McLean–Stanford
Webinar on Suicide20 October, 2021
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Suicide:Basic Facts
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Ross J. Baldessarini, M.D.Professor of Psychiatry & Neuroscience
Harvard Medical School, Boston[No conflicts to disclose]
0 10 20 30 40 50 60Proportion of Excess Deaths (%)
Endocrine
Accidents+Other Violence
Pulmonary
Suicide
Cardiovascular
All Medical
All Violence
Causes of Excess Mortality: Bipolar Disorder Patients
[From Osby et al. Arch Gen Psychiatry 2001; 58: 844–850]
General population suicidal risks (US)
Measure Value Ideation 3000/100k/year Attempts 500/100k/year Suicides 14/100k/year
Ideation/Attempts 6 Attempts/Suicides 36 Ideation/Suicides 214 From Kessler et al. JAMA 2005; 293:2487–2495.
Factors associated with state suicide rates (2001)
Factors in US Correlation
(r) p-value Population density –0.735 <0.001
Male sex +0.576 <0.001
Annual income/capita –0.550 <0.001
Psychiatrists/100,000 –0.544 <0.001
Native-American (%) +0.543 <0.001
Physicians/100,000 –0.528 <0.001
Federal MH aid –0.443 0.001
African-American (%) –0.430 0.002
Uninsured residents (%) +0.391 0.005 From Tondo et al.: J Clin Psychiatry 2006; 67: 517–523 (for 51 states+DC).
Risk factors for suicide ——————————————————————————————————————
n Previous suicide attempts
n Major depression or bipolar disorders n Abuse of alcohol or drugs n Losses, deaths, shame, poverty n Social isolation, unmarried n Lack of access to clinical care n Access to firearms, toxins, medicines n Soon post-hospital discharge ——————————————————————————————————————
0
5
10
15
20
25
30
35
40
45
50
55
60
65%
of L
ong-
term
Fol
low
-up
(±CI
)
BD-I BD-II All-BD UP
Total MorbidityDepression [Hypo]mania
[23 studies; n=3936]
[15 studies; n=2479]
[12 studies; n=2760]
[8 studies; n=822]
Long-Term Morbidity in Clinically Treated Mood-Disorder Patients
[From Forte et al. 2015]
[Depression = 86.4% of the 45.3% of time ill in 9.4 yrs]
% time ill
Forest plots of random-effects meta-analyses of studies of effects of A. modern drugs for psychosis otherthan clozapine (n=28 studies) or B. clozapine (CLZ; n=7) vs. suicidal acts (attempts or suicides), comparedto indicated alternative treatments. Effects of CLZ are highly significant (pooled OR = 0.229 [CI: 0.110–0.476]; z-score = 3.94. p<0.0001), but not drugs other than CLZ (OR = 0.941 [0.790–1.12]; z=0.680,p=0.497).
Antisuicidal Effects of Antipsychotic Drugs: Clozapine vs. Others
[From Forte et al. J Psychopharmacol 2021]
B. Clozapine
A. Other SGAs
0.0 0.1 1.0 10.0 100.0 1000.0Rate Ratio [RR; 95%CI]
Pooled RR
Yervanaian et al. 2007bYerevanian et al. 2007a
Collins & McFarland 2007Gonzalez-Pinto et al. 2006
Angst et al. 2005Yerevanian et al. 2003
Goodwin et al. 2003Calabrese et al. 2003
Bowden et al. 2003Rucci et al. 2002
Coryell et al. 2001Kallner et al. 2000
Brodersen et al. 2000Bauer et al. 2000
Tondo et al. 1998Coppen & Farmer 1998
Bocchetta et al. 1998Greil et al. 1996
Nilsson et al. 1995Kouopoulos et al. 1995
Sharma & Markar 1994Lenz et al. 1994
Felber & Kyber 1994Rihmer et al. 1993
Müller-Oerlinghausen et al. 1992Modestin & Schwarzenbach 1992
Nilsson &Alexsson 1990Lepifker et al. 1985
Hanus & Zapletalek 1984Vankoba-Rao et al. 1982
Ahlfors et al. 1981Poole et al. 1978
Kay & Petterson 1977Prien et al. 1974
Pooled RR [CI] 4.14 [3.02–5.67] (p<0.0001)
10 100 1000
Effects of Lithium:Suicides &Attempts
[From Baldessarini & TondoBipolar Disord 2008; 10:114–115]
[n=34 studies; N=3200 subjects]
Summary & Conclusions——————————————————————————————————————l Major mental illnesses can be fatal: suicide in younger,
with medical illnesses in older patients. l Suicide risks rising in US (declining in many other countries),
with all locales & ages.l Suicide risk: higher with BD than MDD; also high with
substance abuse. l Lethality ratio (attempt/suicides) ca. 30 in general pop.;
<10 in mood disorders. l Risk factors: prior attempt, substance abuse, mood disorder,
unresolved depression, social isolation, losses, post-hospital. l Medical treatments vs. suicide: clozapine (schizophrenia),
lithium (mood disorders). ——————————————————————————————————————