ClinicSpeak: suicidal ideation and suicide in MS

This is a reposting from the 23 March 2014.

How should I address the problem of suicide in MS? #ClinicSpeak #MSBlog #MSResearch

"We know that MSers are at increased risk of suicide; various studies put this risk at between 2 and 7 times the background risk. The study below studies suicidal ideation in MSers and found that at baseline 8% of MSers had suicidal ideation with an increase to 22% within 6 months.Wow 1 in 5 MSers think about suicide within a 6 month period. This much higher than I would have expected. Could the study have primed study subjects to consider suicide as an option? Interestingly being of 65 years of age and been disabled requiring help, predicted suicidal ideation. Not surprising depressive symptoms was also associated with suicidal ideation. I note in this study that gender did not emerge as a risk factor. In previous studies being male was a risk factor."

"How should we use this information in clinical practice? Should we be telling MSers about the increased suicide rate in MSers compared to the general population and people with other chronic diseases? Should we be screening for it on a regular basis using structured questionnaires? It is noteworthy that the ethics committee of the PROXIMUS study have asked us to do regular suicide screening in our study population. I am not convinced this is necessary; MSers who are not depressed may not like being asked about suicide each time they see is in the trial unit. What about assisted suicide in very disabled MSers as part of terminal care? Should we be supporting MSers accessing services that assist with suicide? Assisted suicide is illegal in the UK so many travel to Switzerland for this purpose. I have only one MSer in my care who has registered with Dignitas for this purpose. I had to provide a neutral medical report on their behalf for the clinicians at Dignitas; the report that Dignitas requires is a factual report documenting the diagnosis, level of disability and whether of not the person concerned is mentally competent to make decisions concerning their care. There is no requirement to make a judgement call on whether or not you support assisted suicide or not. When I wrote the report I addressed the report to the patient themselves; I did not feel comfortable writing a report directly to Dignitas. I did not want to be complicit with their decision. I suppose you could argue that because I knew what the report was being used for simply writing it makes me complicit. May be I am a coward? I sincerely hope they never takes up the option of travelling to Switzerland. I suspect they won't they have a very supportive family and is much loved by their partner and children. It has changed the way I manage this patient; I spend much more time with them when they come to clinic and we tend to go walk the extra mile to address quality of health issues; for example respite care for their partner and making sure counselling is ongoing and that their depression is managed as best we can."

"Suicide is difficult topic and may be we should have more open discussions about it as in issue for people with MS. I would appreciate your thoughts on this issue?"

Epub: Viner et al. Prevalence and risk factors for suicidal ideation in a multiple sclerosis population.  J Psychosom Res. 2014 Apr;76(4):312-6. doi: 10.1016/j.jpsychores.2013.12.010. 

OBJECTIVE: To estimate the prevalence, incidence and determinants of suicidal ideation in the MS population.

METHODS: A sample of 188 subjects were randomly selected from a community-based MS clinic registry and participated in as many as 13 interviews over 6 months. Thoughts of "being better off dead" or of "harming oneself" were assessed using item 9 on the Patient Health Questionnaire, Brief (PHQ-9).

RESULTS: At baseline, the 2-week period prevalence of suicidal ideation was 8.3%. Over the course of 6 months, 22.1% of respondents reported having such thoughts at least once. Survival analysis incorporating baseline PHQ-8 scores as a covariate confirmed that being age 65 and over (HR=4.3, 95% CI 1.7-11.3) and having lower quartile self-efficacy ratings (HR=3.5, 95% CI 1.5-8.2) predicted suicidal ideation. Lower levels of task-oriented coping (treated as a continuous variable) also predicted suicidal ideation after adjustment for depressive symptoms (p=0.015), as did self-reported bladder or bowel symptoms (HR=2.6, 95% CI 1.1-6.0) and difficulties with speaking and swallowing (HR=2.9, 95% CI 1.3-6.8). Associations with MS symptoms were not confounded by depressive symptoms.

CONCLUSION: This study identified several potentially modifiable factors that may be useful for preventing suicide in people with MS.

Disclosure: Please note the specific details of the brief case scenario above have been change to make sure the individual patient is unidentifiable.

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