Suicide prevention and mental illness
19 November 2012
Is Kamerow as guilty of lacking specificity and focus as the United States (US) Surgeon General he criticises (1)? "Psychiatric disorders" may be present in around 90% of people who kill themselves, but what does this actually mean?
Meta-analysis of North American psychological autopsies shows that substance misuse, present in 40%, predominates (2). However, this includes "harmful use" of substances, including binge drinking, and even simple alcohol intoxication; no sensible person would consider these phenomena psychiatric disorders.
Mental illness, such as depressive disorder (34%) and schizophrenia (4%), is represented (2), but even these figures warrant closer observation. As depressive disorder is hugely overdiagnosed in life (3), what is there to suggest the same is not true in death? Recent prescription of antidepressants to a deceased subject or retrospective reports of insomnia, lethargy and low mood from family members do not automatically equate to a true diagnosis of depressive disorder. Yet the pragmatic methodology of psychological autopsy studies dictates precisely that.
The reality is that a small minority of people who commit suicide are mentally ill. The vast majority are people encountering difficult life circumstances, to whom suicide seems a logical solution at the time; acts are often carried out impulsively and whilst intoxicated. This is borne out by the close relationship between suicide rates over the last century and international economic trends, exemplified by the recent increase in the US during the current recession (4).
We must not be complacent in the management of people who are indeed unwell, but any suicide-reduction policy targeting psychiatric or primary care services is bound to fail, as has been seen in the US. Successful policies in the United Kingdom, such as restriction of analgesic sales, have restricted access to means.
The US national suicide rate will not dramatically reduce until radical gun law is introduced. Kamerow may be waiting some time.
I remain, Madam, your obedient servant,
Dr Rich Braithwaite
1. Kamerow D. Can suicide be prevented? BMJ 2012; 345:e7557.
2. Arsenault-Lapierre G, Kim C, Turecki G. Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry 2004, 4:37 doi:10.1186/1471-244X-4-37.
3. Aragonès E, Piñol JL, Labad A. The overdiagnosis of depression in non-depressed patients in primary care. Family Practice 2006; 23:363-368. doi:10.1093/fampra/cmi120.
4. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S, Basu S. Increase in state suicide rates in the USA during economic recession. The Lancet 2012; doi:10.1016/S0140-6736(12)61910-2.
5. Hawton K, Townsend E, Deeks J, Appleby L, Gunnell D, Bennewith O, Cooper J. Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ 2001; 322:1203-7.
Competing interests: None declared
Isle of Wight NHS Trust, St Mary's Hospital, Newport, Isle of Wight PO30 5TG
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