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Developmental model of suicide trajectories

  • Monique Séguin (a1), Guy Beauchamp, Marie Robert (a2), Mélanie DiMambro and Gustavo Turecki (a3)...
Abstract
Background

Most developmental studies on suicide do not take into account individual variations in suicide trajectories.

Aims

Using a life course approach, this study explores developmental models of suicide trajectories.

Method

Two hundred and fourteen suicides were assessed with mixed methods. Statistical analysis using combined discrete-time survival (DTS) and growth mixture modelling (GMM) generated various trajectories, and path analysis (Mplus) identified exogenous and mediating variables associated with these trajectories.

Results

Two groups share common risk factors, and independently of these major risk factors, they have different developmental trajectories: the first group experienced a high burden of adversity and died by suicide in their early 20s; and the second group experienced a somewhat moderate or low burden of adversity before they took their own life. Structural equation modelling identified variables specific to the early suicide trajectory: conduct and behavioural difficulties, social isolation/conflicts mediated by school-related difficulties, the end of a love relationship, and previous suicide attempts.

Conclusions

Psychosocial adversity between 10 and 20 years of age may warrant key periods of intervention.

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Copyright
Corresponding author
Dr Monique Séguin, McGill Group for Suicide Studies, Douglas Mental Health University Institute, Frank B. Common Pavilion, 2nd floor, 6875 LaSalle Blvd, Borough of Verdun, Montreal, Quebec, H4H 1R3 Canada. Email: monique.seguin@uqo.ca
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Declaration of interest

None.

Footnotes
References
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Developmental model of suicide trajectories

  • Monique Séguin (a1), Guy Beauchamp, Marie Robert (a2), Mélanie DiMambro and Gustavo Turecki (a3)...
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eLetters

Suicide ontogeny and phylogeny

Paul Brown, Psychiatrist, Pierre Janet Centre
13 April 2016

Seguin et al sought to overcome methodological shortcomings of studies of susceptibility to suicide, notably cross sectional studies, and regression analyses from examination of proxy and distal variables, by a research design based on life course data derived from family interview. They identified two suicide victim groups: one with a high burden of adversity, who died in their early 20s; and those with a moderate or low burden of adversity. Mediating variables included, “conduct and behavioural difficulties, social isolation/conflicts mediated by school-related difficulties, the end of a love relationship, and previous suicide attempts.”

Ontogenetic analysis of suicide is never complete. Phylogenetic analysis, although essential, is very rarely conducted. Just as there are proximal and distal mediating variables in the ontogenetic trajectory of suicide victims, there are key proximal and distal phylogenetic variables. These are social, cultural, and eco-historical.

In the case of Canada, and specifically Montreal, the proximal phylogenetic factors include: street violence, family violence, drug abuse (most recently methamphetamine), and above all, poverty and related disadvantage. These phylogenetic factors, operate both directly in each case, and as part of the determining umwelt in which the victims are embedded. They must be taken into account if suicide trajectories are ever to be comprehensively meaningful. Poverty is rife in Montreal. Up to one in ten Montrealers relies on social assistance. Up to one-third of Montreal children live in poverty. Gang violence and drug abuse are rife. Of crystal meth, in Canada, Craig Pearson wrote, “it’s going to be an epidemic.’ The modern history of Montreal is embedded in Quebec’s ‘conflict with diversity:’ Anglo-French conflict, racial conflict, and immigrant conflict. These factors equally shape suicide trends, trajectories, and susceptibilities.

For suicide autopsy to become effective, it must be more than psychological or even social psychological. It must also be cultural and historical. Ultimately analysis of ontogeny must be combined with analysis of phylogeny.

1. Seguin M, Beauchamp G, Robert M, DiMambro M, Turecki G. Developmental model of suicide trajectories. Br J Psychiatry, 2014; 205: 120-6.

2. Brown P. Suicide and the conflicted soldier. Psychiatria Danubina, 2015; 27: 138-141.

3. Adam A. Report shows Montreal remains one of the poorest cities in Canada. Global News, May 27 2013. http://globalnews.ca/news/432924/report-shows-montreal-remains-one-of-the-poorest-cities-in-canada/.

4. Roy E, Arruda N, Vaillancourt E, Boivin J-F, Morissette C, Leclerc P, Alary M, Bourgois P. Drug use patterns in the presence of crack in downtown. Montréal Drug Alcohol Rev, 2012 ; 31: 72–80.

5. Pearson C. Crystal meth: it’s going to be an epidemic'. Windsor Star December 17, 2014 http://windsorstar.com/news/crystal-meth-its-going-to-be-an-epidemic

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Conflict of interest: None Declared

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Are we failing the emotionally distressed?

Bryony R Corbyn, Ct3 Psychiatry Trainee
07 November 2014

Seguin and colleagues highlight psychosocial adversity as a key determinant of suicide risk in their exploration of suicide trajectories.(1) Their research demonstrates that adverse psychosocial factors represent a more reliable indicator of suicide risk than the presence of established mental illness. In light of this, it is not surprising that the National Confidential Enquiry into Suicide and Homicide by People with Mental Illness report that 72% of those who died by suicide between 2001 and 2011, were not in contact with mental health services in the year before their death.(2)

As a high risk group, one might assume that psychosocially adverse individuals would be targeted by regional crisis teams. However, crisis teams were designed via the Mental Health Policy Implementation Guide specifically to target those with severe mental illnesses; experiencing acute psychiatric crises, of such severity that hospitalisation is otherwise necessary.(3) These inclusion criteria are unlikely to capture the population described by Seguin et al.

In addition to failing crisis team inclusion criteria, individuals onboth trajectories are also unlikely to meet inclusion criteria for other specialist secondary care interventions. Clustering models, which establish secondary care thresholds, fail to distinguish those with severeemotional distress, emerging mental illness or high impact adjustment disorder,(4) despite a well-established association with self-harm.(5) Having failed to meet secondary care thresholds, these individuals remain reliant on primary health care services.

GPs play a vital role in identifying high risk individuals on trajectories towards suicide. The majority of those who complete suicide make contact with their GP during the preceding year.(6) Considering the pressures faced by GPs at a time of such limited resources,(7,8)their ability to respond to these individuals is a concern. One recent newspaperarticle(9) described GP practices at "breaking-point", highlighting one surgery which sent out warning letters to patients deeming themselves to be "unsafe". With primary care services in their current state, can we expect GPs to have the capacity to detect and respond to populations on developmental trajectories leading to suicide?

If mental illness is not the key determinant of suicide risk, a number of issues are brought into question in terms of health care serviceorganisation. Are services sufficiently resourced and designed to best target high-risk psychosocially-adverse populations? If not, does this perhaps reflect a disparity of esteem? At present, those with psychosocialadversity who do not meet criteria for mental illness can fly under the radar of crisis teams as well as other secondary care services. GPs currently have contact with the population at risk but are they sufficiently equipped and supported in identifying these individuals and managing them?

We propose a number of recommendations. Firstly, we encourage a reflection on parity of esteem for sufferers of psychosocial adversity. Secondly, we suggest GP training sessions to raise awareness of this high risk population profile. Thirdly, we suggest a review of crisis team organisation, to take a broader view of risk indicators and to include thesuffering of psychosocial adversity so that specialist support is providedand high-risk individuals appropriately contained.

(1) Seguin M, Beauchamp G, Robert M, DiMambro M, Turecki G. Developmental model of suicide trajectories. Br J Psychiatry 2014; 205: 120-126.

(2) Appleby L, Kapur N, Shaw J, Hunt IM, While D, Flynn S, et al. TheNational Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report: England, Northern Ireland, Scotland and Wales. The University of Manchester, 2014.

(3) Department of Health. The Mental Health Policy Implementation Guide. Department of Health, 2001.

(4) Department of Health Payment by Results Team. Mental Health Clustering Booklet 2013-2014. Department of Health, 2013.

(5) Kripalani M, Nag S, Nag S, Gash A. Integrated care pathway for self-harm: our way forward. Emerg Med J 2010; 27: 544-546.

(6) Appleby L, Kapur N, Shaw J, Windfuhr K, While D, Webb R, et al. Suicide in primary care in England: 2002-2011. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The University of Manchester, 2014.

(7) Gerada C, Mathers N, Riley B, Thomas M. The 2022 GP: compendium of evidence. The Royal College of General Practitioners, 2013.

(8) Deloitte. Under pressure: The funding of patient care in general practice. Deloitte, 2014.

(9) Brown L. It's not safe for you here, overwhelmed GP surgery tellspatients: Letter sent to 10,000 people tells them they will be turned awayunless illness is deemed an emergency. The Daily mail (online), 2014. Available from http://www.dailymail.co.uk/news/article-2718445/It-s-not-safe-overwhelmed-GP-surgery-tells-patients-Letter-sent-10-000-people-tells-turned-away-unless-illness-deemed-emergency.html

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Conflict of interest: None declared

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Are we failing the emotionally distressed?

Dr Bryony R. Corbyn, Ct3 Psychiatry
23 September 2014

Seguin and colleagues highlight psychosocial adversity as a key determinant of suicide risk in their exploration of suicide trajectories.(1) They describe one particular developmental trajectory in which suicide is preceded by a rapid increase in the burden of psychosocial adversity. In contrast, a second trajectory is characterised by the endurance of a chronic burden of psychosocial adversity before suicide. Of clinical significance, the authors' life course model demonstrates that adverse psychosocial factors represent a more reliable indicator of suicide risk than the presence of established mental illness.

In light of this insight, it is not surprising that such a significant proportion of individuals who complete suicide are not in touch with mental health services at their time of death. The recent annual reports by the National Confidential Enquiry into Suicide and Homicide by People with Mental Illness have been highly publicised for highlighting that 72% of those who died by suicide between 2001 and 2011, were not in contact with mental health services for the full year before their death.(2)

Crisis teams, which were originally established via the Mental HealthPolicy Implementation Guide, are designed with specific inclusion criteriain order to target those with severe mental illness; experiencing acute psychiatric crises of such severity that hospitalisation would otherwise be necessary.(3) It strikes us that, whilst these inclusion criteria pick up some important vulnerable groups, they are unlikely to sufficiently capture the majority of high risk individuals as described by Seguin et al. In addition to failing crisis team inclusion criteria, individuals on both trajectories also seem likely to fail to meet the inclusion criteria for other forms of specialist secondary care intervention.

Current secondary mental health care services in England rely on clustering models, which amongst other purposes, function to establish thresholds for secondary care input. These clustering models fail to distinguish those with severe emotional distress or emerging mental illnesses. They also fail to adequately highlight sufferers of high impactadjustment disorder, describing adjustment disorder as an example of a cluster one condition.(4) Adjustment disorder has a well established association with self-harm, as reported by a recent survey of general hospital adult inpatients. This survey demonstrated that 35% of those who had presented in the Accident and Emergency Department with self-harm met criteria for a diagnosis of adjustment disorder.(5) Despite this, it seemsthat the majority of those who complete suicide, who suffer significant psychosocial adversity but do not necessarily meet criteria for a major mental health diagnosis, would not meet current secondary mental health service thresholds. These individuals are therefore dependent on primary health care services to pick up their concerns and respond to their adversity.

GPs play a vital role in identifying high risk individuals on trajectories towards suicide. Suicide risk is associated with frequent GP attendance and the majority of those who complete suicide are likely to have been in contact with their GP during the preceding year. This is demonstrated in a further report by the National Confidential Enquiries, which revealed that 73% of individuals who completed suicide in England between 2002 and 2011 had contact with their GP within the year before their death. In addition, 45% saw their GP within the preceding month. It is concerning to find that these frequencies appear to be on the decline. Previous reports suggest the higher figures of 91% of individuals who complete suicide having presented to their GPs within the preceding year and 47% having presented within the previous month.(6)

It is unclear why there has been a drop in GP attendance in those whocomplete suicide. However, demands on primary health care services are ever increasing and the ability of GP surgeries to withstand the pressureshas become a focus of discussion and recent media attention. The Royal College of General Practitioners reported that between 1995 and 2008, the number of patient consultations within primary care rose by 75%.(7) A recent Deloitte report commissioned by the College has predicted a furtherincrease in demands despite a funding allocation for primary care of only 8% of the NHS budget.(8)

These concerns have been well publicised. One recent newspaper article(9) described GP practices as being at "breaking-point". The article reported that GP surgeries have resorted to measures such as sending out warning letters to all patients stating that they are "unsafe"and only able to respond to calls on the same day if they are considered "medically urgent". The same surgery explained to patients that consultations offered may have to be by telephone rather than face-to-facedue to unsustainable work-load pressures. With primary care services in their current state, is it realistic to expect GPs to have the capacity todetect and respond to the population on developmental trajectories leadingto suicide? Furthermore, after receiving a letter of this nature or reading articles such as these, will high risk individuals who do not perceive their distress to be a medical condition still attend?

Are they any more likely to attend an A&E department? Media reports suggest that Emergency departments in England are also struggling under intense strain. Targets for waiting times are being breached as A&E departments face a serious recruitment crisis. One recent article warned that A&E departments are becoming like "war zones".(10) With A&E departments operating under these pressures, the emotionally distressed may well be discouraged from attending.

If mental illness is not the key determinant of suicide risk, a number of issues are brought into question in terms of the organisation ofour health care services and how we are currently responding to this target population. Are our services sufficiently resourced and designed tobest target the population whose developmental trajectory leads to suicide? Furthermore, are our services geared up to recognise and manage those imminently at risk? If not, why are we not a compassionate service and does this not reflect a disparity of esteem?

The capacity for our health care services under their current organisation to identify and sufficiently respond to those experiencing significant psychosocial adversity is a concern. Those with psychosocial adversity who do not meet criteria for mental illness can fly under the radar of crisis teams as well as other secondary mental health care services. GPs appear to have contact with the population at risk but may be insufficiently equipped to identify these individuals and insufficiently supported in managing them.

We propose a number of measures in order to target those on developmental trajectories leading to suicide. Firstly, we suggest a review of crisis team organisation. Crisis teams need to take a broader view of risk indicators, to include the suffering of rapidly increasing aswell as chronic psychosocial adversity. Secondly, we recommend focussed training sessions targeted at GPs with a view to raise awareness of this high-risk population profile and recommend appropriate interventions. Lastly, we encourage a reflection on the need for parity of esteem amongstsufferers of psychosocial adversity, with consideration of further actionsthat need to be taken in order to contain the risk they present. Would theauthors agree to these suggestions?

(1) Seguin M, Beauchamp G, Robert M, DiMambro M, Turecki G. Developmental model of suicide trajectories. Br J Psychiatry 2014; 205: 120-126.

(2) Appleby L, Kapur N, Shaw J, Hunt IM, While D, Flynn S, et al. TheNational Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report: England, Northern Ireland, Scotland and Wales. The University of Manchester, 2014.

(3) Department of Health. The Mental Health Policy Implementation Guide. Department of Health, 2001.

(4) Department of Health Payment by Results Team. Mental Health Clustering Booklet 2013-2014. Department of Health, 2013.

(5) Kripalani M, Nag S, Nag S, Gash A. Integrated care pathway for self-harm: our way forward. Emerg Med J 2010; 27: 544-546.

(6) Appleby L, Kapur N, Shaw J, Windfuhr K, While D, Webb R, et al. Suicide in primary care in England: 2002-2011. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The University of Manchester, 2014.

(7) Gerada C, Mathers N, Riley B, Thomas M. The 2022 GP: compendium of evidence. The Royal College of General Practitioners, 2013.

(8) Deloitte. Under pressure: The funding of patient care in general practice. Deloitte, 2014.

(9) Brown L. It's not safe for you here, overwhelmed GP surgery tellspatients: Letter sent to 10,000 people tells them they will be turned awayunless illness is deemed an emergency. The Daily mail (online), 2014. Available from http://www.dailymail.co.uk/news/article-2718445/It-s-not-safe-overwhelmed-GP-surgery-tells-patients-Letter-sent-10-000-people-tells-turned-away-unless-illness-deemed-emergency.html

(10) Cooper C. Exclusive: 'It was no accident' - Government blamed for A&E crisis. The Independent (online), 2013. Available from http://www.independent.co.uk/news/uk/politics/exclusive-it-was-no-accident--government-blamed-for-ae-crisis-9032119.html

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Conflict of interest: None declared

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