SELF HARM & SUICIDE
DEFINITIONS
Difficult to define
Deliberate self harm (DSH) and attempted suicide (Hawton & van Heeringen, 2001)
Parasuicide (Kreitman, 1977)
Self harm
Non suicidal self injury (NSSI)
People in the US think people with DSH do not show suicidal intent. Intention is very important -
dichotomous variable - either suicidal or not = NSSI added to DSM-V
In Europe, suicidal intent is seen as a continuum - people are often not sure why they intended to self
harm
Motives for DSH - only ¼ say they wish to kill themselves, others unsure, trying to escape or trying to get
someone’s attention
CAUSES?
Multidimensional malaise (Leenars 1996)
Many aspects - not one thing causing death.
A key life event may push over the edge
Psychological factors are important - psychological pain, hopelessness
Sometimes it is a rational choice for someone whose life is not worth living - plagued by depression - may
not be morally right to stop them
Serotonin? Low 5HIAA in CSF of suicidal individuals, especially in violent individuals
STATISTICS
Suicide every 79 minutes in UK, yet not much money put into it - gets neglected for other things like road
traffic accidents
In 2005, 5,671 suicides, 75% males
But probably UNDERREPORTED - has to be reported by a coroner - hard to tell. Also they resist saying
suicide to help families. Only can tell if obvious method used.
170,000 cases per year presented to hospital in UK
Top 5 cause for hospital admission for both men and women
Oxford monitoring system for attempted suicide - 1976
Now Bristol, Manchester (2-3 years of monitoring)
Increase in episodes for both males & females
More common in females - probably because more females go to hospital (suicide is more common in
males)
Bergen et al (2010) - general decrease for suicide & DSH
METHODS OF DELIBERATE SELF HARM
Most non - violent i.e. poisoning (64% of males, 80% females)
UK - paracetamol more common
, Cutting - 17% males, 9% females
Alcohol - part of method, preparation and long term risk factor
METHODS OF SUICIDE
Males more violent - most common – hanging
Females - self poisoning
INCREASES RISK OF DSH:
Psychiatric patient (current / ex) : x 10 more likely, 50% of total suicides
History of attempted suicide : x 10-30 more likely, 30-47% = most reliable predictor
Patient in 4 weeks following discharge from psychiatric hospital x 200(male), x 100 (female)
Alcoholics / drug users - 20 x more likely
Clinical factors: depression, alcoholism, SZ, personality disorders, suicidal ideation, abuse
Personal factors: family history, memory biases, hopelessness, problem solving, cognitive rigidity,
impulsivity
Social factors: availability of methods, unemployment, media reporting, social support, life events, civil
unrest
4 x higher for lowest social class, 2 or 3 x more likely if unemployed (Puri & Treasden 2010)
PREVENTION
Availability of methods:
The Coal Gas Story (Kreitman, 1976)
- Percentage of carbon monoxide (CO) in domestic gas was removed and replaced with North Sea Gas -
safe = removed popular method of suicide
- CO related deaths dramatically reduced over time
- Had a massive impact on reducing suicide rates overall
- Other methods increased slightly, but huge net reduction
- Not a deliberate intervention, did for economic reasons
Paracetamol Legislation
- Paracetamol is the most popular drug for self poisoning
- As availability increased, so did paracetamol suicides - correlation .86 - very strong relationship
- Hawton et al (1995, 1996) found availability was the main reason for choosing paracetamol.
- 41% thought about it for less than an hour - very impulsive, if drug wasn’t in house maybe they would
have changed their mind - only 31% had suicidal ideation - the other 70% didn’t actually want to kill
themselves
- September 1998 Legislation changed - from 100 tablets available in pharmacies to 32, and 16 at non
pharmacies
- Plus labelling changes to warn of dangers
- Reduces what’s available in the house - can’t stock pile - would have to go out to buy enough to kill
yourself- giving time to change your mind
- Hawton et al. (2001): in year after legislation, a reduction in: deaths from paracetamol poisoning,
admissions to liver units, transplants, reduction in the number of tablets taken
- Hawton et al. (2004): follow up 3 years on - concluded smaller pack sizes sustained beneficial effects -
decrease in deaths, transplants and size of non fatal overdoses
- Hawton et al. (2004): further reduction in pack sizes needed to prevent more deaths
DEFINITIONS
Difficult to define
Deliberate self harm (DSH) and attempted suicide (Hawton & van Heeringen, 2001)
Parasuicide (Kreitman, 1977)
Self harm
Non suicidal self injury (NSSI)
People in the US think people with DSH do not show suicidal intent. Intention is very important -
dichotomous variable - either suicidal or not = NSSI added to DSM-V
In Europe, suicidal intent is seen as a continuum - people are often not sure why they intended to self
harm
Motives for DSH - only ¼ say they wish to kill themselves, others unsure, trying to escape or trying to get
someone’s attention
CAUSES?
Multidimensional malaise (Leenars 1996)
Many aspects - not one thing causing death.
A key life event may push over the edge
Psychological factors are important - psychological pain, hopelessness
Sometimes it is a rational choice for someone whose life is not worth living - plagued by depression - may
not be morally right to stop them
Serotonin? Low 5HIAA in CSF of suicidal individuals, especially in violent individuals
STATISTICS
Suicide every 79 minutes in UK, yet not much money put into it - gets neglected for other things like road
traffic accidents
In 2005, 5,671 suicides, 75% males
But probably UNDERREPORTED - has to be reported by a coroner - hard to tell. Also they resist saying
suicide to help families. Only can tell if obvious method used.
170,000 cases per year presented to hospital in UK
Top 5 cause for hospital admission for both men and women
Oxford monitoring system for attempted suicide - 1976
Now Bristol, Manchester (2-3 years of monitoring)
Increase in episodes for both males & females
More common in females - probably because more females go to hospital (suicide is more common in
males)
Bergen et al (2010) - general decrease for suicide & DSH
METHODS OF DELIBERATE SELF HARM
Most non - violent i.e. poisoning (64% of males, 80% females)
UK - paracetamol more common
, Cutting - 17% males, 9% females
Alcohol - part of method, preparation and long term risk factor
METHODS OF SUICIDE
Males more violent - most common – hanging
Females - self poisoning
INCREASES RISK OF DSH:
Psychiatric patient (current / ex) : x 10 more likely, 50% of total suicides
History of attempted suicide : x 10-30 more likely, 30-47% = most reliable predictor
Patient in 4 weeks following discharge from psychiatric hospital x 200(male), x 100 (female)
Alcoholics / drug users - 20 x more likely
Clinical factors: depression, alcoholism, SZ, personality disorders, suicidal ideation, abuse
Personal factors: family history, memory biases, hopelessness, problem solving, cognitive rigidity,
impulsivity
Social factors: availability of methods, unemployment, media reporting, social support, life events, civil
unrest
4 x higher for lowest social class, 2 or 3 x more likely if unemployed (Puri & Treasden 2010)
PREVENTION
Availability of methods:
The Coal Gas Story (Kreitman, 1976)
- Percentage of carbon monoxide (CO) in domestic gas was removed and replaced with North Sea Gas -
safe = removed popular method of suicide
- CO related deaths dramatically reduced over time
- Had a massive impact on reducing suicide rates overall
- Other methods increased slightly, but huge net reduction
- Not a deliberate intervention, did for economic reasons
Paracetamol Legislation
- Paracetamol is the most popular drug for self poisoning
- As availability increased, so did paracetamol suicides - correlation .86 - very strong relationship
- Hawton et al (1995, 1996) found availability was the main reason for choosing paracetamol.
- 41% thought about it for less than an hour - very impulsive, if drug wasn’t in house maybe they would
have changed their mind - only 31% had suicidal ideation - the other 70% didn’t actually want to kill
themselves
- September 1998 Legislation changed - from 100 tablets available in pharmacies to 32, and 16 at non
pharmacies
- Plus labelling changes to warn of dangers
- Reduces what’s available in the house - can’t stock pile - would have to go out to buy enough to kill
yourself- giving time to change your mind
- Hawton et al. (2001): in year after legislation, a reduction in: deaths from paracetamol poisoning,
admissions to liver units, transplants, reduction in the number of tablets taken
- Hawton et al. (2004): follow up 3 years on - concluded smaller pack sizes sustained beneficial effects -
decrease in deaths, transplants and size of non fatal overdoses
- Hawton et al. (2004): further reduction in pack sizes needed to prevent more deaths
