levels was intended to be a toxic overdose. Another interesting study I'm going to add in here is a 2017 study where they looked at all causes of deaths

in residence from the year of 2000 to 2014. and they found that there was only four per 100,000 person years of suicide, whereas, you know, at that age group, it's about 13 in the general population. So in general, medical residents are actually committing less suicide, which we hear a lot about how they have higher rates of burnout, high rates of depression, higher rates of suicide, especially in the first months of residence. and suicide, the suicide rate actually is the highest that first three months of residency when, you know, you're in a new place, new people, new mentors, all of these things. So it's the highest those first three months in like a three or four year program. But in general, you know, residents actually kill themselves a whole lot less than the general population.

Now, that doesn't hold true as doctors get older into their, into the later years, but at least for residency, it's a lower rate of suicide. Right. I think that's a really important point to make is that distinction between burnout and suicidality, because often it gets conflated in the news that suicide rates are higher in residence, and that's just not the case. Yeah, and I think I'll go into more nuance about probably why our scores are higher in burnout. There's a lot of nuance in how they actually test burnout. They don't really correlate burnout and the scoring of burnout with psychiatric measures very often. But how it was generally made was that they said the bottom one-third of people

who scored in this measure of burnout had burnout. And so when you think about it that way, whenever we look at any study with doctors, the consensus is there's a certain line where about 33% are below. And if you hit that line or below, then you're considered according to the mass law burnout in Victoria is burned out. But what does that actually mean? Is that clinically relevant? Is that important? Or would people score lower on that just because we're working, you know, 80 to 120 hours a week? Right. Absolutely. And we're, you know, often pulled away from our friends and our family to work as much as we do. So I'll go into a deep dive into burnout in the future. I've given lectures on that. Okay, so far we covered some of the epidemiology of it.

We covered the risk factors, sad person we went into that in detail. We talked about the different mood disorders, depression, the different subtypes of depression, bipolar, schizophrenia, OCD, personality disorders. And we talked about substance use and the importance of, you know, how substance use is really increasing the risk factors. We are going to bring this to a close today. all of these notes I'm going to be putting up as a blog on my website and a link will be in the show notes. The reason why we're putting this up is to give you guys all the citations. All of the details are there if you're curious about it. And I think we have about 23 citations so far just for this part.

So I hope you guys enjoy that. If you have any questions or thoughts, please jump onto my social media. I'll put a post about this episode. and in the future episodes we're probably going to have either a two or a three part series on this with Jagger here is we're going to go through

the genetics of suicide. We're going to go through lessons from autopsies. We're going to go through things that we can do to decrease suicide. And we'll also go through environmental factors

that contributed to suicide. Specifically with the things that we can do to decrease suicide, we'll talk about everything from medications that have been shown to decrease suicide. to different types of psychotherapy.

And really we're just getting started here. So I hope you guys have enjoyed this. If you have, send me a direct message on my social media profiles. Love to hear from you guys. I probably get one message a day, which is very encouraging, keeps me energized to make good content. So I appreciate you guys. And if you haven't already, I really do appreciate and read every review that comes in

through iTunes or Stitcher. so if you can take a moment to put in a review, I would be most grateful. Until next time.