Suicide among people with dual diagnosis, Victoria 2009-2010 - - PowerPoint PPT Presentation

Suicide among people with dual diagnosis, Victoria 2009-2010

Alcohol, Tobacco & other Drugs Council Tasmania

Friday 26 September 2014 Dr Jeremy Dwyer Case Investigator Coroners Prevention Unit

Co-contributors: Mary Hyland and Dr Lyndal Bugeja

SAMHSA White Paper 2009

2

“A growing body of studies has demonstrated that alcohol and drug abuse are second only to depression and other mood disorders as the most frequent risk factors for suicide” (p.10) “This document […] acknowledges the critical interrelationships among substance abuse, mental illness and suicide risk” (p.1)

3

Structure of presentation Disclaimer

• Introduction to the Victorian Suicide Register (VSR)
• Early findings on health service contacts among people with

dual diagnosis who suicide, Victoria 2009-2010

• I do not speak on behalf of Victoria’s coroners
• Any views I express on a question or issue are not the ‘official’

views of the Court

4

VSR History (1)

5

VSR History (2)

Coroner Paresa Spanos, Finding without Inquest into Death of B, case 3651 of 2009, published 10 August 2011

6

VSR History (3)

Potential gambling-related variables:

• Duration of gambling
• Frequency of gambling
• Types of gambling
• Locations of gambling
• Amounts gambled
• Evidence of impact on family and

friends

• Quantification of losses
• Concomitant drug and alcohol use
• Evidence of gambling as a motive for

suicide Potential gambling-related variables:

• Time of day
• How the rail suicide location was

accessed

• Distance from rail suicide location to

deceased’s usual residence

• Any fences or trees at location
• Speed of train
• When the train driver saw the

deceased

• Evidence of deceased previously

visiting rail suicide location

7

VSR History (4)

Detail from VSR version 5.2, November 2013

8

VSR History (5)

Detail from VSR version 5.2, November 2013

9

Enhanced dataset: dual diagnosis (1)

Detail from VSR enhanced dataset interface, dual diagnosis, July 2014

10

Enhanced dataset: dual diagnosis (2)

Detail from VSR enhanced dataset interface, dual diagnosis, July 2014

11

Case identification

Table 1: Frequency of suicide deaths by presence of mental illness and drug dependence, Victoria 2009-2010. Drug dependence Mental illness excluding substance use disorders

Diagnosed Suspected None Total Yes – clinically documented (diagnosed disorder)

87 2 6 95

Yes – clinically documented (no diagnosed disorder)

118 28 2 148

Yes – not clinically documented

46 60 21 127

No

383 154 216 735

Total

634 244 245 1123

12

All suicides vs dual diagnosis cohort (1)

Table 2: Frequency by sex of all suicide deaths and dual diagnosis cohort suicide deaths, Victoria 2009-2010.

Sex All Dual diagnosis cohort Female 272 (24.2%) 58 (28.3%) Male 851 (75.8%) 147 (71.7%) Total 1123 (100.0%) 205 (100.0%)

Table 3: Proportion by age group of all suicide deaths and dual diagnosis cohort suicide deaths, Victoria 2009-2010.

Age group All Dual diagnosis cohort 10 to 17 2.6% 2.0% 18 to 24 10.1% 10.7% 25 to 34 18.3% 25.9% 35 to 44 20.8% 30.2% 45 to 54 21.8% 21.5% 55 to 64 13.4% 8.3% 65 to 74 6.1% 1.5% 75 to 84 5.3% 0.0% 85 and over 1.7% 0.0% Total 100.0% 100.0%

13

All suicides vs dual diagnosis cohort (2)

Table 4: Proportion by location of usual residence, of all suicide deaths and dual diagnosis cohort suicide deaths, Victoria 2009-2010.

Location of usual residence All Dual diagnosis cohort Metropolitan 65.2% 73.7% Rural 33.2% 23.9% Other 1.6% 2.4% Total 100.0% 100.0%

Table 5: Proportion by suicide method of all suicide deaths and dual diagnosis cohort suicide deaths, Victoria 2009-2010.

Suicide method All Dual diagnosis cohort Hanging 49.0% 53.2% Poisoning 16.2% 21.5% MVEG 9.1% 8.8% Firearm 6.2% 2.4% Jump from height 4.9% 4.4% Rail 4.7% 4.4% Other threat to breathing 3.0% 1.5% Other methods 6.9% 3.9% Total 100.0% 100.0%

14

Drugs of dependence

Table 6: Frequency of dual diagnosis cohort suicide deaths by nature of drug dependence, Victoria 2009-2010.

Nature of drug dependence All Dual diagnosis cohort Single drug dependent 104 50.7% Poly-drug dependent 101 49.3% Total 205 100%

Table 7: Frequency of dual diagnosis cohort suicide deaths by nature of dependence and drugs used, Victoria 2009-2010.

Drugs Single drug dependent (n = 104) Poly-drug dependent (n = 101) Illegal drugs Cannabis 10 54 Heroin 7 38 Amphetamines 4 32 Other illegal 10 Pharmaceutical drugs Benzodiazepines 7 36 Opioids 7 Antidepressants Antipsychotics 3 Other 2 6 Other Alcohol 74 65

15 Table 8: Frequency of diagnosed mental and behavioural disorders excluding substance use disorders among dual diagnosis suicide deceased (n = 250), Victoria 2009-2010.

Diagnosed Mental and Behavioural Disorders: ICD10 Frequency Organic, including symptomatic, mental disorders 1 Schizophrenia, schizotypal and delusional disorders 28 Mood [affective] disorders 166 Neurotic, stress-related and somatoform disorders 71 Behavioural syndromes associated with physiological disturbances 7 Disorders of adult personality and behaviour 33 Mental retardation 1 Disorders of psychological development 2 Behavioural and emotional disorders with onset in childhood and adolescence 7 Unspecified mental disorders 1

Diagnosed mental illness

16

Most recent care episode and conditions treated

Table 9: Frequency of dual diagnosis cohort suicide deaths by proximity of most recent care episode and reason for care, Victoria 2009-2010. Conditions treated Proximity to suicide of most recent care episode

<1 week 1 to 6 weeks 6 wk to 6 m 6 m to 1 yr 1 yr to 2 yrs Not known None Total Mental illness and substance abuse 64 66 16 3 1 5 155 Mental illness only 13 18 3 3 37 Substance abuse only 3 3 Other 2 2 Unknown 4 4 None 4 4 Total 80 86 19 3 1 12 4 205

17

Proximity and locus of most recent care episode

Table 10: Frequency of dual diagnosis suicide deaths by locus and proximity of most recent care episode Victoria 2009-2010. Locus of care in most recent care episode Proximity to suicide of most recent care episode

<1 week 1 to 6 weeks 6 wk to 6 m 6 m to 1 yr 1 yr to 2 yrs Not known None Total Primary health General practitioner 29 42 13 3 5 92 Emergency department 4 2 1 7 Mental health services Community 23 30 3 1 2 59 Residential 1 1 Supported accommodation 3 3 CATT 6 2 1 9 Hospital-based (inpatient) 5 5 10 AOD services Community 5 4 1 10 Residential 1 1 Supported accommodation 1 1 Hospital-based (inpatient) 1 1 Other Other health services 2 1 3 Unknown 4 4 No evidence of care 4 4 Grand Total 80 86 19 3 1 12 4 205

18

Most recent AOD contact ever

Table 11: Frequency of most recent AOD contact (if any) and proximity of contact to suicide, among dual diagnosis suicide deceased, Victoria 2009-2010. Most recent AOD contact ever prior to suicide Proximity to suicide of most recent AOD contact

<1 week 1 to 6 weeks 6 wk to 6 m 6 m to 1 yr 1 yr to 2 yrs > 2 yrs UK Total AOD contact 9 15 13 7 6 13 20 83 Community 7 12 9 3 5 2 12 50 Residential 1 2 4 4 9 5 25 Supported accommodation 1 1 2 Hospital-based 1 1 2 Other 1 3 4 No AOD contact 122 Grand Total 205

19

Mental illness and drug dependence are inter-related (1)

“[The deceased's] abuse of alcohol was an attempt to cope with her

• verwhelming emotions, which were often triggered by interpersonal

conflict and chronic social anxiety. Alcohol and intoxication increased the deceased's risk of self harm.”

Statement of psychologist.

“Deceased's doctors told the deceased to stop consuming alcohol, although the deceased did this to cope with his ‘physical and mental pain’ and also used it to help the deceased sleep at night.”

Investigating police member’s summary.

“He started drinking earlier in the day than he used to. I would never have describe [deceased] as an alcoholic or anything like that, he just enjoyed a drink socially. In the last couple of months [deceased] would tell me that he was feeling down and the alcohol made him feel better, it seemed to lift his mood.”

Statement of deceased’s partner.

20

Mental illness and drug dependence are inter-related (2)

“My initial formulation of [deceased] was that he suffered from depression with a strong anxiety component. He had developed a pattern of trying to manage his anxiety by using alcohol. Unfortunately this both maintained and exacerbated his problems.”

Statement of psychiatrist.

“As a result of her illicit drug use the deceased had been diagnosed as suffering from drug induced paranoia and depression."

Coroner’s finding.

“Following the doctor's assessment, it was considered that [deceased] was experiencing an exacerbation of schizophrenia, secondary to non-compliance with antipsychotic medication and probable alcohol / cannabis use.”

Investigating police member’s summary.

21

Mental illness and drug dependence are inter-related (3)

“[Deceased’s treating psychiatrist] took a history that included depression, polysubstance abuse, hepatitis C and self harming

• behaviour. She noted that he had attempted to commit suicide in the

past and that he had also experienced psychotic episodes, which she believed were likely to be a consequence of amphetamine use.”

Coroner’s finding.

“[The deceased] was diagnosed with major depression with co-morbid cannabis dependence and anti social personality disorder."

Statement of psychiatrist.

“[The deceased] had multiple admissions from the year 2000 with a psychotic disorder in the setting of substance use.”

Statement of clinician at hospital.

22

Mental illness and drug dependence underpin

• r exacerbate other stressors (1)

“[The deceased] was unhappy due to the family not being together but he was also unhappy with his drug problems. He wanted us to get back together and live in Melbourne. I told him he needed to sort

• ut the drug problems first.”

Coroner’s finding.

“About three weeks before he passed away he went into a chemist and stole Sudafed tablets. That was when the police came over to our house and took [the deceased] back to [police station].”

Statement of relative.

“Deceased began his drug use again and became dependent on heroin; using it 3-4 times a day, according to the deceased's sister. This caused the deceased's wife to leave the deceased.”

Summary from investigating police member.

23

Mental illness and drug dependence underpin

• r exacerbate other stressors (2)

“[Deceased] reported decrease in overall functioning the prior seven months since he was evicted from his family home. His mother also refused to see him and didn't allow his younger siblings or grandparents to see him.”

Statement of psychiatrist.

“He was in rehabilitation for about a week. When he came out that's when all the big problems started. He became very aggressive, mostly

• verbally. He stayed off the marijuana but he became more depressed not

having it.”

Statement of acquaintance.

“Now I look into the mirror at 24 with drug addiction, no qualifications, no money and no hope or will to continue fighting. [...] All my memories are painful, I can never in my life remember being happy unless under the influence of drugs and alcohol. I cannot see a future for me.”

Suicide note.

24

Mental illness and drug dependence underpin

• r exacerbate other stressors (3)

“[Deceased] had mental health issues which has been diagnosed as Bipolar Affective Disorder. This has been a long issue for the deceased. The deceased also had a severe problem with alcohol abuse, according to his treating doctor to the point where he could no longer be effective in his profession.”

Summary from investigating police member.

Every time they split [deceased] would drink then they'd get back together and she would drink less. [...] Towards the end I told her she had to stop doing this to herself. She knew, she could see the pattern

• f behaviour.”

Statement from relative.

25

Services treating mental illness and drug dependence are fragmented (1)

“There is the constant problem of division between Mental Health services and Drug and Alcohol services, which [deceased] found very frustrating.”

From family member’s statement to coroner

“[...] her Drug and Alcohol worker [...] explained [deceased's] main issue was depression and that she was not an addict like the other people he saw.”

26

Services treating mental illness and drug dependence are fragmented (2)

Victorian Department of Health, Dual Diagnosis: Key Directions and Priorities for Service Development, 2007, p.14.

27

Services treating mental illness and drug dependence are fragmented (3)

“Alcohol and drug treatment providers have successfully delivered treatment services across organisational, planning and service boundaries since the 1997 reforms. However, successive ad hoc initiatives and a failure to act on more than 30 reviews have left the system fragmented and moribund, unable to adapt or to deliver consistent, integrated responses to service users and their families. When people get good quality treatment and connection to the

• ther systems and support that they need, it comes from the

dedication and commitment of individuals working in the system, rather than the effectiveness of the system itself.”

Victorian Department of Health, New Directions for Alcohol and Drug Treatment Services: A Roadmap, 2012, p.11.

28

Prevention (1)

“GP education on suicide prevention works, is cost-effective and may reduce suicide by 10%. The GP setting provides opportunities to detect risk. A core competency for all doctors is suicide prevention education and training. The provision of new training materials, developed by GPs for GPs is urgently needed.”

Christensen H, “Preventing Suicide”, MJA Insight, 8 September 2014.

29

Prevention (2)

Higher Lower

Health and quality

• f life

Years in treatment

30

Prevention (3) Psychological autopsy Health service-based root cause analysis Health system analysis

31

Prevention (4)

“Educating primary health care workers to recognise depression and other mental and substance use disorders and performing detailed evaluations of suicide risk are important for preventing

• suicide. Training should take place continuously or repeatedly over

years and should involve the majority of health workers in a region

• r country.”

World Health Organization, Preventing Suicide: A Global Imperative, 2014, p.42.

32

Prevention (5)

“Although Victorians’ physical and mental health needs are met by a wide range of public and private health professionals and other staff beyond the Victorian specialist mental health service system, these workforces are not considered in this strategy. There is also a range

• f other services that work with

people with a mental illness and their families on a broader basis such as police, schools, homelessness agencies and nursing homes that are similarly out

• f scope for this strategy.” (p.2)

33

Prevention (6)

Victorian Department of Health, New Directions for Alcohol and Drug Treatment Services: A Roadmap, 2012, p.17.

34

Further information

Dr Lyndal Bugeja Manager Coroners Prevention Unit Coroners Court of Victoria <lyndal.c.bugeja@coronerscourt.vic.gov.au> (03) 8688 0769

35

Thank you