Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study

Faraz Mughal; Lana Bojanić; Cathryn Rodway; Jane Graney; Saied Ibrahim; Leah Quinlivan; Sarah Steeg; Su-Gwan Tham; Pauline Turnbull; Louis Appleby; Roger T Webb; Nav Kapur

doi:10.3399/BJGP.2022.0589

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Recent GP consultation before death by suicide in middle-aged males
Marion Brown

Published on: 07 July 2023
Gate openers for the prevention of suicide in rural communities
Ryuichi Ohta

Published on: 03 July 2023
Recent GP consultation before death by suicide in middle-aged men: a national consecutive case series study
Phillip Oliver

Published on: 29 March 2023

Published on: (7 July 2023)
Page navigation anchor for Recent GP consultation before death by suicide in middle-aged males
Recent GP consultation before death by suicide in middle-aged males
Marion Brown, retired, none
This article¹makes for troubling reading:
“Males prescribed an SSRI/SNRI antidepressant, oral antipsychotic, or benzodiazepine were more likely to have seen their GP within 3 months of suicide, which may indicate that mental health reviews were conducted or there was a deterioration in their mental health. In practice it is important to recognise this and explore self-harm and suicidal thoughts in males taking these medications.”

The work of Helmeland et al (2019)²and Hengartner and Ploderl (2019)³ questions the problematic advice of suicide prevention experts over the widespread use of antidepressants for treatment of depression:
“One of the recommended [suicide prevention] strategies is pharmacological treatment of depression. This recommendation is deeply problematic for several reasons… [including that] the many and serious side effects of antidepressants are not considered. Thus, the recommendation may have deleterious consequences for countless numbers of people, and, in fact, contribute to an increase in the suicide rate rather than a decrease.”²
“…when based on the number of patients randomized rather than PEY [patient exposure years], the data presented herein suggest that antidepressants significantly increase the suicide risk in adults with major depression.” ^3.

Of course, antidepressants ar...
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This article¹makes for troubling reading:
“Males prescribed an SSRI/SNRI antidepressant, oral antipsychotic, or benzodiazepine were more likely to have seen their GP within 3 months of suicide, which may indicate that mental health reviews were conducted or there was a deterioration in their mental health. In practice it is important to recognise this and explore self-harm and suicidal thoughts in males taking these medications.”

The work of Helmeland et al (2019)²and Hengartner and Ploderl (2019)³ questions the problematic advice of suicide prevention experts over the widespread use of antidepressants for treatment of depression:
“One of the recommended [suicide prevention] strategies is pharmacological treatment of depression. This recommendation is deeply problematic for several reasons… [including that] the many and serious side effects of antidepressants are not considered. Thus, the recommendation may have deleterious consequences for countless numbers of people, and, in fact, contribute to an increase in the suicide rate rather than a decrease.”²
“…when based on the number of patients randomized rather than PEY [patient exposure years], the data presented herein suggest that antidepressants significantly increase the suicide risk in adults with major depression.” ^3.

Of course, antidepressants are prescribed by GPs for all manner of indications – not only for treatment of depression – and the complex and adverse effects of these drugs are experienced by people who are prescribed the drugs for whatever reason.

The April 2023 article by John Read looking at suicide inquests⁴ is surely a wake-up call:
“We can say, however, that ADs [antidepressants] failed to lift the depression sufficiently to prevent 2,718 hangings, 2,329 overdoses, 440 cases of jumping or falling to one’s death, 126 cases of shooting oneself, and 40 of setting oneself on fire. In none of the 3,543 cases for which the coroner reached a clear “suicide” verdict, can ADs be reasonably described as effective.”

David Healy’s article in the same journal⁵ confirms what is happening.
“We risk compromising the safety of all if we prohibit judgments about cause-and-effect based on an examination of specific case, in which the question is, did this drug cause that effect?”

References

1. Mughal F, Bojanić L, Rodway C, et al. Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study. Br J Gen Pract. 2023;73(732):e478-e485.
2. Helmeland H, Jaworski K, Knizek B, Marsh I. Problematic advice from suicide prevention experts. Ethical Human Psychology and Psychiatry 2019; 20(2). DOI: 10.1891/1559-4343.20.2.79
3. Hengartner MP, Plöderl M. Newer-generation antidepressants and suicide risk in randomized controlled trials: a re-analysis of the FDA database. Psychother Psychosom. 2019;88(4):247-248. doi:10.1159/000501215.
4. Read J. Antidepressants and Suicide: 7,829 Inquests in England and Wales, 2003–2020. Ethical Human Psychology and Psychiatry (2023) DOI: 10.1891/EHPP-2022-0015
5. Healy D. Diagnosis, verdict conclusion and causality. Ethical Human Psychology and Psychiatry 2023. DOI: 10.1891/EHPP-2023-0001.

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Competing Interests: None declared.
Published on: (3 July 2023)
Page navigation anchor for Gate openers for the prevention of suicide in rural communities
Gate openers for the prevention of suicide in rural communities
Ryuichi Ohta, Family physician, Unnan City Hospital, Japan
I have read, with great respect, the research titled “Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study.”¹ This research clarified that middle-aged patients committed suicide tend to use medical care, especially general practitioners. Although general practitioners do their best for their patients’ management, the last time the prevention of their suicide can be in the interactions between general practitioners and middle-aged people with various psychosocial stressors.

In rural Japanese, suicide in socially isolated middle-aged males increase in numbers because of a decrease in the marriage rate and an increase in caregiver burden. As this study shows, not only mental burdens in jobs but also psychological and physical burdens in private lives can impinge on socially isolated middle-aged males’ lives, increasing the risk of suicide.¹ Especially in rural Japanese, the trend is progressing because of aging societies.² As a family physician in rural Japanese, I have experienced various suicide cases with multiple initial symptoms among middle-aged males because of the psychological and physical burdens of caregiving. As family physicians, encountering middle-aged males with multiple vague symptoms in primary care settings should be a chance to gate openings for preventing suicide in rural communities and collaboration among various medical and co...
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I have read, with great respect, the research titled “Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study.”¹ This research clarified that middle-aged patients committed suicide tend to use medical care, especially general practitioners. Although general practitioners do their best for their patients’ management, the last time the prevention of their suicide can be in the interactions between general practitioners and middle-aged people with various psychosocial stressors.

In rural Japanese, suicide in socially isolated middle-aged males increase in numbers because of a decrease in the marriage rate and an increase in caregiver burden. As this study shows, not only mental burdens in jobs but also psychological and physical burdens in private lives can impinge on socially isolated middle-aged males’ lives, increasing the risk of suicide.¹ Especially in rural Japanese, the trend is progressing because of aging societies.² As a family physician in rural Japanese, I have experienced various suicide cases with multiple initial symptoms among middle-aged males because of the psychological and physical burdens of caregiving. As family physicians, encountering middle-aged males with multiple vague symptoms in primary care settings should be a chance to gate openings for preventing suicide in rural communities and collaboration among various medical and community professionals.

References
1. Mughal F, Bojanic L, Rodway C, et al. Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study. Br J Gen Pract 2023;73(732): e478-e485. DOI: 10.3399/BJGP.2022.0589.
2. Naito Y, Ohta R, Sano C. Solving Social Problems in Aging Rural Japanese Communities: The Development and Sustainability of the Osekkai Conference as a Social Prescribing during the COVID-19 Pandemic. Int J Environ Res Public Health 2021;18(22) (In eng). DOI: 10.3390/ijerph182211849.

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Competing Interests: None declared.
Published on: (29 March 2023)
Page navigation anchor for Recent GP consultation before death by suicide in middle-aged men: a national consecutive case series study
Recent GP consultation before death by suicide in middle-aged men: a national consecutive case series study
Phillip Oliver, GP & Clinical Lecturer, University of Sheffield
I would like to thank Mughal et al., for their research on death by suicide in middle aged men. My colleagues and I carried out a regional review of suicides in the South Yorkshire and Bassetlaw during 2018 and 2019 (paper in preparation) and found similar rates of GP consultation in the 3-month period prior to death (54%). We also found around half of these consultations were mental health-related (48%). Suicidal thoughts were mentioned in a third of cases at this consultation.

Given that these individuals would go on to die from suicide within 3 months or less, the proportion of consultations that were not mental health-related or had any mention of suicidal thoughts is striking. Contemporary models of suicide, such as O’Connor’s IMV model, imply that a number of predisposing factors are present in the period leading up to suicide.¹ Given the pressures facing general practice and the impact on continuity of care, it is easy to see how the opportunity to identify and enquire about some of the factors may be compromised. We know that middle aged men are less likely to consult with their GP² which makes these consultations of great value for opportunistic screening. Perhaps the time has come to adopt an approach similar to that taken in the identification of domestic violence/abuse and make routine enquiry into suicidal thoughts in all middle age men who consult with GPs or other health professionals.

References...
Show More

I would like to thank Mughal et al., for their research on death by suicide in middle aged men. My colleagues and I carried out a regional review of suicides in the South Yorkshire and Bassetlaw during 2018 and 2019 (paper in preparation) and found similar rates of GP consultation in the 3-month period prior to death (54%). We also found around half of these consultations were mental health-related (48%). Suicidal thoughts were mentioned in a third of cases at this consultation.

Given that these individuals would go on to die from suicide within 3 months or less, the proportion of consultations that were not mental health-related or had any mention of suicidal thoughts is striking. Contemporary models of suicide, such as O’Connor’s IMV model, imply that a number of predisposing factors are present in the period leading up to suicide.¹ Given the pressures facing general practice and the impact on continuity of care, it is easy to see how the opportunity to identify and enquire about some of the factors may be compromised. We know that middle aged men are less likely to consult with their GP² which makes these consultations of great value for opportunistic screening. Perhaps the time has come to adopt an approach similar to that taken in the identification of domestic violence/abuse and make routine enquiry into suicidal thoughts in all middle age men who consult with GPs or other health professionals.

References

1. O’Connor RC, Kirtley OJ. 2018 The integrated motivational–volitional model of suicidal behaviour. Phil. Trans. R. Soc B 373: 20170268.
2. Wang Y, Hunt K, Nazareth I, et al. Do men consult less than women? An analysis of routinely collected UK general practice data. BMJ Open 2013;3: e003320.
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Competing Interests: None declared.