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Soldier Suicides

14 Jan, 10 | by Steven Reid, Evidence-Based Mental Health

“Of the more than 30000 people who fall to suicide nationwide each year, 20 per cent are veterans. About 18 veterans commit suicide every day”. The US Veterans Affairs Secretary, Eric Shinseki, was speaking at the 2010 Departments of Defense and Veterans Affairs Suicide Prevention Conference – it’s hard to imagine the UK Ministry of Defence holding one.

Suicide in military and ex-military personnel is attracting headlines at the moment and a cohort study of veterans of the UK Armed Forces is the subject of this month’s EBMH Editor’s Choice (free to access). In common with the new US data young men (under the age of 25) are at particular risk, notably in the first two years post-discharge. The commentary points to evidence for pre-service vulnerability as a significant risk factor. Another one, presumably, is access to means i.e. weapons.

Respecting the right to die…revisited

2 Oct, 09 | by Steven Reid, Evidence-Based Mental Health

With the recording of a narrative verdict following the inquest, the death of Kerrie Woolterton is once again making headlines. I wrote about this case of a young woman presenting with self-poisoning and refusing treatment one year ago, in a blog which attracted some thoughtful comment. The coroner stated: “She had capacity to consent to treatment which, it is more likely than not, would have prevented her death. She refused such treatment in full knowledge of the consequences and died as a result.” Sheila McLean, a Professor of Law and Medical Ethics, concurs with this view and clarifies the law in a commentary for the BMJ. She is correct, of course, in highlighting that if Ms Woolterton was thought to have capacity to make a decision about her treatment at the time of assessment the presence of an advance directive was indeed irrelevant.

Yet I still find the outcome of this case troubling. We are relying on details of events reported by the media, but given the context of this woman’s suicide would the presumption that she had capacity to decline treatment be so straightforward? Professor McLean makes the point that the presence of mental illness or indeed personality disorder is not in itself evidence of a lack of capacity. I would agree, but that does not mean they have no potential to influence or impair decision-making. Ms Woolterton had repeatedly presented after self-poisoning and would have known that treatment would be offered. That she still chose to call an ambulance to take her to hospital, albeit that she stated she was only seeking comfort and company, suggests to me a degree of ambivalence.

Key to the concept of capacity is the determination that a person understands the information relevant to a decision, and can use or weigh that information as part of the process of making the decision. As a legal concept that’s pretty clear but in a clinical setting where so many factors can be at play that determination can become murky. And of course, people often do not say what they mean or mean what they say.

In the last year I have discussed this case with a range of clinicians, and although the majority state that given this scenario they would have questions about the patient’s capacity and opt to treat them in their best interests, opinions are mixed. So the outcome (life or death) may have as much to do with our variable views as any objective measure of capacity which makes me uneasy. Vivienne Nathanson, head of science and ethics at the BMA, said the Mental Capacity Act had clarified the law for doctors. Maybe so, but it hasn’t made challenging dilemmas such as this any easier to resolve.

Financial Suicide

19 Jan, 09 | by Steven Reid, Evidence-Based Mental Health

The fall in share prices was unprecedented. His stocks were now worthless and the President of the New York County Trust Bank, J.J. Riordan, had lost a fortune. As the bank closed for the week, he took a pistol from a teller’s desk, went home and shot himself. The year however was not 2008, but 1929 and Riordan’s suicide followed the Wall Street Crash. Recent weeks have seen a number of modern day versions of this story reported in the press: on the 6th of January, a German billionaire, Adolf Merckle, threw himself in front of a train after his business empire was threatened with collapse. In December, Christen Schnor, HSBC’s head of insurance, was found hanging by a belt in the closet of a hotel room in London. Unsurprisingly, it’s a big story on the internet: have a look at the Daily Beast. You can even follow Greenspan’s Body Count, named after the former head of the Federal Reserve, keeping a grim tally of suicides (and murders) attributable to the financial meltdown. So are we on the verge of a ‘suicide epidemic’?

In my view certainly not, and comparisons with the Great Crash of 1929 are instructive. The US suicide rate in the months following the Crash actually declined when compared with the previous year, even in New York. Rates did rise in the following years, from 14 to 17 per 100000 between 1929 and 1933, although it’s by no means clear that this change was solely due to the Depression. The incidence of suicide had been increasing gradually for some years prior to 1929. In addition, some states only started reporting mortality statistics to the government during this period, and more of them were western states with above average suicide rates. Unemployment is associated with suicide but the relationship is not straightforward – factors such as social isolation and notably mental illness all add to the mix. Paradoxically, with a history of mental illness your risk of suicide goes up if you are in active employment or have a higher income. Changes in the suicide rate are more likely to be due to gradual changes in the economy, with unemployment growing from 3 percent to 25 percent during the Depression, than a specific response to the stock market Crash.

“…the newspapers and the public merely seize on such suicides as occur to show that people were reacting appropriately to their misfortunes. Enough deaths could be related in one way or another to the market to serve. Beginning soon after Black Thursday, stories of violent self-destruction began to appear in the papers with some regularity.” That was JK Galbraith writing in 1955 on the Great Crash. Take a closer look at Greenspan’s Body Count – how many of those suicides really are a direct consequence of the economic downturn? 

Antiepileptic Alert: scaremongering or suicide prevention?

8 Jan, 09 | by Steven Reid, Evidence-Based Mental Health

The debate has been rumbling on for a year, but last month the US Food and Drug Administration (FDA) announced that manufacturers of antiepileptic drugs will have to add warnings to package inserts stating that these drugs increase the risk of suicide. They have also issued a public health advisory requiring that “health care professionals should notify patients, their families and caregivers of the potential for an increase in the risk of suicidal thoughts or behaviors so that patients may be closely observed”. These alerts arrive following a review of 199 clinical trials that showed a doubling of risk of suicidality (not completed suicide) in people using antiepileptics. So warning patients makes sense doesn’t it? But then why are so many neurologists, psychiatrists and notably the American Epilepsy Society unhappy with the decision?

It boils down to the perception of risk and the old relative vs. absolute question. The trials included over 40000 patients and found that the absolute risk of suicidal thinking or behavior was 0.43% in the group taking antiepileptics versus 0.24% in the group on placebo. That equates to one additional case of suicidality (again, not completed suicide) for every 500 patients taking the active drug. Do antiepileptics seem quite so scary now?

The FDA says that the warnings are needed to promote monitoring for a significant, even if small, risk. Given that epilepsy itself is associated with a threefold increased risk of completed suicide watching for signs of depression should be routine. As well as epilepsy antiepileptics are also used in bipolar disorder and with chronic pain – conditions with their own significant risk of suicide. But a regulator urging increased monitoring doesn’t seem to affect clinical practice. Take the case of antidepressant prescribing in adolescents (see an earlier post). When trials indicated an increased risk of suicidality with SSRIs the FDA slapped on a black box warning. The adolescent suicide rate went up (possibly coincidental) and prescribing rates plummeted (probably not coincidental). That’s the concern with this latest alert: people will be put off taking antiepileptic drugs, and unlike antidepressants there is no alternative treatment. Providing information is important but so is context and I think this is a decidedly dubious decision by the FDA.

Respecting the right to die

20 Oct, 08 | by Steven Reid, Evidence-Based Mental Health

A BMJ blogger, William Lee, writes of his disquiet following a visit to a meeting held by Dr Philip Nitschke, director of EXIT International, who is in the UK promoting his new ‘guide to suicide’. He describes a strange-sounding meeting with little consideration of the relationship between suicidality and mental illness, and the issue of mental capacity warranting only a cursory mention, including the bizarre recommendation to ‘get a friend to do an MMSE test before your suicide to demonstrate possession of capacity’. Assisted suicide and the ‘right to die’ feature prominently in the news media at the moment. A 45-year-old woman, Debbie Purdey, is seeking clarification of the UK law relating to assisted suicide. She doesn’t want her husband to be prosecuted should he support her in visiting Dignitas, the Swiss organisation providing facilities for euthanasia. Police are currently investigating the case of David James, a 23-year-old left with quadriplegia after sustaining a spinal injury while playing rugby. After several previous attempts he committed suicide at a clinic in Switzerland

Another case has been less widely reported, although I consider it to be no less significant (read about it here). It’s a common scenario that will be familiar to anyone with experience of working in an emergency department – someone presenting with self-poisoning and then refusing treatment. The inquest began last week into the death of Kerrie Wooltorton, a woman with a history of borderline personality disorder, who was taken to Norfolk and Norwich University Hospital after drinking antifreeze (ethylene glycol). On arrival she stated that she did not want treatment and was ‘100 per cent aware of the consequences’. She also brought in a living will (advance directive) that she had written three days previously. The physician responsible for her care thought that she had capacity to make decisions about her treatment and reported that she was ‘calm’ and ‘not agitated’. He felt that it was his ‘duty to follow her wishes’. After consultation with the hospital’s medical director and legal adviser she was not given treatment and died the following day.

The law in the UK (recently codified in the Mental Capacity Act) is clear on the question of treatment for physical illness without consent. If the subject has capacity such treatment would constitute an assault or battery. Yet there are aspects of this case which are troubling. Ms Wootorton had attempted suicide by swallowing antifreeze on nine occasions in less than a year and had previously accepted treatment (including dialysis). She also had a number of recent psychiatric admissions and had been detained under the Mental Health Act. A psychiatrist who saw her in the months before her death said he believed she had the mental capacity to make the advance directive but how can he be certain that this was the case when she wrote it? Given the context of her recent history would there not have been reasonable grounds to doubt her capacity? It’s not uncommon for people turning up in A&E after deliberate self-harm to express ambivalence about treatment and subsequently change their mind, especially in those with borderline personality disorder where impulsivity is a prominent feature. Also, suicidality fluctuates in this group, and if her intent was so clear why come to hospital at all?

These decisions are always difficult and not really made any easier by the Mental Capacity Act. My inclination would have been to treat her on this occasion with an agreement that if she maintained her wish to decline future treatment and in the cold light of day clearly had capacity, an advance directive could be drawn up with the acknowledgment that it was valid by people involved in her care. A paternalistic abuse of a person’s autonomy? Maybe, but what do you think?

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