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 “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) 2
Structure of presentation - Introduction to the Victorian Suicide Register (VSR) - Early findings on health service contacts among people with dual diagnosis who suicide, Victoria 2009-2010 Disclaimer 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 3
VSR History (1) 4
VSR History (2) Coroner Paresa Spanos, Finding without Inquest into Death of B , case 3651 of 2009, published 10 August 2011 5
VSR History (3) Potential gambling-related variables: Potential gambling-related variables: - Duration of gambling - Time of day - Frequency of gambling - How the rail suicide location was accessed - Types of gambling - Distance from rail suicide location to - Locations of gambling deceased’s usual residence - Amounts gambled - Any fences or trees at location - Evidence of impact on family and - Speed of train friends - When the train driver saw the - Quantification of losses deceased - Concomitant drug and alcohol use - Evidence of deceased previously visiting rail suicide location - Evidence of gambling as a motive for suicide 6
VSR History (4) Detail from VSR version 5.2, November 2013 7
VSR History (5) Detail from VSR version 5.2, November 2013 8
Enhanced dataset: dual diagnosis (1) Detail from VSR enhanced dataset interface, dual diagnosis, July 2014 9
Enhanced dataset: dual diagnosis (2) Detail from VSR enhanced dataset interface, 10 dual diagnosis, July 2014
Case identification Table 1 : Frequency of suicide deaths by presence of mental illness and drug dependence, Victoria 2009-2010. Mental illness excluding substance use disorders Drug dependence Diagnosed Suspected None Total Yes – clinically documented 87 2 6 95 (diagnosed disorder) Yes – clinically documented 118 28 2 148 (no diagnosed disorder) Yes – not clinically documented 46 60 21 127 383 154 216 735 No 634 244 245 1123 Total 11
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% 12
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% 13
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. Single drug Poly-drug Drugs dependent (n = 104) dependent (n = 101) Illegal drugs Cannabis 10 54 Heroin 7 38 Amphetamines 4 32 Other illegal 0 10 Pharmaceutical drugs Benzodiazepines 7 36 Opioids 0 7 Antidepressants 0 0 Antipsychotics 0 3 Other 2 6 Other Alcohol 74 65 14
Diagnosed mental illness 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 15
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. Proximity to suicide of most recent care episode Conditions treated 1 to 6 6 wk to 6 m to 1 yr to Not <1 week None Total weeks 6 m 1 yr 2 yrs known 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 16
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. Proximity to suicide of most recent care episode Locus of care in most 1 to 6 6 wk to 6 m to 1 yr to Not recent care episode <1 week None Total weeks 6 m 1 yr 2 yrs known 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 17
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. Proximity to suicide of most recent AOD contact Most recent AOD contact <1 1 to 6 6 wk to 6 m to 1 yr to ever prior to suicide > 2 yrs UK Total week weeks 6 m 1 yr 2 yrs 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 18
Mental illness and drug dependence are inter-related (1) “ [The deceased's] abuse of alcohol was an attempt to cope with her overwhelming 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 . 19
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 . 20
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