Suicidal Behavior Needs Long-Term Follow-Up

Article excerpt

SEATTLE -- Suicide attempt behavior is best viewed in most instances as a chronic condition embedded in long-term psychiatric illness and lifestyle problems, Annette L. Beautrais, Ph.D., asserted in her Edwin S. Shneidman Award lecture at the annual conference of the American Association of Suicidology.

This view--supported by her two large longitudinal studies, as well as by the work of others--is at odds with the short-term crisis intervention approach to suicidal behavior predominant during the past 2 decades.

Crisis intervention for suicide attempters is essential but not sufficient. The crisis intervention model has yielded little payoff in terms of suicide prevention--in fact, rates are climbing in Scandinavia, the United Kingdom, and other places where accurate figures are kept--and there is reason to believe preventive efforts based upon the concept of suicidality as a chronic condition might be more fruitful, said Dr. Beautrais of the Canterbury Suicide Project at Christchurch (New Zealand) School of Medicine.

"Currently, once those who attempt suicide are discharged from hospital after treatment for the medical consequences of their attempt, their psychiatric and social work care is at best often haphazard and nonsystematic. There are no protocols for their follow-up care, generally, and no one takes responsibility for coordinating their care," she continued.

"I think services have been unresponsive, largely because of a widely held misapprehension that suicide is an impulsive response in a single crisis situation. The evidence suggests, rather, that it's a repetitive response to ongoing life-course adversity."

Some of the most persuasive supporting evidence for this proposition comes from her landmark 5-year prospective study of 302 consecutive patients of all ages who made medically serious suicide attempts, defined as attempts requiring specialized care in an ICU, burn unit, hyperbaric chamber, or surgery under general anesthesia.

Unlike most longitudinal studies of suicidality, this one featured extensive baseline patient interviews conducted within 48 hours after the attempt. Also interviewed face-to-face were the patient's significant others, primary care physician, and mental health professional, if they had one. Follow-up interviews with patients and their primary care physician were conducted at 6, 18, 30, and 60 months.

Within 5 years, 8.9% of subjects were dead. Fifty-nine percent of deaths were by suicide, and another 15% were deemed probable suicide. This equated to a confirmed suicide rate 48 times higher than in the general New Zealand population, and a total mortality five times greater than expected. Most completed suicides involved a switch to a more highly lethal method than used in the index medically serious attempt, suggesting a hardening of intent.

By 10 years, mortality was 14.2%, with 70% of deaths from suicide or suspected suicide. Fifty-nine percent of all deaths occurred within 18 months of the index suicide attempt, although mortality remained elevated throughout the full 10 years.

The most striking study finding involved the high and enduring rates of psychopathology and psychosocial problems present throughout the first 5 years after the index suicide attempt. (See chart.)

For example, 39.8% of subjects met diagnostic criteria for a mood disorder 6 months postattempt--and this despite the fact that all patients had been thoroughly assessed at the time of their attempt and offered treatment, if appropriate. At 30 months, 23.4% of patients had a mood disorder, as did 21.7% at 5 years. And while 37.6% of patients were admitted to a psychiatric hospital within the first 6 months postattempt, nearly one-quarter of subjects had a psychiatric hospital admission during months 7-18, and one-tenth in months 31-60.

Psychosocial end points, including interpersonal, financial, employment, and legal difficulties, reflected substantial ongoing personal chaos. …