Signature: Med Sci Monit, 2003; 9(4): SR9-19 PMID: 12709685
Received: 2002.12.11 Accepted: 2003.02.06 Published: 2003.04.23
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Toxicology of suicide: touchstone for suicide prevention? Dirk M. Dhossche Department of Psychiatry & Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, USA
Summary Background:
Systematic studies of consecutive suicides show that risk for suicide concentrates heavily in people with psychiatric illness, particularly depressive disorders and substance abuse. It is generally assumed that suicide is preventable although there is currently no conclusive evidence for efficacy of any preventive action, including use of psychotropic prescription medications. The low base-rate of suicide and ethical concerns of studying suicidal people in controlled trials of medications or psychotherapy are the two most important obstacles for progress in suicide research. No prevention suicide program currently includes routine toxicological monitoring of suicide or other violent death. The use of toxicological monitoring in suicide was examined in this study.
Material/Methods:
Review of the literature on toxicological studies of suicide, in particular of a study done in consecutive suicides in Mobile County, Alabama, between 1990–1998.
Results:
Toxicological studies in suicides support that there is undertreatment of depressive disorders in people who are at risk for suicide and that substance abuse is an important risk factor. Higher detection rates of antidepressants in recent suicide samples may indicate higher treatment rates of depression.
Conclusion:
Surveillance of psychoactive substances among suicides may be a novel and practical way to assess efficacy of selected medical interventions aimed at reducing the number of suicides. Use of toxicological monitoring in suicide should be explored in future studies.
key words: Full-text PDF: Word count: Tables: Figures: References:
Author’s address:
toxicology • suicide • prevention • monitoring • psychotropic medications
http://www.MedSciMonit.com/pub/vol_9/no_4/3339.pdf 4947 3 1 74
Dirk M. Dhossche, Department of Psychiatry & Human Behavior, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216, USA, email:
[email protected]
SR9
Special Report
Med Sci Monit, 2003; 9(4): SR9-19
BACKGROUND Suicide is tragic, rare, and controversial. Some data suggest that suicide in young people has increased in most countries over the last few decades. Ongoing efforts to decrease the number of suicide in young people are important to prevent these serious human and economic losses. It is equally true that rates of suicide increase with age, especially in men, in most countries. Unsurprisingly, a complete understanding of suicide, including its predisposing, facilitating, and protective factors, has not yet been obtained given the complexity of the phenomenon [1]. Continued efforts to study suicide and to find ways to prevent it should remain a priority. Mental illness as a risk factor for suicide Suicide often evokes strong opinions on a multitude of philosophical, cultural, religious, social, and medical issues. A paramount finding from systematic studies of consecutive suicides since the late fifties is that suicide nearly always occurs in people with psychiatric illness. The observation is crucial to link suicide as a fatal outcome of psychiatric illness. Eleven studies of consecutive suicides are summarized in Table 1. Thorough postmortem psychiatric investigations were conducted in all studies [2–12]. A psychiatric disorder was diagnosable in most suicides. Any depressive disorder was found between 47–89%, any substance use disorder between 19–51%, and schizophrenic disorder between 2–16%. No disorder was found in 0–19% of cases. Harris & Barraclough [13] have summarized the relative risk of suicide for having a mental disorder. Their findings show that virtually all mental disorders have an
increased risk of suicide except mental retardation and dementia and that suicide risk heavily concentrates in people with psychiatric disorders although the risk varies according to diagnosis. No disorder is found in a small group of suicides. In a study of adolescent suicide, the group with no apparent disorder still had more risk factors for suicide (such as family history of suicide, past suicidal behavior, legal problems) than community controls [14]. Attempted suicide as a risk factor for suicide Attempted suicide is an important risk factor for suicide. The risk for suicide was found to be 38 times higher in suicide attempters than in any specific psychiatric diagnosis, including major depression or alcoholism [13]. In a review of studies [15], it was estimated that between 0.8–2.6% of suicide attempters had committed suicide at one year follow-up. After nine years or more, the suicide rate was between 5–11 % (median of 7%). It is estimated that about 15% of those with one or more suicide attempts will eventually commit suicide [16]. More than half of suicides have no prior suicide attempts. Among 134 consecutive suicides in St. Louis in 1956–1957 [2], 78% died at their first attempt. Rate of suicide at first attempt are between 56–79% in other studies [2–12,17,18]. There was a marked sex difference in the Finnish study [18] as more males than females died at their first attempt (62% versus 38%). In 19% of males and 39% of females, a suicide attempt was reported in the final year. These findings support suicide attempts as a risk factor for suicide, but limit the hope that preventing suicide in suicide attempters, especially males, will have a major impact on the overall suicide rate. A greater effect can be expected in female suicide attempters, however.
Table 1. Psychiatric disorders among consecutive suicides in studies using psychological autopsy methods. Study Unselected cases Robins et al. Dorpat and Ripley Barraclough et al. Chynoweth et al. Rich et al. Arato et al. Cheng Age
