Suicide

Attempted suicide by self-immolation is a powerful predictive variable for survival of burn injuries

Up to 9% of all burn victims in western countries are reported to have been caused by self-immolation with suicidal intent and usually involve extensive injuries. The authors sought to identify differences between suicide burn victims as opposed to those who sustained their injuries accidentally with regard to injury severity and mortality and determine the possible impact of suicide as a prognostic variable in the context of a scoring system such as the Abbreviated Burns Severity Index (ABSI). The data of all burns patients treated at the Specialist Burns Intensive Care Unit, University Hospital Zürich, between 1968 and 2008 were analyzed retrospectively. Of the 2813 patients included in the study, 191 were identified as attempted suicides, most commonly involving the use of accelerants. Thirty percent of all suicide victims had preexisting psychiatric diagnoses. Suicide victims presented with significantly more extensive burns (53.7%, ±0.98 SEM vs 21.4 %, ±0.36 SEM, P < .0001), had higher total ABSI scores (8.4, ±0.23 SEM vs 6.6, ±0.05 SEM, P < .0001), and had higher mortality rates (42.9% [83/191] vs 16.3% [426/2622]) than accident victims. Furthermore, logistic regression revealed suicide to be a significant predictor of mortality as inhalation injury (odds ratio 2.2, 95% confidence interval 1.4-3.5, P < .0003 and odds ratio 2.4, 95% confidence interval 1.4-4.0, P < .0009, respectively). The odds of dying from an attempted suicide are twice as high compared with those of accident patients in the same ABSI category, making suicide a powerful predictor of mortality. The authors therefore suggest including it as a fixed variable in scoring systems for estimating a patient's mortality after burn injuries such as the widely used ABSI.

Gender-specific differences among patients treated for suicide attempts in the emergency departments of four general hospitals in Shenyang, China

OBJECTIVE

We aimed to identify gender-specific characteristics of suicide attempters admitted to general hospital emergency departments in urban China.

METHODS

The Structured Clinical Interview for the DSM-IV, the Suicide Ideation Scale, the Hamilton Depression Rating Scale and a quality of life measure were administered to 239 suicide attempters who were treated consecutively in the emergency departments of four general hospitals randomly selected in Shenyang, China.

RESULTS

Among the 239 enrolled subjects, 53 (22.2%) were men, and 186 (77.8%) were women. Compared to women, men were more likely to be a minority, live with their families and/or suffer from substance-related disorders. Men were less likely to be living alone or cohabitating. Women were more likely to express suicide ideation compared with men. Thirty-seven (69.8%) men and 129 (69.4%) women had mental illness. The prevalence of psychiatric diagnosis was not significantly different between men and women (χ(2)=.004, df=1, P=.95).

CONCLUSION

The rate of attempted suicide is higher among women than among men in the emergency departments of urban China. Except for race, living situation and suicide ideation, there are few gender differences regarding socio-demographic and clinical characteristics in the current study that are not consistent with reports from other countries. However, similar to other studies, men are more likely to suffer from substance-related disorders than are women. The unique, gender-specific characteristics pertaining to suicide attempters in urban China emphasizes the need for gender-specific interventions in future clinical treatment.

Retrospective identification of episodes of deliberate self-harm from emergency room registers in general hospitals: an example from Shanghai

The objective of this study was to assess the feasibility of using currently available emergency department (ED) records to retrospectively ascertain the prevalence and characteristics of episodes of medically treated deliberate self-harm (DSH). Discussions with ED staff identified 10 ED diagnoses in persons 12 years of age or older that were commonly used for episodes of DSH and another 7 injury-related diagnoses that could, under specific conditions, be acts of DSH. A retrospective analysis of the ED registry of one large general hospital in Shanghai for 2007 to 2010 identified all cases with one of these diagnoses. Diagnosis-specific algorithms based on the characteristics of each case were applied to classify cases as "probable DSH," "possible DSH" or "probably not DSH." The 1,495 cases of DSH identified accounted for 0.2% of all ED admissions over the 4 years; only 6 of them (0.4%) had an ED diagnosis of "suicide attempt." Three ED diagnoses-overdose of medication, fall from height, and pesticide ingestion-accounted for 1,275 (85.3%) of the DSH cases. There were substantial differences in the characteristics of male and female cases of DSH and a 43% drop in the proportion of ED admissions for DSH over the 4 years. In locations where it is not feasible to develop prospective registries of suicide attempts treated in EDs, retrospective analysis of ED records that use algorithms to classify the intentionality of injuries can provide estimates of the prevalence and characteristics of medically treated episodes of DSH.

Combined influence of serious mental illness and criminal offending on suicide risk in younger adults

PURPOSE

We conducted a national epidemiological study to determine how mental illness and criminal offending combine to influence suicide risk in younger adults.

METHODS

Using completely interlinked registers, we generated a nested case-control study from the cohort of all Danish people born 1965 and onwards. We identified 2,384 suicides aged 15-41 years during 1981-2006, and 56,016 age and sex-matched living controls. We examined all criminal charges from 1980, and all psychiatric admissions from 1969 and outpatient episodes from 1995. Exposure odds ratios were estimated using conditional logistic regression models.

RESULTS

A quarter of male and 17 % of female suicides had histories of both criminal justice system contact and secondary care psychiatric treatment, with a marked elevation in risk seen compared with having neither risk factor: male odds ratio (OR) 34.0, 95 % confidence interval (CI) 29.1-39.6; female OR 72.7, CI 49.4-107.1. Among those treated for psychiatric illness, contact with the criminal justice system predicted higher risk: male OR 1.4, CI 1.1-1.7; female OR 1.7, CI 1.1-2.4, although these effects were attenuated and became non-significant with adjustment for socio-demographic risk factors. In men, risk was especially high if first criminal justice system contact occurred before first psychiatric treatment episode, and if these two challenging life events coalesced within a year of each other.

CONCLUSION

These younger age adults should be monitored carefully for signs of suicidal behaviour. The need for well coordinated multiagency care is indicated, and a broad range of psychiatric illnesses should be considered carefully when assessing their suicide risk.

Exploring the impact of suicide on clinicians: a multidisciplinary retreat model

OBJECTIVE

We developed an every other year, scheduled retreat model for clinicians and trainees to explore emotional and professional reactions that they may face after a patient's suicide.

METHODS

Psychiatry ambulatory clinical staff, residents, and faculty participated in a halfday retreat, which consisted of an opening panel discussion, in which panel members related their experiences of patient suicide, break out groups, and a final panel discussion. Unlinked preand post-retreat surveys were electronically sent to all potential participants.

RESULTS

The pre-retreat survey was completed by 103 clinicians; 20% of the respondents were trainees or fellows, and 47% reported that they had experienced a patient suicide. Text responses to the pre-retreat survey reflected the wish to obtain a better understanding of the impact of patient suicide on caregivers, to cope with the event from a personal and professional standpoint, and to get a clearer understanding of what supports are available within the department. The post-retreat survey was completed by 45 clinicians. Comments after the retreat reflected an increased awareness of both shortand long-term effects on clinicians after a patient suicide and the extensive impact that a patient suicide can have on providers within their ambulatory care department.

CONCLUSION

An alldepartment ambulatory retreat model has value in providing clinicians with support and information in a structured, educational setting to help reduce the sense of stigma and provide an increased awareness of the magnitude of the impact on clinicians who experience the death of a patient by suicide.

Self-regulation of unattainable goals in suicide attempters: a two year prospective study

BACKGROUND

Although suicide is a global public health concern with approximately one million people dying by suicide annually, our knowledge of the proximal risk mechanisms is limited. In the present study, we investigated the utility of two proximal mechanisms (goal disengagement and goal reengagement) in the prediction of hospital-treated self-harm repetition in a sample of suicide attempters.

METHODS

Two hundred and thirty-seven patients hospitalised following a suicide attempt completed a range of clinical (depression, anxiety, hopelessness, suicidal ideation) and goal regulation measures (goal reengagement and disengagement) while in hospital. They were followed up two years later to determine whether they had been re-hospitalised with self-harm between baseline and the follow-up.

RESULTS

Self-harm hospitalisation in the past 10 years, suicidal ideation and difficulty reengaging in new goals independently predicted self-harm two years later. In addition, among younger people, having difficulty re-engaging in new goals further predicted self-harm re-hospitalisation when disengagement from existing unattainable goals was also low. Conversely, the deleterious impact of low reengagement in older people was elevated when goal disengagement was also high.

LIMITATIONS

Only hospital-treated self-harm and suicide were recorded at follow-up, episodes of less medically serious self-harm were not recorded.

CONCLUSIONS

Suicidal behaviour is usefully conceptualised in terms of goal self-regulation following the experience of unattainable goals. Treatment interventions should target the self-regulation of goals among suicide attempters and clinicians should recognise that different regulation processes need to be addressed at different points across the lifespan.

Suicidal ideation and temperament: an investigation among college students

BACKGROUND

Suicide is a major health problem accounting for up to 1.5 percent of all deaths worldwide and represents one of the most common causes of death in adolescents and young adults. A number of studies has been performed to establish risk factors for suicide in patients with psychiatric disorders including temperamental features. This study set out to assess the relationship between suicidal ideation and temperament in young adults.

METHODS

A cross-sectional sample of healthy college students (n=1381) was examined using a self-rating questionnaire. Suicidal ideation, social background, educational status, substance abuse, and affective temperament according to TEMPS-M were assessed. Predictors of lifetime suicidal ideation were examined in multivariate logistic regression analyses.

RESULTS

Suicidal ideation was reported by 12.5% of all subjects at some point in their life and was higher in nicotine dependents, youth with alcohol related problems and users of illicit substances as well as in youth with lower educational status. Lifetime suicidal ideation was associated with the anxious, depressive and cyclothymic temperament in both sexes and the irritable temperament in males. These results remained significant after adjustment for smoking status, frequency of alcohol consumption, drug experience and educational status in a multivariate logistic regression analysis.

LIMITATIONS

The use of self-rating instruments always reduces objectivity and introduces the possibility of misreporting.

CONCLUSIONS

Considering the fact that many subjects completing suicide have never been diagnosed with mental disorders it might be reasonable to include an investigation of temperament in screenings for risk of suicide. This might be especially useful for health care professionals without mental health care background.

Psychiatric disorders in women with fertility problems: results from a large Danish register-based cohort study

STUDY QUESTION

Do women who don't succeed in giving birth after an infertility evaluation have a higher risk of psychiatric disorders compared with women who do?

SUMMARY ANSWER

The results indicated that being unsuccessful in giving birth after an infertility evaluation could be an important risk factor for psychiatric disorders.

WHAT IS KNOWN ALREADY

Several studies have investigated the association between fertility treatment and psychological distress, but the results from these studies show substantial variation and lack of homogeneity that may be due to methodological limitations.

STUDY DESIGN, SIZE AND DURATION

A retrospective cohort study was designed using data from a cohort of 98 320 Danish women evaluated for fertility problems during 1973-2008 and linked to several Danish population-based registries. All women were followed from the date of first infertility evaluation until date of hospitalization for the psychiatric disorder in question, date of emigration, date of death or 31 December 2008, whichever occurred first. Owing to the precise linkage between the infertility cohort and the Danish population-based registries, using the unique Danish personal identification number, virtually no women were lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

Information on reproductive status for all women in the infertility cohort was obtained by linkage to the Danish Medical Birth Registry. A total of 53 547 (54.5%) women gave birth after the initial infertility evaluation, whereas 44 773 (45.5%) women did not gave birth after the evaluation. To determine psychiatric disorders diagnosed in the women after enrolment in the infertility cohort, the cohort was linked to the Danish Psychiatric Central Registry. A total of 4633 women were hospitalized for a psychiatric disorder. The Cox proportional hazard regression model was applied to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for the association between parity status after the initial infertility evaluation and risk of hospitalization for various groups of psychiatric disorders, including 'all mental disorders' and six main discharge subgroups labelled: 'alcohol and intoxicant abuse', 'schizophrenia and psychoses', 'affective disorders', 'anxiety, adjustment and obsessive compulsive disorders', 'eating disorder' and 'other mental disorders'.

MAIN RESULTS AND THE ROLE OF CHANCE

The incidence rate for all mental disorders was 393 cases per 100 000 person-years among women who did not succeed in giving birth after the infertility evaluation but only 353 cases per 100 000 person-years among women who succeeded in giving birth after the infertility evaluation. Women not giving birth after the infertility evaluation had an increased risk of hospitalization for all mental disorders (HR 1.17, 95% CI 1.11; 1.25), alcohol and intoxicant abuse (HR 2.02, 95% CI 1.69; 2.41), schizophrenia and psychoses (HR 1.46, 95% CI 1.17; 1.82) and other mental disorders (HR 1.42, 95% CI 1.27; 1.58) compared with women who gave birth after the infertility evaluation. In contrast, the risk of affective disorders (HR 0.90, 95% CI 0.81; 0.99) was decreased among women not giving birth after the infertility evaluation. Finally, the risk of anxiety, adjustment and obsessive compulsive disorders (HR 1.07, 95% CI 0.97; 1.17) as well as of eating disorders (HR 1.40, 95% CI 0.88; 2.22) was not significantly affected by parity status after the infertility evaluation.

LIMITATIONS, REASON FOR CAUTION

As only psychiatric conditions warranting hospitalization could be included in the present study, the true incidence of all psychiatric disorders among women with fertility problems is likely to be somewhat underestimated. Furthermore, since detailed information on fertility treatment was not available for all cohort members the association between different modalities of assisted reproductive techniques and risk of psychiatric disorders was not assessed.

WIDER IMPLICATIONS OF THE FINDINGS

Clinicians and other healthcare personnel involved in diagnosis and treatment of women with fertility problems should be aware of the potential risk modification of psychiatric disorders associated with unsuccessful fertility treatment. Hence, our results may point to new aspects of follow-up of women with fertility problems who are unsuccessful in giving birth in order to prevent or identify and treat these possible psychological side effects.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by the Danish Cancer Society (award number: 96 222 54). All authors report no conflicts of interest.

Oxytocin plasma levels in psychiatric patients with and without recent suicide attempt

Easily available biomarkers for suicidality would be valuable for the identification of individuals at risk. Oxytocin has been shown to be associated with mental illness. We assessed basal oxytocin plasma levels of patients with (SA, n=41) and without (NSA, n=40) a 1-year history of attempted suicide. SA and NSA groups did not differ with respect to oxytocin levels. Plasma oxytocin may not be a biological suicide marker candidate.

Suicide bereavement and complicated grief

Losing a loved to suicide is one is one of life's most painful experiences. The feelings of loss, sadness, and loneliness experienced after any death of a loved one are often magnified in suicide survivors by feelings of quilt, confusion, rejection, shame, anger, and the effects of stigma and trauma. Furthermore, survivors of suicide loss are at higher risk of developing major depression, post-traumatic stress disorder, and suicidal behaviors, as well as a prolonged form of grief called complicated grief. Added to the burden is the substantial stigma, which can keep survivors away from much needed support and healing resources. Thus, survivors may require unique supportive measures and targeted treatment to cope with their loss. After a brief description of the epidemiology and circumstances of suicide, we review the current state of research on suicide bereavement, complicated grief in suicide survivors, and grief treatment for survivors of suicide.

Suicide mortality in São Gabriel da Cachoeira, a predominantly indigenous Brazilian municipality

OBJECTIVE

To describe the characteristics and the raw suicide mortality rates (RSMR) during the period 2000-2007 in the municipality with the largest proportion of self-reported indigenous people in Brazil, São Gabriel da Cachoeira (SGC), State of Amazonas.

METHOD

A retrospective descriptive study was carried out using data from the Information Department of the Brazilian Unified Health System (DATASUS). We considered suicide the cause of death coded in the records as voluntary self-Inflicted injuries according to the International Classification of Diseases and Related Health Problems, 10th revision.

RESULTS

Forty-four suicide cases were registered in this period. The average RSMR was 16.8 per 100,000 inhabitants (male, 26.6; female, 6.3). The highest rates were observed in the age groups 15-24 years and 25-34 years, with RSMR of 43.1 and 30.2 per 100,000 inhabitants, respectively. Most suicides occurred among indigenous people (97.7%), males (81.8%), and unmarried people (70.5%). In most cases, deaths occurred at home (86.4%), during weekends (59.1%) and mainly by hanging (97.7%).

CONCLUSION

Suicide is a significant health and social problem in SGC. The suicide profile observed in this municipality was, as a whole, more similar to that observed in certain indigenous communities than that found in most urban and non-indigenous environments, demonstrating the sociocultural specificity of these events in Brazil.

Suicide risk among violent and sexual criminal offenders

Risk of suicide in people who have perpetrated specific forms of violent or sexual criminal offenses has not been quantified accurately or precisely. Also, gender comparisons have not been possible due to sparse data problems in the smaller studies that have been conducted to date. We therefore aimed to estimate these effects in the whole Danish population over a 26-year period. By completely interlinking national criminal, psychiatric, sociodemographic and cause-specific mortality registers, we conducted a nested case-control study of more than 27,000 adult suicides, during 1981-2006, and more than half a million age and gender-matched living controls. Elevated suicide risk was found in male sexual offenders. Risk was even higher among violent offenders, with greater effect sizes seen in females. It was markedly raised with serious violence, reaching a peak in relation to homicide or attempted homicide: male odds ratio (OR) 12.0, 95% confidence interval (CI) [8.3, 17.3]; female OR 30.9, CI [11.9, 80.6]. Following adjustment for psychiatric and social risk factors, relative risk in violent offenders was comparable to that seen among nonviolent offenders. These findings underline the importance of understanding why some people are violent toward themselves as well as other people, and why suicide risk is so much higher in people who have perpetrated serious acts of violence. They also indicate a clear need for developing effective multiagency interventions that effectively tackle both forms of destructive behavior.

Suicidality among adults with intellectual disability

BACKGROUND

The objective of the current study is to arrive at a better understanding of individuals with intellectual disability (ID) who threaten or attempt suicide.

METHODS

From a sample of 751 adults with ID who experienced a crisis, demographic and clinical profiles of 39 adults who threatened to commit suicide were compared to 28 adults who attempted suicide. These individuals were then compared to 337 adults who behaved aggressively toward others.

RESULTS

Individuals who attempted suicide appeared similar to those who voiced suicide with the exception that suicide attempters were younger and more likely to visit the emergency department. Females, higher functioning individuals, and persons with a history of self-harm had higher odds of attempting or threatening suicide

LIMITATIONS

Research findings based on informant reported data, so diagnoses and delivery of services in hospital cannot be validated.

CONCLUSIONS

Suicidality does occur in adults with ID, and can result in emergency department visits and hospitalizations. Recognition of variables associated with suicidality among those with ID by clinicians may allow for enhanced assessment, treatment services and ultimately more positive mental health outcomes for this group.

Anxiety symptoms and suicidal feelings in a population sample of 70-year-olds without dementia

BACKGROUND

The role of anxiety in late-life suicidal behavior has received relatively little attention. The aim was to explore the association between anxiety symptoms and suicidal feelings in a population sample of 70-year-olds without dementia, and to test whether associations would be independent of depression.

METHODS

Face-to-face interviews (N = 560) were carried out by psychiatric nurses and past month symptoms were rated with the Comprehensive Psychopathological Rating Scale (CPRS). The Brief Scale for Anxiety (BSA) was derived from the CPRS to quantify anxiety symptom burden. Past month suicidal feelings were evaluated with the Paykel questions.

RESULTS

Anxiety symptom burden was associated with suicidal feelings and the association remained after adjusting for major depression. One individual BSA item (Inner tension) was independently associated with suicidal feelings in a multivariate regression model. The association did not remain, however, in a final model in which depression symptoms replaced depression diagnosis.

CONCLUSIONS

Results from this population study suggest an association between anxiety and suicidal feelings in older adults. The role of anxiety and depression symptoms needs further clarification in the study of suicidal behavior in late life.

Ante- and perinatal circumstances and risk of attempted suicides and suicides in offspring: the Northern Finland birth cohort 1966 study

PURPOSE

To investigate those ante- and perinatal circumstances preceding suicide attempts and suicides, which have so far not been studied intensively.

METHODS

Examination of the Northern Finland Birth Cohort 1966 (n = 10,742), originally based on antenatal questionnaire data and now followed up from mid-pregnancy to age 39, to ascertain psychiatric disorders in the parents and offspring and suicides or attempted suicides in the offspring using nationwide registers.

RESULTS

A total of 121 suicide attempts (57 males) and 69 suicides (56 males) had occurred. Previously unstudied antenatal factors (maternal depressed mood and smoking, unwanted pregnancy) were not related to these after adjustment. Psychiatric disorders in the parents and offspring were the risk factors in both genders. When adjusted for these, the statistically significant risk factors among males were a single-parent family for suicide attempts (OR 3.71, 95% CI 1.62-8.50) and grand multiparity for suicides (OR 2.67, 95% CI 1.15-6.18). When a psychiatric disorder in females was included among possible risk factors for suicide attempts, it alone remained significant (OR 15.55, 8.78-27.53).

CONCLUSIONS

A single-parent family was a risk factor for attempted suicides and grand multiparity for suicides in male offspring even after adjusting for other ante- and perinatal circumstances and mental disorders in the parents and offspring. Mothers' antenatal depressed mood and smoking and unwanted pregnancy did not increase the risk of suicide, which is a novel finding.

Alcohol and Repeated Deliberate Self-Harm

Background: Repeated episode(s) of deliberate self-harm (RDSH) is a major risk factor for suicide. Aims: To identify specific risk factors for RDSH among patients admitted following an episode of deliberate self-harm (DSH) through acute intoxication. Methods: A prospective 6-month study was conducted with 184 patients (71% female) admitted to the emergency room (ER) as a result of self-poisoning (SP). Results: Rate of RDSH stood at 18% after 6 months. The sociodemographic variables associated with repeated deliberate self-harm were to have no principal activity, consultation with a medical professional during the 6 months preceding the self-poisoning, and referral to psychiatric services upon release from the ER. The clinical variable associated with RDSH was alcohol addiction (OR = 2.7; IC 95% = 1.2–6.1, p < .05) as assessed at the time of the initial ER admission. Conclusions: When patients are initially admitted to the ER as a result of self-poisoning, it is important to evaluate specific factors, particularly alcohol use, that could subsequently lead to repeated deliberate self-harm. The goal is to improve the targeting and referral of patients toward structures that can best respond to their needs.

[Suicide risk and health risk behavior among youth between the ages of 18 and 24 years: a descriptive study]

The aim of this study was to assess suicide risk and risk behavior in young people. A cross-sectional study in the urban area of Pelotas, Rio Grande do Sul State, Brazil was performed using systematic sampling with young people between the ages of 18 to 24 years. We measured the risk of suicide (MINI), behavior (YRBSS), abuse/substance dependence (ASSIST) and socioeconomic status (ABEP). Data was analyzed using SPSS software. The sample consisted of 1,560 young people and the prevalence of suicide risk was 8.6%. Suicide risk was associated with: having suffered an accident that required a visit to the emergency room (p = 0.011), fighting (p = 0.016), carrying a weapon (p = 0.001) and carrying a firearm (p ≤ 0.001), substance abuse/dependence (p ≤ 0.001), not having used a condom during the last sexual relationship (p = 0.025), not having a steady partner (p ≤ 0.001) and having sex with five or more people (p = 0.018). Young people that present risk behavior also represent a suicide risk.

Literature-based recommendations for suicide assessment in the emergency department: a review

BACKGROUND

Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide.

OBJECTIVES

Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment.

METHODS

A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed.

RESULTS

The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan.

CONCLUSION

Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.

Personality disorders, violence, and antisocial behavior: a systematic review and meta-regression analysis

The risk of antisocial outcomes in individuals with personality disorder (PD) remains uncertain. The authors synthesize the current evidence on the risks of antisocial behavior, violence, and repeat offending in PD, and they explore sources of heterogeneity in risk estimates through a systematic review and meta-regression analysis of observational studies comparing antisocial outcomes in personality disordered individuals with controls groups. Fourteen studies examined risk of antisocial and violent behavior in 10,007 individuals with PD, compared with over 12 million general population controls. There was a substantially increased risk of violent outcomes in studies with all PDs (random-effects pooled odds ratio [OR] = 3.0, 95% CI = 2.6 to 3.5). Meta-regression revealed that antisocial PD and gender were associated with higher risks (p = .01 and .07, respectively). The odds of all antisocial outcomes were also elevated. Twenty-five studies reported the risk of repeat offending in PD compared with other offenders. The risk of a repeat offense was also increased (fixed-effects pooled OR = 2.4, 95% CI = 2.2 to 2.7) in offenders with PD. The authors conclude that although PD is associated with antisocial outcomes and repeat offending, the risk appears to differ by PD category, gender, and whether individuals are offenders or not.

Suicide: An Indian perspective

Suicide is the third leading cause of death among young adults worldwide. There is a growing recognition that prevention strategies need to be tailored to the region-specific demographics of a country and to be implemented in a culturally-sensitive manner. This review explores the historical, epidemiological and demographic factors of suicide in India and examines the strategies aimed at the prevention of suicide. There has been an increase in the rates of suicide in India over the years, although trends of both increases and decline in suicide rates have been present. Distinct from global demographic risk factors, In India, marital status is not necessarily protective and the female: male ratio in the rate of suicide is higher. The motives and modes of suicide are also distinct from western countries. Preventive strategies implemented at a community level and identifying vulnerable individuals maybe more effective than global strategies.

Cigarette smoking and risk of completed suicide: a meta-analysis of prospective cohort studies

BACKGROUND

Epidemiologic studies have reported conflicting results relating smoking to suicide risk. We conducted a meta-analysis of prospective cohort studies to evaluate the association of cigarette smoking with completed suicide.

METHODS

Eligible prospective cohort studies were identified from PubMed and EMbase databases (from 1966 to May 2011) and the reference lists of retrieved articles. Two authors independently extracted data and assessed study quality using the Newcastle-Ottawa Scale. Study-specific risk estimates were pooled using random-effects model and generalized least squares trend estimation was used to assess dose-response relationship.

RESULTS

Fifteen prospective cohort studies involving 2395 cases among 1,369,807 participants were included in the meta-analysis. Our data suggested that cigarette smoking significantly increased the risk of completed suicide. Compared with never smokers, the pooled RR was 1.28 (95% CI: 1.001-1.641) for former smokers, and 1.81 (95% CI: 1.50-2.19) for current smokers, respectively. Subgroup analyses showed that the increased suicide risk among current smokers appeared to be consistent, although there was heterogeneity among studies of current smoking (p < 0.001). Significant dose-response relationship was found between smoking and suicide, and the risk of suicide was increased by 24% for each increment of 10 cigarettes smoked per day (RR, 1.24; 95% CI: 1.20-1.28).

CONCLUSIONS

Our meta-analysis robustly demonstrates that cigarette smoking is associated with an increased risk of completed suicide, consistent with a dose-response relationship. This conclusion has an important public health message for countries with high smoking prevalence and high suicide rate such as China.

Deficit of cognitive inhibition in depressed elderly: a neurocognitive marker of suicidal risk

BACKGROUND

Cognitive deficits, in relation to ventral and dorsal prefrontal cortex dysfunctions, have been associated with a higher risk of suicidal acts in young adult patients. Although a public health concern, much less is known about the neurocognitive basis of suicidal behavior in elderly. Here, we aimed at assessing alterations in cognitive inhibition, a suspected major mechanism of the suicidal vulnerability, in suicidal depressed elderly.

METHODS

We compared 20 currently depressed patients, aged 65 and older who recently attempted suicide to 20 elderly subjects with a current depression but no personal history of suicide attempt and 20 elderly controls. Using an extensive neuropsychological battery, we particularly examined different aspects of cognitive inhibition: access to relevant information (using the Reading with distraction task), suppression of no longer relevant information (Trail Making Test, Rule Shift Cards), and restraint of cognitive resources to relevant information (Stroop test, Hayling Sentence Completion test, Go/No-Go).

RESULTS

After adjustment for age, intensity of depression, Mini-Mental State Examination score and speed of information processing, suicidal depressed elderly showed significant impairments in all 3 domains of cognitive inhibition in comparison to both control groups.

LIMITATIONS

Our results need replication in a larger sample size.

CONCLUSIONS

Our study suggests that the inability to inhibit neutral information access to working memory, restrain and delete irrelevant information may impair the patient's capacity to respond adequately to stressful situations subsequently leading to an increased risk of suicidal behavior during late-life depression. Interventions may be developed to specifically target cognitive impairment in the prevention of suicide in depressed elderly.

Non-fatal suicide attempt by intentional stab wound: Clinical management, psychiatric assessment, and multidisciplinary considerations

Background:

Suicide by means of self-inflicted stab wounds is relatively uncommon and little is known about this population and their management.

Materials and Methods:

Retrospective review of adult trauma patients admitted to our Level-1 trauma center between January 2005 and October 2009 for management of non-fatal, self-inflicted stab wounds.

Results:

Fifty-eight patients were evaluated with self-inflicted stab wounds. Four patients died due to their injuries (mortality, 7%). Of the non-fatal stab wounds, 78% were male ranging in age from 19-82 (mean: 45 years). The most common injury sites were the abdomen (46%), neck (33%), and chest (20%). In terms of operative interventions, 56% of abdominal operations were therapeutic, whereas 100% of neck and chest operations were therapeutic. When assessing for suicidal ideation, 44 patients (81%) admitted to suicidal intentions whereas 10 patients (19%) described accidental circumstances. Following psychiatric evaluation, 8 of the 10 patients with “accidental injuries” were found to be suicidal. Overall, 54 patients (98%) met criteria for a formal psychiatric diagnosis with 48 patients (89%) necessitating inpatient or outpatient psychiatric assistance at discharge.

Conclusions:

Compared to previous reports of stab wounds among trauma patients, patients with self- inflicted stab wounds may have a higher incidence of operative interventions and significant injuries depending on the stab location. When circumstances surrounding a self-inflicted stabbing are suspicious, additional interviews by psychiatric care providers may uncover a suicidal basis to the event. Given the increased incidence of psychiatric illness in this population, it is imperative to approach the suicidal patient in a multidisciplinary fashion.

Employment status, inflation and suicidal behaviour: an analysis of a stratified sample in Italy

BACKGROUND

There is abundant empirical evidence of a surplus risk of suicide among the unemployed, although few studies have investigated the influence of economic downturns on suicidal behaviours in an employment status-stratified sample.

AIMS

We investigated how economic inflation affected suicidal behaviours according to employment status in Italy from 2001 to 2008.

METHODS

Data concerning economically active people were provided by the Italian Institute for Statistical Analysis and by the International Monetary Fund. The association between inflation and completed versus attempted suicide with respect to employment status was investigated in every year and quarter-year of the study time frame. We considered three occupational categories: employed, unemployed who were previously employed and unemployed who had never worked.

RESULTS

The unemployed are at higher suicide risk than the employed. Among the PE, a significant association between inflation and suicide attempt was found, whereas no association was reported concerning completed suicides. No association was found between completed and attempted suicides among the employed, the NE and inflation. Completed suicide in females is significantly associated with unemployment in every quarter-year.

CONCLUSION

The reported vulnerability to suicidal behaviours among the PE as inflation rises underlines the need of effective support strategies for both genders in times of economic downturns.

Suicide in the US Army

Suicide in the US Army is a high-profile public health problem that is complex and poorly understood. Adding to the confusion surrounding Army suicide is the challenge of defining and understanding individuals/populations dying by suicide. Data from recent studies have led to a better understanding of risk factors for suicide that may be specifically associated with military service, including the impact of combat and deployment on increased rates of psychiatric illness in military personnel. The next steps involve applying these results to the development of empirically supported suicide prevention approaches specific to the military population. This special article provides an overview of suicide in the Army by synthesizing new information and providing clinical pearls based on research evidence.

Suicide rates and income in São Paulo and Brazil: a temporal and spatial epidemiologic analysis from 1996 to 2008

BACKGROUND

In a classical study, Durkheim noted a direct relation between suicide rates and wealth in the XIX century France. Since that time, several studies have verified this relationship. It is known that suicide rates are associated with income, although the direction of this association varies worldwide. Brazil presents a heterogeneous distribution of income and suicide across its territory; however, evaluation for an association between these variables has shown mixed results. We aimed to evaluate the relationship between suicide rates and income in Brazil, State of São Paulo (SP), and City of SP, considering geographical area and temporal trends.

METHODS

Data were extracted from the National and State official statistics departments. Three socioeconomic areas were considered according to income, from the wealthiest (area 1) to the poorest (area 3). We also considered three regions: country-wide (27 Brazilian States and 558 Brazilian micro-regions), state-wide (645 counties of SP State), and city-wide (96 districts of SP city). Relative risks (RR) were calculated among areas 1, 2, and 3 for all regions, in a cross-sectional approach. Then, we used Joinpoint analysis to explore the temporal trends of suicide rates and SaTScan to investigate geographical clusters of high/low suicide rates across the territory.

RESULTS

Suicide rates in Brazil, the State of SP, and the city of SP were 6.2, 6.6, and 5.4 per 100,000, respectively. Taking suicide rates of the poorest area (3) as reference, the RR for the wealthiest area was 1.64, 0.88, and 1.65 for Brazil, State of SP, and city of SP, respectively (p for trend <0.05 for all analyses). Spatial cluster of high suicide rates were identified at Brazilian southern (RR = 2.37), state of SP western (RR = 1.32), and city of SP central (RR = 1.65) regions. A direct association between income and suicide were found for Brazil (OR = 2.59) and the city of SP (OR = 1.07), and an inverse association for the state of SP (OR = 0.49).

CONCLUSIONS

Temporospatial analyses revealed higher suicide rates in wealthier areas in Brazil and the city of SP and in poorer areas in the State of SP. We further discuss the role of socioeconomic characteristics for explaining these discrepancies and the importance of our findings in public health policies. Similar studies in other Brazilian States and developing countries are warranted.

Spatial clusters of suicide in the municipality of São Paulo 1996-2005: an ecological study

BACKGROUND

In a classical study, Durkheim mapped suicide rates, wealth, and low family density and realized that they clustered in northern France. Assessing others variables, such as religious society, he constructed a framework for the analysis of the suicide, which still allows international comparisons using the same basic methodology. The present study aims to identify possible significantly clusters of suicide in the city of São Paulo, and then, verify their statistical associations with socio-economic and cultural characteristics.

METHODS

A spatial scan statistical test was performed to analyze the geographical pattern of suicide deaths of residents in the city of São Paulo by Administrative District, from 1996 to 2005. Relative risks and high and/or low clusters were calculated accounting for gender and age as co-variates, were analyzed using spatial scan statistics to identify geographical patterns. Logistic regression was used to estimate associations with socioeconomic variables, considering, the spatial cluster of high suicide rates as the response variable. Drawing from Durkheim's original work, current World Health Organization (WHO) reports and recent reviews, the following independent variables were considered: marital status, income, education, religion, and migration.

RESULTS

The mean suicide rate was 4.1/100,000 inhabitant-years. Against this baseline, two clusters were identified: the first, of increased risk (RR=1.66), comprising 18 districts in the central region; the second, of decreased risk (RR=0.78), including 14 districts in the southern region. The downtown area toward the southwestern region of the city displayed the highest risk for suicide, and though the overall risk may be considered low, the rate climbs up to an intermediate level in this region. One logistic regression analysis contrasted the risk cluster (18 districts) against the other remaining 78 districts, testing the effects of socioeconomic-cultural variables. The following categories of proportion of persons within the clusters were identified as risk factors: singles (OR=2.36), migrants (OR=1.50), Catholics (OR=1.37) and higher income (OR=1.06). In a second logistic model, likewise conceived, the following categories of proportion of persons were identified as protective factors: married (OR=0.49) and Evangelical (OR=0.60).

CONCLUSIONS

This risk/ protection profile is in accordance with the interpretation that, as a social phenomenon, suicide is related to social isolation. Thus, the classical framework put forward by Durkheim seems to still hold, even though its categorical expression requires re-interpretation.

Effect of assertive outreach after suicide attempt in the AID (assertive intervention for deliberate self harm) trial: randomised controlled trial

OBJECTIVE

To assess whether an assertive outreach intervention after suicide attempt could reduce the frequency of subsequent suicidal acts, compared with standard treatment.

DESIGN

Randomised, parallel group, superiority trial with blinded outcome assessment.

SETTING

Outpatient intervention at one location at Copenhagen University Hospital, Denmark.

PARTICIPANTS

Patients older than 12 years admitted to regional hospitals in Copenhagen with a suicide attempt within the past 14 days. We excluded patients diagnosed with schizophrenia spectrum disorders and patients living in institutions.

INTERVENTION

Case management through assertive outreach that provided crisis intervention and flexible problem solving. This approach incorporated motivational support and actively assisted patients to scheduled appointments to improve adherence with after-treatment as an add on to standard treatment.

MAIN OUTCOME

Repeated suicide attempt and death by suicide, recorded in medical records and death register at 1-year follow-up.

RESULTS

243 patients were included. During 12 months of follow-up, 20/123 (16%) patients in the intervention group had been registered in hospital records with subsequent suicide attempt, compared with 13/120 (11%) in the control group (odds ratio 1.60, 95% confidence interval 0.76 to 3.38; P=0.22). By contrast, self reported data on new events showed 11/95 (12%) in the intervention group versus 13/74 (18%) in the control group (0.61, 0.26 to 1.46; P=0.27). By imputing missing data on the selfreported outcomes, we estimated 15/123 (12%) events in the intervention group and 23/120 (19%) in the control group (0.69, 0.34 to 1.43; P=0.32).

CONCLUSION

Assertive outreach showed no significant effect on subsequent suicide attempt. The difference in rates of events between register data and self reported data could indicate detection bias.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00700089.

Religious and spiritual factors in depression: review and integration of the research

Depressive symptoms and religious/spiritual (R/S) practices are widespread around the world, but their intersection has received relatively little attention from mainstream mental health professionals. This paper reviews and synthesizes quantitative research examining relationships between R/S involvement and depressive symptoms or disorders during the last 50 years (1962 to 2011). At least 444 studies have now quantitatively examined these relationships. Of those, over 60% report less depression and faster remission from depression in those more R/S or a reduction in depression severity in response to an R/S intervention. In contrast, only 6% report greater depression. Of the 178 most methodologically rigorous studies, 119 (67%) find inverse relationships between R/S and depression. Religious beliefs and practices may help people to cope better with stressful life circumstances, give meaning and hope, and surround depressed persons with a supportive community. In some populations or individuals, however, religious beliefs may increase guilt and lead to discouragement as people fail to live up to the high standards of their religious tradition. Understanding the role that R/S factors play in preventing depression, facilitating its resolution, or leading to greater depression will help clinicians determine whether this is a resource or a liability for individual patients.

Forty years of increasing suicide mortality in Poland: undercounting amidst a hanging epidemic?

Background

Suicide rate trends for Poland, one of the most populous countries in Europe, are not well documented. Moreover, the quality of the official Polish suicide statistics is unknown and requires in-depth investigation.

Methods

Population and mortality data disaggregated by sex, age, manner, and cause were obtained from the Polish Central Statistics Office for the period 1970-2009. Suicides and deaths categorized as ‘undetermined injury intent,’ ‘unknown causes,’ and ‘unintentional poisonings’ were analyzed to estimate the reliability and sensitivity of suicide certification in Poland over three periods covered by ICD-8, ICD-9 and ICD-10, respectively. Time trends were assessed by the Spearman test for trend.

Results

The official suicide rate increased by 51.3% in Poland between 1970 and 2009. There was an increasing excess suicide rate for males, culminating in a male-to-female ratio of 7:1. The dominant method, hanging, comprised 90% of all suicides by 2009. Factoring in deaths of undetermined intent only, estimated sensitivity of suicide certification was 77% overall, but lower for females than males. Not increasing linearly with age, the suicide rate peaked at ages 40-54 years.

Conclusion

The suicide rate is increasing in Poland, which calls for a national prevention initiative. Hangings are the predominant suicide method based on official registration. However, suicide among females appears grossly underestimated given their lower estimated sensitivity of suicide certification, greater use of “soft” suicide methods, and the very high 7:1 male-to-female rate ratio. Changes in the ICD classification system resulted in a temporary suicide data blackout in 1980-1982, and significant modifications of the death categories of senility and unknown causes, after 1997, suggest the need for data quality surveillance.

Mortalidade por suicídio em pessoas com 60 anos ou mais nos municípios brasileiros no período de 1996 a 2007

Este trabalho teve como objetivo conhecer a magnitude do suicídio em idosos em nível nacional. Foi feita uma descrição da mortalidade por suicídio nos municípios brasileiros, visando estabelecer aqueles de maior frequência do evento. Empregou-se dados do Sistema de Informação sobre Mortalidade (SIM/MS) para o período de 1996 a 2007 (triênios), sendo utilizados os eventos com códigos X60 a X84 e Y87.0 da 10ª revisão da Classificação Internacional de Doenças (CID-10). As taxas foram padronizadas segundo critérios da OMS. Verificou-se que 3.039 municípios brasileiros têm registros de casos de suicídio de pessoas com 60 anos ou mais em pelo menos um dos triênios analisados (54,6% do total de municípios). Um total de 29,3% de municípios se localiza na região Sul, 29,6%, na região Sudeste e 27,5% na região Nordeste. O Rio Grande do Sul concentra o maior percentual de municípios com casos nos quatro triênios (27,3%), sendo seguido pelos estados de São Paulo (17,4%) e Santa Catarina (9,1%). Quanto à evolução temporal, observou-se redução das taxas do triênio inicial para o triênio final em 32 dos 51 municípios com taxas mais elevadas em todo o período de análise. A razão média de óbitos homem/mulher foi de 2,8 mortes masculinas para cada morte feminina. O principal meio empregado é o enforcamento, estrangulamento e sufocação tanto entre homens (58,2%) quanto entre mulheres (49,8%).

Multiple substance use and self-reported suicide attempts by adolescents in 16 European countries

Substance use and suicide attempts are high-risk behaviors in adolescents, with serious impacts on health and well-being. Although multiple substance use among young people has become a common phenomenon, studies of its association with suicide attempts are scarce. The present study examines the association between multiple substance use and self-reported suicide attempts in a large multinational sample of adolescent students in Europe. Data on multiple substance use (tobacco, alcohol, tranquillizers/sedatives, cannabis, other illegal drugs) and self-reported suicide attempts were drawn from the 2007 European School Survey Project on Alcohol and Other Drugs (ESPAD). The ESPAD survey follows a standardized methodology in all participating countries. The present study is based on 45,086 16-year-old adolescents from 16 countries that had used the optional "psychosocial module" of the questionnaire, thereby including the question on suicide attempts. Logistic regression analyses were performed to examine the associations of any self-reported suicide attempt (dependent variable) with substance use controlling for country and gender. The strongest association with self-reported suicide attempts was for any lifetime tranquillizer or sedative use (odds ratio 3.34, 95 % confidence interval 3.00-3.71) followed by any lifetime use of illegal drugs other than cannabis (2.41, 2.14-2.70), 30-day regular tobacco use (2.02, 1.84-2.21), 30-day frequent alcohol use (1.47, 1.32-1.63) and any 30-day cannabis use (1.37, 1.18-1.58). The odds ratio of reporting a suicide attempt approximately doubled for every additional substance used. These findings on the association between multiple substance use, including legal drugs (tranquillizers or sedatives and tobacco), and the life-threatening behavior of suicide attempts provide important cues for shaping prevention policies.

Hopelessness, defeat, and entrapment in posttraumatic stress disorder: their association with suicidal behavior and severity of depression

Research has shown an increased frequency of suicidal behaviors in those with PTSD, but few studies have investigated the factors that underlie the emergence of suicidal behavior in PTSD. Two theories of suicide, the Cry of Pain and the Schematic Appraisal Model of Suicide, propose that feelings of hopelessness, defeat, and entrapment are core components of suicidality. This study aimed to examine the association between suicidal behavior and hopelessness, defeat, and entrapment in trauma victims with and without a PTSD diagnosis. The results demonstrated that hopelessness, defeat, and entrapment were significantly positively associated with suicidal behavior in those with PTSD. Hopelessness and defeat were also significantly positively associated with suicidal behavior in trauma victims without PTSD. In those with PTSD, the relationship between suicidal behavior and hopelessness and entrapment remained significant after controlling for comorbid depression. The findings provide support for the contemporary theories of suicidality and have important clinical implications.

Fatores associados com a mortalidade por suicídio de idosos nos municípios brasileiros no período de 2005-2007

Este trabalho teve como objetivo realizar análise ecológica sobre suicídio de pessoas com 60 anos ou mais nos municípios brasileiros no triênio 2005-2007, investigando-se fatores associados ao evento. Foram utilizados dados referentes aos óbitos por suicídio extraídos do Sistema de Informação sobre Mortalidade (SIM), códigos X60 a X86 e Y87.0 (CID-10). Foram ajustados modelos de regressão de Poisson, binomial negativa e binomial negativa inflacionada de zeros (ZINB). Este último exibiu os melhores resultados quando da comparação de modelos. Foram identificados como fatores associados ao suicídio: proporção de não brancos (associação negativa), taxa de internação por transtornos de humor (associação positiva) e razão de sexo (associação negativa).

Suicide by pedestrian versus motor vehicle: a case report

Suicide is the deliberate act of ending one's own life. Historically, men commit suicide more frequently than do women; however, rates have increased for women worldwide in recent years. Transportation injuries have been widely reported as means of suicide such as operators of motor vehicles or jumpers into the pathway of trains. Few definitive reports exist of pedestrians deliberately jumping into the pathway of a motor vehicle. A security camera demonstrates a pedestrian deliberately entering the pathway of a moving vehicle resulting in death from multiple blunt force trauma.

Factors associated with suicidal behaviors in mainland China: a meta-analysis

Background

Suicide is a major public health issue in China. Studies of suicide risk factors have reported both inconsistent and inconclusive results. This review aimed to determine suicide risk factors in China.

Methods

Medline/PubMed, EMBASE, CNKI (China National Knowledge Infrastructure) and VIP (Chinese Journal of Science and Technology of VIP) were searched for relevant reports. Two investigators independently assessed the eligibility of identified studies and extracted data. Pooled odds ratios (and 95% confidence intervals) were calculated for each factor with Revman 5.0.

Results

Forty-four studies with 192,362 subjects were included. The pooled results indicated that mood disorders and stressful life events (physical illness, suicide of relatives) increased the risk of suicide ideation among the entire population. Socio-family environment (single or remarried parent, study pressure and academic achievement) and unhealthy behaviors (smoking, alcohol drinking, and drug use) were risk factors for suicide ideation among youth. Unhealthy behaviors (smoking and alcohol drinking), mood disorders, and stressful life events (suicide of relatives) were the main risk factors for attempted suicide. Persons living in rural areas, and those with lower education, mood disorders, and/or a history of negative life events had a higher risk of completed suicide. In China, before 2000, females had a significantly higher rate of completed suicide than males, while after 2000, no significant gender difference was found.

Conclusions

Socio-family environment, lifestyle, life events and psychiatric/psychological factors are associated with suicidal behaviors in China. Further case–control or cohort studies are needed to better understand suicide behaviors in China. Meanwhile, there is an urgent need for comprehensive studies of suicide interventions among high-risk populations.

A systematic review of help-seeking interventions for depression, anxiety and general psychological distress

BACKGROUND

Depression and anxiety are treatable disorders, yet many people do not seek professional help. Interventions designed to improve help-seeking attitudes and increase help-seeking intentions and behaviour have been evaluated in recent times. However, there have been no systematic reviews of the efficacy or effectiveness of these interventions in promoting help-seeking. Therefore, this paper reports a systematic review of published randomised controlled trials targeting help-seeking attitudes, intentions or behaviours for depression, anxiety, and general psychological distress.

METHODS

Studies were identified through searches of PubMed, PsycInfo, and the Cochrane database in November 2011. Studies were included if they included a randomised controlled trial of at least one intervention targeting help-seeking for depression or anxiety or general psychological distress, and contained extractable data on help-seeking attitudes or intentions or behaviour. Studies were excluded if they focused on problems or conditions other than the target (e.g., substance use, eating disorder).

RESULTS

Six published studies of randomised controlled trials investigating eight different interventions for help-seeking were identified. The majority of trials targeted young adults. Mental health literacy content was effective (d = .12 to .53) in improving help-seeking attitudes in the majority of studies at post-intervention, but had no effect on help-seeking behaviour (d = -.01, .02). There was less evidence for other intervention types such as efforts to destigmatise or provide help-seeking source information.

CONCLUSIONS

Mental health literacy interventions are a promising method for promoting positive help-seeking attitudes, but there is no evidence that it leads to help-seeking behaviour. Further research investigating the effects of interventions on attitudes, intentions, and behaviour is required.

Age-adjusted relative suicide risk by marital and employment status over the past 25 years in Japan

BACKGROUND

There have been no longitudinal studies in Japan examining national-level data for suicide risk by marital and employment status. We examined the age-adjusted relative suicide risk (RR) by marital and employment status from national data acquired for all suicides in Japan occurring in the past 25 years.

METHODS

All deaths identified as suicides according to ICD-9 and ICD-10 were extracted from vital statistics data of Japan for the years 1980, 1985, 1990, 1995, 2000 and 2005. Population statistics for Japanese residents aged ≥15 years were obtained from the census.

RESULTS

Suicide rates for almost all categories analyzed decreased in both genders between 1985 and 1990 and increased between 1995 and 2000, especially among men. Unemployed and divorced men had a consistently higher RR in each year analyzed. Unemployed and divorced women had a higher risk than those in other categories, especially in 2000 and 2005. In women, particularly in 1980, 1985 and 1990, those who were unemployed and never married had a similar RR to those who were unemployed and divorced.

CONCLUSIONS

Unemployed and divorced people were at a high risk of suicide over the past 25 years, particularly in 2000 and 2005. Our findings suggest that the effects of divorce and unemployment on suicide risk are synergistic.