Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study

Self-harm in the Australian asylum seeker population: A national records-based study

Background

Systematic research into self-harm in the Australian asylum seeker population is scarce, largely due to the lack of accessible data. The aim of this study was to examine the incidence and characteristics of self-harm across the Australian asylum seeker population, and to ascertain whether self-harm rates and characteristics vary by processing arrangements (i.e. community-based arrangements, community detention, onshore detention, offshore detention (Nauru), and offshore detention (Manus Island)), and gender.

Methods

Data relating to the incidence of self-harm, method(s) used to self-harm, processing arrangements, and gender were extracted from all self-harm incidents recorded as occurring among the Australian asylum seeker population between 1st August 2014 and 31st July 2015. Self-harm episode rates were calculated using the average estimated adult population figures for the 12-month period for each asylum seeker population.

Results

949 self-harm episodes were included in the analyses. Rates ranged from 5 per 1000 asylum seekers in community-based arrangements to 260 per 1000 asylum seekers in offshore detention in Nauru. Rates were highest among asylum seekers in offshore and onshore detention facilities, and lowest among asylum seekers in community-based arrangements and community detention. The most common methods of self-harm were cutting (37%), self-battery (26%), and attempted hanging (11%), with asylum seekers in held detention using a wider variety of methods than those in community-based arrangements and community detention.

Conclusions

Our findings highlight the exceptionally high rates of self-harm among detained asylum seekers compared to rates observed in the general Australian population, and among asylum seekers in community-based settings. These findings point clearly to the deleterious impact of immigration detention, and warrant urgent attention.

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Rates of self-harm among asylum seekers were exceptionally high.

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Rates were highest in held detention, lowest in community-based settings.

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High rates of hanging were observed for both women and men.

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Asylum seekers in held detention used a wide variety of self-harm methods.

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Findings point to the deleterious impact of immigration detention.

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation

Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation.

Engagement in physical activity, suicidal thoughts and suicide attempts among older people in five developing countries

BACKGROUND

Suicide causes rising economic costs and public health risks for communities in the worldwide. Physical activity (PA) is considered a potentially feasible approach to reduce risk of suicide with low cost and high accessibility, and therefore attracting increasing attention. However, current literature on the association between PA and suicidal behavior amongst elderly people in low- and middle-income countries (LMICs) are scarce. Therefore, in this study we aimed to examine the relationship between suicidal thoughts (ST) and suicidal attempts (SA) with PA among elderly people in five LMICs.

METHODS

Cross-sectional data were collected from WHO's Study of Global Ageing and Adult Health (SAGE) with 2,861 participants aged 50 years or above. Variables included: self-reported occurrence of ST and SA during past 12 months and four types of PA (vigorous physical activity (VPA), moderate physical activity (MPA), walking/bike riding, moderate leisure time physical activity (MLPA)).

RESULTS

The overall prevalence of taking >75 min of VPA/week, >150 min/week, MLPA and walking/bike riding were, respectively, 85.4% (95% CI [81.3-88.7]), 61.6% (95% CI [52.9-69.6]), 9.6% (95% CI [7.2-12.6]) and 75.1% (95% CI [68.7-80.6]). Respectively, 31.0% (95% CI [24.3-38.7]) and 5.5% (95% CI [3.9-7.5]) of the respondents reported having morbid thoughts and SA during last 12 months. In adjusted multivariable regression analysis, not engaging in PA revealed positive association with higher odds of having morbid thoughts and SA, however, with varying degrees for different types of PA among men and women and across countries. The adjusted odds ratio among elderly who encountered ST increased significantly with PA levels (1.265 in male and 1.509 in female with VPA, 1.292 in male and 1.449 in female with MPA, 1.669 in female with LMPA and 3.039 in women with walk/bike); similarly, with SA (1.526, 1.532, 1.474 and 1.392 in women with VPA, MPA, LMPA and Walk/bike, respectively). The degree of adjusted odds ratio varied between genders and among countries.

CONCLUSION

Although the data were cross-sectional, and no linear dose-response relationship was observed between PA and morbid thought and suicide ideation, the findings provide important indications of potential harmful effects of no/inadequate PA on psychological morbidities among older individuals. Promoting adequate PA among older individuals through community-based suicide prevention programs can potentially contribute to reduction in the burden of PA in LMICs.

Suicide attempts by jumping and length of stay in general hospital: A retrospective study of 225 patients

OBJECTIVE

Violent suicide attempts, such as jumping from a height, frequently lead to hospitalization in general hospital with high length of stay (LOS). We investigated features associated with LOS in this context.

METHODS

We retrospectively included all patients admitted after suicide attempts by jumping in non-psychiatric wards of a university hospital between 2008 and 2016. Several socio-demographic and clinical data were collected, including psychiatric diagnoses, coded with the International Classification of Diseases-10th Revision. We used general linear models to identify factors associated with LOS.

RESULTS

Among 225 patients (125 men; mean age ± sd: 37.5 ± 15.4 years), several clinical factors were independently associated with a longer LOS: number of injuries (β = 8.2 p < .001), external fixator (β = 18.1 p = .01), psychotic disorder (β = 14.6 p = .02) and delirium (β = 16.6 p = .005). Admission in psychiatric ward at discharge tended to be associated with lower LOS (β = -15.3 p = .07).

CONCLUSION

In patients admitted in non-psychiatric wards after suicide attempt by jumping, the presence of a psychotic disorder may increase LOS by several days, and indirectly costs of hospitalization, to a similar extent of non-psychiatric factors. The association of transfer in psychiatric ward with lower LOS suggests that the psychiatric disorder might interfere with medical care.

Psychological and psychiatric aspects of face transplantation: Lessons learned from the long-term follow-up of six patients

Since 2005, at least 38 face transplantations have been performed worldwide. Available recommendations on psychological management are based on isolated cases or small case series, either not focused on mental health or with a short follow-up. We propose herein a clinical commentary on psychological and psychiatric outcomes from the follow-up of a prospective single-center cohort of six patients over a period of 3.5 to 9 years. Seven patients received a face transplant between January 2007 and April 2011: two patients with neurofibromatosis, four with self-inflicted ballistic trauma, one with self-immolation. One patient died at 63 days of cerebral sequelae from cardiac arrest in the setting of bacterial infection. The six other patients were routinely evaluated with unstructured psychological interviews up to May 2016 and with the Short Form 36-item health survey and the Mini-International Neuropsychiatric Interview at one year and at the end of the follow-up. Clinically meaningful observations were the following: a history of mental disorders before disfigurement was associated with poor physical and mental outcomes, including poor adherence and one suicide; untreated depression was associated with poor adherence; acceptance of the new face occurred rapidly and without significant distress in all of the patients; fear of transplant rejection was present to some degree in all of the patients and did not substantially differ from other transplantation settings; media exposure may be disturbing but may also have had positive psychological effects on some of the patients. Mental health issues related to chronic rejection and re-transplantation remain to be explored.

Method of self-harm and risk of self-harm repetition: findings from a national self-harm registry

BACKGROUND

Risk of self-harm repetition has consistently been shown to be higher following self-cutting compared to intentional drug overdose (IDO) and other self-harm methods. The utility of previous evidence is limited due to the large heterogeneous method categories studied. This study examined risk of hospital presented self-harm repetition according to specific characteristics of self-harm methods.

METHODS

Data on consecutive self-harm presentations to hospital emergency departments (2010-2016) were obtained from the National Self-Harm Registry Ireland. Associations between self-harm method and repetition were analysed using survival analyses.

RESULTS

Overall, 65,690 self-harm presentations were made involving 46,661 individuals. Self-harm methods associated with increased repetition risk included minor self-cutting, severe self-cutting, multiple drug IDOs involving psychotropic drugs and self-harm by blunt object. Minor self-cutting was the method associated with highest repetition risk (adjusted hazard ratio (AHR) 1.38, 95% CI 1.31-1.45). Risk of repetition was comparable following IDOs of four or more drugs involving psychotropic drugs (AHR = 1.29, 95% CI 1.20-1.39), severe self-cutting (AHR 1.25, 95% CI 1.16-1.34) and blunt object (AHR = 1.23, 95% CI 1.07-1.42).

LIMITATIONS

Information was not available on suicide or other causes of mortality.

CONCLUSIONS

Self-harm method and the associated risk of repetition should form a core part of biopsychosocial assessments and should inform follow-up care for self-harm patients. The observed differences in repetition associated with specific characteristics of IDO underline the importance of safety planning and monitoring prescribing for people who have engaged in IDO.

The prediction of suicide in severe mental illness: development and validation of a clinical prediction rule (OxMIS)

Assessment of suicide risk in individuals with severe mental illness is currently inconsistent, and based on clinical decision-making with or without tools developed for other purposes. We aimed to develop and validate a predictive model for suicide using data from linked population-based registers in individuals with severe mental illness. A national cohort of 75,158 Swedish individuals aged 15-65 with a diagnosis of severe mental illness (schizophrenia-spectrum disorders, and bipolar disorder) with 574,018 clinical patient episodes between 2001 and 2008, split into development (58,771 patients, 494 suicides) and external validation (16,387 patients, 139 suicides) samples. A multivariable derivation model was developed to determine the strength of pre-specified routinely collected socio-demographic and clinical risk factors, and then tested in external validation. We measured discrimination and calibration for prediction of suicide at 1 year using specified risk cut-offs. A 17-item clinical risk prediction model for suicide was developed and showed moderately good measures of discrimination (c-index 0.71) and calibration. For risk of suicide at 1 year, using a pre-specified 1% cut-off, sensitivity was 55% (95% confidence interval [CI] 47-63%) and specificity was 75% (95% CI 74-75%). Positive and negative predictive values were 2% and 99%, respectively. The model was used to generate a simple freely available web-based probability-based risk calculator (Oxford Mental Illness and Suicide tool or OxMIS) without categorical cut-offs. A scalable prediction score for suicide in individuals with severe mental illness is feasible. If validated in other samples and linked to effective interventions, using a probability score may assist clinical decision-making.

Recurrence and mortality 1 year after hospital admission for non-fatal self-harm: a nationwide population-based study

AIMS

A large number of people present each day at hospitals for non-fatal deliberate self-harm (DSH). Examination of the short-term risk of non-fatal recurrence and mortality at the national level is of major importance for both individual medical decision-making and global organisation of care.

METHODS

Following the almost exhaustive linkage (96%) of two national registries in France covering 45 million inhabitants (i.e. 70% of the whole population), information about hospitalisation for DSH in 2008-2009 and vital status at 1 year was obtained. Individuals who died during the index hospital stay were excluded from analyses.

RESULTS

Over 2 years, 136,451 individuals were hospitalised in medicine or surgery for DSH. The sample comprised 62.8% women, median age 38 in both genders, with two peaks at 16 and 44 years in women, and one peak at 37 years in men. The method used for DSH was drug overdose in 82.1% of cases. Admission to an intensive care unit occurred in 12.9%. Following index hospitalisation, 71.3% returned home and 23.7% were transferred to a psychiatric inpatient care unit. DSH recurrence during the following year occurred in 12.4% of the sample, within the first 6 months in 75.2%, and only once in 74.6%. At 1 year, 2.6% of the sample had died. The overall standardised mortality ratio was 7.5 but reached more than 20 in young adults. The causes were natural causes (35.7%), suicide (34.4%), unspecified cause (17.5%) and accident (12.4%). Most (62.9%) deaths by suicide occurred within the first 6 months following index DSH. Violent means (i.e. not drug overdose) were used in 70% of suicide cases. Concordance between means used for index DSH and for suicide was low (30% overall), except for drug overdose. Main suicide risk factors were older age, being male, use of a violent means at index DSH, index admission to an intensive care unit, a transfer to another medical department or to a psychiatric inpatient unit, and recurrence of DSH. However, these factors had low positive predictive values individually (below 2%).

CONCLUSIONS

Non-fatal DSH represent frequent events with a significant risk of short-term recurrence and death from various causes. The first 6 months following hospital discharge appear to be a critical period. Specific short-term aftercare programs targeting all people with a DSH episode have to be developed, along other suicide prevention strategies.

Suicidal Risk and Affective Temperaments, Evaluated with the TEMPS-A Scale: A Systematic Review

BACKGROUND

Among risk factors for suicidal behavior, there is growing interest in associations with stable affective temperament types, particularly based on assessment with the TEMPS-A self-rating scale.

AIM

As research on this topic has not been reviewed systematically, we synthesized relevant, reported research findings.

METHODS

Systematic searching identified peer-reviewed reports pertaining to associations of suicidal behavior or ideation with affective temperament types evaluated with TEMPS-A. We summarized available findings and applied quantitative meta-analytic methods to compare scale scores in suicidal versus nonsuicidal subjects.

RESULTS

In 21 of 23 TEMPS-A studies meeting inclusion criteria, anxious, cyclothymic, depressive, or irritable temperament scores were significantly higher with previous or recent suicide attempts or ideation in both psychiatric and general population samples compared to nonsuicidal controls, whereas hyperthymic temperament scores were lower in 9 of 11 reports. These findings were synthesized by random-effects meta-analyses of standardized mean differences in TEMPS-A temperament scores in suicidal versus nonsuicidal subjects. Associations ranked: depressive ≥ irritable > cyclothymic > anxious > hyperthymic (negative).

CONCLUSIONS

Affective temperaments, especially depressive and irritable, were strongly associated with suicidal risk, whereas hyperthymic temperament appeared to be protective.

Impact, Diagnosis, Phenomenology, and Biology

This section provides summaries of the epidemiology, phenomenology, nosology, and the suspected biological substrates of the depressive disorders. It particularly emphasizes the historical evolution of the pertinent diagnostic constructs and the prognostic import both of the various diagnostic groupings and of the individual symptoms and symptom clusters.

Diseño y validación de una escala para evaluar el Riesgo Suicida (ERS) en adolescentes colombianos

El objetivo del estudio fue construir y validar una escala para la evaluación del riesgo suicida en adolescentes. Los ítems iniciales se elaboraron con base en la revisión bibliográfica y se sometió a evaluación de expertos con el fin de analizar aspectos teóricos y lingüísticos. La muestra fue de 537 adolescentes entre 13 y 18 años, con una media de 15.2 (DE = 1.1), 268 hombres (49.9 %) y 269 (50.1 %) mujeres. La consistencia interna total del instrumento fue de 0.934; las escalas mostraron alfa de Cronbach entre 0.71 y 0.929; se aplicó el omega de Mcdonald con el uso del software R y los resultados fueron muy similares. Se realizó análisis factorial exploratorio método VARIMAX y análisis factorial confirmatorio con el uso del programa estadístico AMOS. Los análisis de ítems, correlación y efectos de suelo y techo mostraron correlaciones entre 0.411** y 0.784** con el puntaje global. Las correlaciones de los ítems con las dimensiones fluctuaron entre 0.71** y 0.908**. Una vez obtenida la agrupación de los ítems en cuatro factores, se hallaron correlaciones significativamente altas entre las subescalas con el puntaje global (0.749**a 0.868**). En conclusión, el instrumento constituye una medida válida y confiable para la evaluación del riesgo suicida en adolescentes colombianos.

Risk factors for suicide in bipolar disorder: a cohort study of 12 850 patients

OBJECTIVE

Bipolar disorder carries a high risk of suicide. Identification of risk factors is important. The aim of this study was to study risk factors for suicide in a large cohort of men and women with bipolar disorder.

METHOD

A prospective cohort study using clinical data from the Swedish National Quality Register for Bipolar Affective Disorder (BipoläR). The outcome variable was suicide captured in the Cause of Death Register between 2004 and 2014. Hazard ratios (HR) were calculated using Cox proportional hazards models.

RESULTS

Of 12 850 persons (4844 men and 8006 women) with bipolar disorder, 90 (55 men and 35 women) died by suicide during the follow-up period (between 1 and 10 years). Male sex (HR 2.56), living alone (HR 2.45), previous suicide attempts (HR 4.10), comorbid psychiatric disorder (HR 2.64), recent affective episodes (HR 2.39), criminal conviction (HR 4.43), psychiatric inpatient care (HR 2.79), and involuntary commitment (HR 3.50) were significant risk factors for suicide. Several of the statistically significant risk factors for suicide in bipolar disorder differed between men and women.

CONCLUSIONS

Risk factors for suicide in bipolar disorder include factors associated with suicide in general, but also diagnosis-specific factors.

Characteristics of a suicide attempt predict who makes another attempt after hospital discharge: A decision-tree investigation

The year following discharge from psychiatric hospitalization is a high-risk period for suicidal behavior, particularly among patients initially hospitalized after a suicide attempt. Demographic and clinical correlates have been identified; however, characteristics of the initial attempt may provide insight into risk for subsequent attempts as well. This investigation examined whether individual or a combination of suicide attempt characteristics predicted future attempts. Two hundred and eighteen psychiatric inpatients from the MacArthur Violence Risk Assessment Study with a recent suicide attempt were administered items from the Suicide Intent Scale and followed one year after discharge. Sixty-nine (31.65%) made a subsequent attempt. Data were analyzed by a stepwise logistic regression, followed by an iterative receiver operator curve (IROC) analysis, a recursive partitioning classification tree. The cross-validated IROC, but not logistic regression, predicted subsequent suicide attempts. Furthermore, the IROC found that participants who made definite plans and underwent extensive preparation were at highest risk for subsequent attempts. These findings suggest that suicide attempt characteristics preceding psychiatric hospitalization can help identify patients at elevated risk for another attempt post-discharge.

Method of self-harm in adolescents and young adults and risk of subsequent suicide

BACKGROUND

Self-harm is common in youth and an important risk factor for suicide. Certain self-harm methods might indicate a higher risk of suicide. The main aim of this study was to determine whether some methods of self-harm in adolescents (10-17 years) and young adults (18-24 years) are associated with a particularly high risk of suicide. A secondary aim was to ascertain how different self-harm methods might affect the probability of psychiatric follow-up.

METHOD

Five Swedish registers were linked in a national population-based cohort study. All nonfatal self-harm events recorded in specialist health care, excluding psychiatry and primary care services, among 10-24 year olds between 2000 and 2009 were included. Methods were classified as poisoning, cutting/piercing, violent method (gassing, hanging, strangulation/suffocation, drowning, jumping and firearms), other and multiple methods. Hazard Ratios (HR) for suicide were calculated in Cox regression models for each method with poisoning as the reference. Odds Ratios (OR) for psychiatric inpatient care were determined in logistic regression models. Analyses were adjusted for important covariates and stratified by age group and treatment setting (inpatient/outpatient).

RESULTS

Among adolescents with initial medical hospitalisation, use of a violent method was associated with a near eightfold increase in HR for suicide compared to self-poisoning in the adjusted analysis [HR 7.8; 95% confidence interval (CI) 3.2-19.0]. Among hospitalised young adult women, adjusted HRs were elevated fourfold for both cutting [4.0 (1.9-8.8)] and violent methods [3.9 (1.5-10.6)]. Method of self-harm did not affect suicide risk in young adult men. Adolescents using violent methods had an increased probability of psychiatric inpatient care following initial treatment for self-harm.

CONCLUSIONS

Violent self-harm requiring medical hospitalisation may signal particularly high risk of future suicide in adolescents (both sexes) and in young adult women. For the latter group this is the case for cutting requiring hospitalisation as well.

Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007-2016

PURPOSE

Rates of hospital-treated self-harm are highest among young people. The current study examined trends in rates of self-harm among young people in Ireland over a 10-year period, as well as trends in self-harm methods.

METHODS

Data from the National Self-Harm Registry Ireland on presentations to hospital emergency departments (EDs) following self-harm by those aged 10-24 years during the period 2007-2016 were included. We calculated annual self-harm rates per 100,000 by age, gender and method of self-harm. Poisson regression models were used to examine trends in rates of self-harm.

RESULTS

The average person-based rate of self-harm among 10-24-year-olds was 318 per 100,000. Peak rates were observed among 15-19-year-old females (564 per 100,000) and 20-24-year-old males (448 per 100,000). Between 2007 and 2016, rates of self-harm increased by 22%, with increases most pronounced for females and those aged 10-14 years. There were marked increases in specific methods of self-harm, including those associated with high lethality.

CONCLUSIONS

The findings indicate that the age of onset of self-harm is decreasing. Increasing rates of self-harm, along with increases in highly lethal methods, indicate that targeted interventions in key transition stages for young people are warranted.

Psychological Symptoms in Late Adolescence and Long-Term Risk of Suicide and Suicide Attempt

Mental disorders in the general population are associated with increased risk of suicidality, but less is known about the independent predictive ability of self-reported psychological symptoms. We followed 49,321 screened and interviewed Swedish conscripts through 36-year follow-up to test whether psychological symptoms predicted suicide and hospitalization for suicide attempts. There were 619 suicides and 1,230 suicide attempts during the follow-up period. After excluding subjects with any psychiatric diagnoses (n = 5,691, 12%) and controlling for other psychological symptoms, severe symptoms of anger, trouble falling asleep, and feeling down predicted suicide. Similarly anger, headaches, feeling down, and nervousness predicted suicide attempt. Self-reported psychological symptoms may have a predictive value beyond psychiatric diagnosis.

Neuroticism and anxious attachment as potential vulnerability factors of repeat suicide attempts

The recurrence risk of suicide attempts can reach 50% in the first year, each attempt increasing suicide-risk by 32%. No screening tool efficiently identifies potential repeat suicide attempters who are too often regarded as borderline personality. Our aim was to identify individual and interpersonal psychopathological dimensions that could represent a vulnerability to repeat suicide attempts. Sixty first-time and repeat suicide attempters consecutively admitted in emergency rooms were compared for fundamental dimensions of personality, patterns of attachment, personality and mental disorders using standardized questionnaires. Confounding and significantly different factors were evaluated using univariate and multivariate logistic regressions. Repeat suicide attempters differed from first-attempters by higher neuroticism and anxious attachment. Combined in an 11-item measure, these two parameters identified a 3.99 times higher risk of repeat suicide attempt. These traits associated with the other two best predictors (non-suicidal self-injury history, current psychotropic drugs) provide a vulnerability model with better screening performance compared to each factor individually. Repeat suicide attempters have more psychological features impairing emotional stability and social interactions than first attempters. Cross-sectional study design, sample size, lack of independent sample and of fearful-avoidant attachment evaluation are the main limitations. The model needs to be validated in a prospective and controlled study.

Women, Femininity, Indirect and Direct Self-Destructiveness. A Review

The aim of this work was to review results of research into direct and indirect self-destructiveness in women. Studied projects covered two populations: individuals who attempted suicide and individuals who did not attempt suicide. The Chronic Self-Destructiveness Scale and Bem Sex Role Inventory were used. Intensity of indirect self-destructiveness is lower in women. A probable explanation of the gender paradox in suicides may be the hypothesis that suicides attempted by men more often end in death as men display stronger indirect self-destructiveness. Masculinity and male sex are factors that predispose to indirect self-destructiveness, while femininity and female sex are factors protecting against it. Gender schema opposite to biological sex is significant to intensity of indirect self-destructiveness.

Suicide Risk in Young Men and Women After Substance Intoxication

This study investigates suicide and overdoses in 1,119 consecutive patients (64% women), 15 to 34 years of age, presenting at the emergency department after self-poisoning from1994 to 2000 and followed regarding death to 2006. Regression and Kaplan-Meier survival analyses were performed for suicide and other causes of death. The patients had about a 60 times higher risk (SMR = 61.95) of death due to suicide and 26 times higher (SMR = 26.47) for all-cause mortality. Men had a nearly 2 times higher risk for suicide than women and half of the suicides occurred during the first 2 years after admission. Poisoning was the most common suicide method and early prevention of self-poisoning is crucial to reducing future deaths.

Patients admitted to hospital after suicide attempt with violent methods compared to patients with deliberate self-poisoning -a study of background variables, somatic and psychiatric health and suicidal behavior

BACKGROUND

In Norway, there are about 550 suicides recorded each year. The number of suicide attempts is 10-15 times higher. Suicide attempt is a major risk factor for suicide, in particular when violent methods are used. Suicide attempts with violent methods have hardly been studied in Norway. This study describes demographic, psychiatric and somatic health in patients admitted to somatic hospitals in Norway after suicide attempt by violent methods compared with suicide attempters using deliberate self-poisoning (DSP).

METHODS

Patients admitted to somatic hospital after suicide attempt aged > 18 years were included in a prospective cohort study, enrolled from December 2010 to April 2015. Demographics (gender, age, marital and living condition, educational and employment status), previous somatic and psychological health were registered. Patients who had used violent methods were compared with patients admitted after suicide attempt by DSP.

RESULTS

The study included 80 patients with violent methods and 81 patients with DSP (mean age both groups 42 yrs.). Violent methods used were cutting (34%), jumping from heights (32%), hanging (14%), others (10%), shooting (7%) and drowning (4%). Patients with violent methods had more often psychosis than patients admitted with DSP (14% vs 4%, p <  0.05), less anxiety disorders (4% vs 19%, p <  0.01) and less affective disorders (21% vs. 36%, p <  0.05). There were no significant differences between the numbers of patients who received psychiatric treatment at the time of the suicide attempt (violent 55% versus DSP 48%) or reported previous suicide attempt, 58% in patients with violent methods and 47% in DSP. Patients with violent methods stayed longer in hospital (14.3 (mean 8.3-20.3) vs. 2.3 (mean 1.6-3.1) days, p <  0.001), stayed longer in intensive care unit (5 days vs. 0.5 days, p <  0.001) and were in need of longer mechanical ventilation (1.4 vs 0.1 days, p <  0.001).

CONCLUSIONS

Patients with violent methods had more often psychosis, less anxiety disorders and affective disorders than patients with DSP. Psychiatric treatment before the attempt and previous suicide attempt was not significantly different between the groups and about half of the patients in both groups were in psychiatric treatment at the time of the suicide attempt.

Suicide in obsessive-compulsive disorder: a population-based study of 36 788 Swedish patients

The risk of death by suicide in individuals with obsessive-compulsive disorder (OCD) is largely unknown. Previous studies have been small and methodologically flawed. We analyzed data from the Swedish national registers to estimate the risk of suicide in OCD and identify the risk and protective factors associated with suicidal behavior in this group. We used a matched case-cohort design to estimate the risk of deaths by suicide and attempted suicide in individuals diagnosed with OCD, compared with matched general population controls (1:10). Cox regression models were used to study predictors of suicidal behavior. We identified 36 788 OCD patients in the Swedish National Patient Register between 1969 and 2013. Of these, 545 had died by suicide and 4297 had attempted suicide. In unadjusted models, individuals with OCD had an increased risk of both dying by suicide (odds ratio (OR)=9.83 (95% confidence interval (CI), 8.72-11.08)) and attempting suicide (OR=5.45 (95% CI, 5.24-5.67)), compared with matched controls. After adjusting for psychiatric comorbidities, the risk was reduced but remained substantial for both death by suicide and attempted suicide. Within the OCD cohort, a previous suicide attempt was the strongest predictor of death by suicide. Having a comorbid personality or substance use disorder also increased the risk of suicide. Being a woman, higher parental education and having a comorbid anxiety disorder were protective factors. We conclude that patients with OCD are at a substantial risk of suicide. Importantly, this risk remains substantial after adjusting for psychiatric comorbidities. Suicide risk should be carefully monitored in patients with OCD.

Predictors of daily life suicidal ideation in adults recently discharged after a serious suicide attempt: A pilot study

The aims of the study are to examine the predictive role of fluctuations in daily life mood, social contexts, and behavior on subsequent suicidal ideation (SI); and to identify clinical and psychological factors associated with the general frequency of SI in a high-risk sample. The sample comprised 42 adults (73.8% female) hospitalized for a suicide attempt. Immediately following hospital discharge, they used Ecological Momentary Assessment for seven consecutive days, providing repeated measures of SI, environmental, contextual, and behavioral factors. Controlling for prior SI, a number of contextual variables were associated with subsequent SI. Being at home or at work were both associated with an increased probability of SI, while being in the home of close others, or in a festive or leisure environment decreased SI probability. Working, passive leisure and inactivity all increased the likelihood of SI. Being alone increased SI while being with close others significantly reduced this risk. Finally, no overall effect for stressful events was found but negative family events specifically were associated with increased likelihood of SI (γ = 0.448, t = 2.255, df = 29, p < 0.05). The findings provide preliminary results regarding proximal environmental and behavioral factors associated with the occurrence of suicidal ideation in a high-risk sample.

Risk-taking behaviors and subgrouping of suicide in Iran: A latent class analysis of national registries data

Suicide is one the most important public health problem which is rapidly growing concerns. The aim of this study was to subgroup suicide using LCA method. This cross-sectional study was conducted in Iran based on 66990 records registered in Ministry of Health in 2014. A case report questionnaire in the form of software was used for case registries. Latent class analysis was used to achieve the research objectives. Four latent classes were identified; (a) Non-lethal attempters without a history of psychiatric disorders, (b) Non-lethal attempters with a history of psychiatric disorders, (c) Lethal attempters without a history of psychiatric disorders, (d) Lethal attempters with a history of psychiatric disorders. The probability of completed/an achieved suicide is high in lethal attempter classes. Being male increases the risk of inclusion in lethal attempters' classes (OR = 4.93). Also, being single (OR = 1.16), having an age lower than 25 years (OR = 1.14) and being a rural citizen (OR = 2.36) associate with lethal attempters classes. The males tend to use more violent methods and have more completed suicide. Majority of the individuals are non-lethal attempters who need to be addressed by implementing preventive interventions and mental support provision.

Combination of self-harm methods and fatal and non-fatal repetition: A cohort study

BACKGROUND

Assessment and aftercare for people who self-harm needs to be related to an understanding of risks of adverse outcomes. We aimed to determine whether self-harm by a combination of methods and its early repetition are associated with adverse outcomes - especially non-fatal repetition and suicide.

METHOD

10,829 consecutive general hospital attendances due to self-harm in one large English city were monitored, through scrutiny of Emergency Department attendances, over three years and followed up to determine the incidence of non-fatal repetition. Subsequent deaths, by any cause and by suicide, were determined from national statistical records.

RESULTS

6155 patients accounted for the 10,829 episodes: 72% by self-poisoning, 21% self-injury, and 746 episodes (7%) due to a combination of methods. After a combined-methods index episode, non-fatal repetition (P=0.001) and suicide (P=0.002) occurred sooner and more frequently than it did among those who had self-poisoned. Further hospital attendance due to self-harm within a month was associated with a 3.7-fold (95% CI 2.1-6.4) risk of subsequent suicide.

LIMITATIONS

The data exclude self-harm episodes that do not result in a hospital attendance. Index episodes in the study are not generally life-time first episodes so follow-up data are based on an arbitrary start-point. Both of these limitations are common to all studies of this kind.

CONCLUSIONS

At psychosocial assessment and the making of aftercare arrangements, combined methods of self-harm or another recent episode should be considered 'red-flag' indicators for attention to care.

Suicide in Tourette's and Chronic Tic Disorders

BACKGROUND

Persons with neuropsychiatric disorders are at increased risk of suicide, but there is little data concerning Tourette's and chronic tic disorders (TD/CTD). We aimed to quantify the risk of suicidal behavior in a large nationwide cohort of patients with TD/CTD, establish the contribution of psychiatric comorbidity to this risk, and identify predictors of suicide.

METHODS

Using a validated algorithm, we identified 7736 TD/CTD cases in the Swedish National Patient Register during a 44-year period (1969-2013). Using a matched case-cohort design, patients were compared with general population control subjects (1:10 ratio). Risk of suicidal behavior was estimated using conditional logistic regressions. Predictors of suicidal behavior in the TD/CTD cohort were studied using Cox regression models.

RESULTS

In unadjusted models, TD/CTD patients, compared with control subjects, had an increased risk of both dying by suicide (odds ratio: 4.39; 95% confidence interval [CI]: 2.89-6.67) and attempting suicide (odds ratio: 3.86; 95% CI: 3.50-4.26). After adjusting for psychiatric comorbidities, the risk was reduced but remained substantial. Persistence of tics beyond young adulthood and a previous suicide attempt were the strongest predictors of death by suicide in TD/CTD patients (hazard ratio: 11.39; 95% CI: 3.71-35.02, and hazard ratio: 5.65; 95% CI: 2.21-14.42, respectively).

CONCLUSIONS

TD/CTD are associated with substantial risk of suicide. Suicidal behavior should be monitored in these patients, particularly in those with persistent tics, history of suicide attempts, and psychiatric comorbidities. Preventive and intervention strategies aimed to reduce the suicidal risk in this group are warranted.

Associations between substance use disorders and suicide or suicide attempts in people with mental illness: a Danish nation-wide, prospective, register-based study of patients diagnosed with schizophrenia, bipolar disorder, unipolar depression or personality disorder

AIM

To estimate and test associations between substance use disorders (SUDs) and both completed suicides and suicide attempts in a population with severe mental illness.

DESIGN

Register-based cohort study with adjusted Cox regression of substance use disorders as time-varying covariates.

SETTING

Denmark.

PARTICIPANTS

People born in Denmark since 1955 with a diagnosis of schizophrenia (n = 35 625), bipolar disorder (n = 9279), depression (n = 72 530) or personality disorder (n = 63 958).

MEASUREMENTS

Treated SUDs of alcohol and illicit substances identified in treatment registers; suicide attempt identified in treatment registers; and completed suicides identified in the Cause of Death register. Covariates were sex and age at diagnosis.

FINDINGS

Having any SUD was associated with at least a threefold increased risk of completed suicide when compared with those having no SUD. Alcohol misuse was associated with an increased risk of completed suicide in all populations with hazard ratios (HR) between 1.99 [95% confidence interval (CI) = 1.44-2.74] and 2.70 (95% CI = 2.40-3.04). Other illicit substances were associated with a two- to threefold risk increase of completed suicide in all populations except bipolar disorder, and cannabis was associated with increased risk of attempted suicide only in people with bipolar disorder (HR = 1.86, 95% CI = 1.15-2.99). Alcohol and other illicit substances each displayed strong associations with attempted suicide, HR ranging from 3.11 (95% CI = 2.95-3.27) to 3.38 (95% CI = 3.24-3.53) and 2.13 (95% CI = 2.03-2.24) to 2.27 (95% CI = 2.12-2.43), respectively. Cannabis was associated with suicide attempts only in people with schizophrenia (HR = 1.11, 95% CI = 1.03-1.19).

CONCLUSION

Substance use disorders are associated strongly with risk of completed suicides and suicide attempts in people with severe mental illness.

Association Between Deliberate Self-harm and Violent Criminality

IMPORTANCE

Individuals who self-harm may have an increased risk of aggression toward others, but this association has been insufficiently investigated. More conclusive evidence may affect assessment, treatment interventions, and clinical guidelines.

OBJECTIVE

To investigate the association between nonfatal self-harm and violent crime.

DESIGN, SETTING, AND PARTICIPANTS

This population-based longitudinal cohort study, conducted from January 1, 1997, through December 31, 2013, studied all Swedish citizens born between 1982 and 1998 who were 15 years and older (N = 1 850 252). Individuals who emigrated from Sweden before the age of 15 years (n = 104 051) or immigrated to Sweden after the age of 13 years (ie, <2 years before the beginning of the follow-up; n = 22 009) were excluded. Data analysis was performed from April 21, 2016, to June 4, 2016.

EXPOSURES

Receipt of self-harm-associated clinical care.

MAIN OUTCOMES AND MEASURES

Conviction of a violent crime according to the Swedish penal code.

RESULTS

The study cohort consisted of 1 850 525 individuals (950 382 males and 900 143 females), and the mean (SD) follow-up time was 8.1 (4.7) years (range, 0-17.0 years; minimum age, 15 years; maximum age, 32 years). During a mean follow-up period of 8.1 years, 55 185 individuals (3.0%) received clinical care for self-harm. The crude hazard ratio was 4.9 (95% CI, 4.8-5.0) for violent crime conviction in exposed individuals compared with the unexposed group. Women who self-harm were at particularly high risk for expressing violent behaviors. After adjustment for relevant psychiatric comorbidities and socioeconomic status, an almost doubled hazard of violent offense remained (hazard ratio, 1.8; 95% CI, 1.8-1.9).

CONCLUSIONS AND RELEVANCE

Self-harm is associated with an increased risk of conviction for a violent offense in both sexes. The risk of violence, as well as the risk of suicide and self-harm, should be assessed among offending and self-harming individuals.

Suicidal Behavior Among People Living with HIV (PLHIV) in Medical Care in Estonia and Factors Associated with Receiving Psychological Treatment

People living with HIV (PLHIV) have higher rates of suicidal behavior than the general population. This study assessed suicidal behavior (ideation and/or attempts, ever and in the past 12 months) among PLHIV receiving outpatient HIV medical care in Estonia and associations between suicidal behavior and psychological treatment. The cross-sectional study collected data from January to November 2013 using a self-report questionnaire. Eight hundred PLHIV participated, 39 % (n = 306) of whom had been suicidal. Lifetime prevalence was 36 % for suicidal ideation and 20 % for attempts. Younger age, incarceration, having ever abused alcohol and also injected drugs, having lived with HIV for more than 10 years, and being depressed were associated with lifetime suicidal behavior. Suicidal behavior within the past 12 months was reported by 20 % (n = 156) of respondents. Of these, 27 % received psychological treatment (counseling and/or psychotherapy), 20 % had taken antidepressants, and 49 % sedatives. Individuals perceiving a need for treatment were significantly more likely to receive psychological treatment when experiencing suicidal behavior (OR 25.65, 95 % CI 2.92-225.47). In conclusion, suicidal behavior is frequent among PLHIV but psychological treatment is not often received. One of the barriers to treatment is patients' lack of perceived need for help.

Psychiatric heterogeneity of recent suicide attempters: A latent class analysis

Presence of, and comorbidity between, psychiatric disorders is a risk factor for suicide attempts. No study to date has used a person-centered approach to determine whether there are subgroups of attempters showing differing patterns of psychiatric disorders. This study aimed to identify psychiatric subgroups amongst recent suicide attempters (i.e., hospitalized within 24h of their attempt) and to determine whether identified classes could be differentiated in terms of important clinical correlates. Participants included 97 adult patients who were hospitalized due to a recent suicide attempt at a large Trauma 1 hospital. A structured diagnostic interview assessed a range of psychiatric disorders, and a battery of measures assessed acute and distal clinical correlates and characteristics of the current attempt. The person-centered analytic approach of latent class analysis was used to identify psychiatric diagnostic subgroups, or classes, of attempters. Three psychiatric subgroups were identified: Major Depressive Disorder, High Externalizing Disorders, and High Internalizing High Externalizing Disorders. Classes were found to significantly differ on a range of acute and distal clinical correlates, but not by demographics. Identification of psychiatric subgroups of individuals who have recently attempted suicide has important practical implications for increasing subsequent treatment utilization and tailoring treatment interventions for this population.

Clinical Prediction of Suicide and Undetermined Death: A Pseudo-Prospective Clinical and Medico-Legal Study of Substance Abusers

This study examines aspects of prediction of suicide and death of undetermined intent. We investigated all consecutive, autopsied patients between 1993 and 1997 who had been in contact with the Addiction Centre in Malmö from 1968 onwards. The staff was asked, shortly after autopsy but before they knew of the manner of death, if they thought the patient had committed suicide. The case records were blindly evaluated, and toxicological autopsy findings for alcohol in blood samples investigated. The specificity of prediction was 83% and significantly more often correct than the sensitivity, which was only 45% for suicide and for suicide/death of undetermined intent (93% versus 39%). Suicidal communication was more often considered non-serious before death of undetermined intent than before suicide. The former could be predicted by ideation but not by suicide attempt reported in case records, unlike suicide, which was predicted by both. The undetermined group also showed higher levels of alcohol in the blood at autopsy. We concluded that more serious clinical investigation of suicidal feelings, which may be hidden and not taken seriously, and treatment of alcohol use disorders with active follow-up appear urgent in the efforts to prevent suicide.

Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide

The objective of this study was to investigate the role of therapeutic alliance on suicide ideation as outcome measure in a brief therapy for patients who attempted suicide. Sixty patients received the 3-session therapy supplemented by follow-up contact through regular letters. Therapeutic alliance was measured with the Helping Alliance Questionnaire (HAQ). Outcome at 6 and 12 months was measured with the Beck Scale for Suicide Ideation (BSS). Therapeutic alliance increased from session 1 to session 3. Higher alliance measures correlated with lower suicidal ideation at 12 months follow-up. A history of previous attempts and depression had a negative affect on therapeutic alliance. The results suggest that in the treatment of suicidal patients therapeutic alliance may be a moderating factor for reducing suicide ideation.

Multicomponent Intervention for Patients Admitted to an Emergency Unit for Suicide Attempt: An Exploratory Study

Suicide is a major cause of premature deaths worldwide and belongs to the top priority public health issues. While suicide attempt is the most important risk factor for completed suicide, intervention for suicide attempters (SA) have produced mixed results. Since an important proportion of SA request medical care, emergency units (EU) are an opportune setting to implement such interventions. This exploratory study evaluated the feasibility and acceptability of a multicomponent intervention for SA admitted to an EU. The intervention consisted of coordination by a case manager of a joint crisis plan (JCP), an early meeting with relatives and the existing care network, as well as phone contacts during 3 months after suicide attempt. Among 107 SA admitted to the emergency unit during the study period, 51 could not be included for logistical reason, 22 were excluded, and intervention was offered to 34. Of these, 15 refused the intervention, which was thus piloted with 19 SA. First-time attempters most frequently declined the intervention. Feasibility and acceptability of phone contacts and case manager were good, while JCPs and meetings were difficult to implement and perceived as less acceptable. Refusal pattern questions the global acceptability and is discussed: JCPs and meetings will have to be modified in order to improve their feasibility and acceptability, especially among first-time attempters.

The Modular Assessment of Risk for Imminent Suicide (MARIS): A proof of concept for a multi-informant tool for evaluation of short-term suicide risk

BACKGROUND

To date, no diagnostic tool has demonstrated clinical value for the assessment of short-term suicide risk among high-risk individuals. To this end we have developed the Modular Assessment of Risk for Imminent Suicide (MARIS), a modular patient and clinician informed risk evaluation instrument. Here we assess its predictive validity for suicidal behavior (SB) in psychiatric patients following discharge from an inpatient unit.

METHODS

The MARIS and a psychological test battery were administered to 136 adult psychiatric patients hospitalized for high risk of suicide. Eighty-six participants had complete data at discharge and 59 (69.8%) were reached for follow-up. Logistic regressions were used to assess the predictive validity of the MARIS for SB over the 4-8weeks following hospital discharge and its incremental predictive validity over standard risk factors.

RESULTS

Patients who exhibited SB in the period between initial assessment and follow-up had significantly higher MARIS scores. ROC analysis indicated good sensitivity and specificity of MARIS in identifying risk (OR=19). Further, MARIS total score significantly improved predictive validity by the standard risk factors when added to a model comprising global depression severity, hopelessness, and lifetime number of suicide attempts, and was the only factor that approached independent significance.

CONCLUSION

The MARIS appears to be a practical and effective tool for detecting short-term suicide risk following hospital discharge, supporting the validity of modular multi-informant approach to suicide risk evaluation. Replication of these findings and further investigation of the applications of such an approach are warranted.

Interpersonal violence and the prediction of short-term risk of repeat suicide attempt

In this multi-center cohort study, suicide attempters presenting to hospital (N = 355, 63% women) were interviewed using the Karolinska Interpersonal Violence Scale (KIVS) and followed-up by medical record review. Main outcome was non-fatal or fatal repeat suicide attempt within six months. Also, repeat attempt using a violent method was used as an additional outcome in separate analyses. Data were analyzed for the total group and for men and women separately. Repeat attempts were observed within six months in 78 persons (22%) and 21 (6%) of these used a violent method. KIVS total score of 6 or more was associated with repeat suicide attempt within six months (OR = 1.81, CI 1.08–3.02) and predicted new attempts with a sensitivity of 62% and a specificity of 53%. A three-fold increase in odds ratio was observed for repeat attempt using a violent method (OR = 3.40, CI 1.22–9.49). An association between exposure to violence in adulthood and violent reattempt was seen in women (OR = 1.38, CI 1.06–1.82). The overall conclusions are that information about interpersonal violence may help predict short-term risk for repeat suicide attempt, and that structured assessment of interpersonal violence may be of value in risk assessment after attempted suicide.

Previous Suicide Attempt and Its Association With Method Used in a Suicide Death

INTRODUCTION

Non-fatal suicide attempts are a risk factor for suicide, but less is known about its effect on the method of injury used in an eventual suicide death. This study examines the association between history of non-fatal suicide attempt and the risk of a poisoning suicide versus firearm or hanging suicide in Colorado.

METHODS

Nine years (2004-2012, N=7,020) of suicide deaths in Colorado were compiled through the National Violent Death Reporting System. With these data, a retrospective cohort study was conducted in 2015, examining the risk associated with a history of suicide attempt and an eventual suicide death by poisoning versus a firearm or hanging suicide death. Multivariable log-binomial regression modeling was used to analyze the possible confounders of age and county type and gender as an effect modifier.

RESULTS

Suicide decedents with evidence of prior suicide attempt were twice as likely to eventually die by suicide via self-poisoning rather than by firearm injury (relative risk=1.94, 95% CI=1.8, 2.1, p<0.001). A significant interaction (p<0.001) between prior attempt and gender was identified and the relationship between prior attempt and method (poisoning versus firearm) was stronger among male than female suicides (female attempt history, 1.16, 95% CI=1.07, 1.27, p<0.001; male attempt history, 1.91, 95% CI=1.69, 2.16, p<0.001).

CONCLUSIONS

Individuals with a history of non-fatal suicide attempt are more likely to die by suicide via poisoning rather than firearm. Gender has a significant effect on this association. This information can be useful when discussing means restriction and suicide prevention efforts.

Suicide Attempt as a Risk Factor for Completed Suicide: Even More Lethal Than We Knew

OBJECTIVE

While suicide attempt history is considered to robustly predict completed suicide, previous studies have limited generalizability because of using convenience samples of specific methods/treatment settings, disregarding previous attempts, or overlooking first-attempt deaths. Eliminating these biases should more accurately estimate suicide prevalence in attempters.

METHOD

This observational retrospective-prospective cohort study using the Rochester Epidemiology Project identified 1,490 (males, N=555; females, N=935) Olmsted County residents making index suicide attempts (first lifetime attempts reaching medical attention) between January 1, 1986, and December 31, 2007. The National Death Index identified suicides between enrollment and December 31, 2010 (follow-up 3-25 years). Medical records were queried for sex, age, method, and follow-up care for index attempt survivors. Coroner records yielded data on index attempt deaths.

RESULTS

During the study period, 81/1,490 enrollees (5.4%) died by suicide. Of the 81, 48 (59.3%) perished on index attempt; 27 of the surviving 33 index attempt survivors (81.8%) killed themselves within a year. Males were disproportionately represented: 62/81 (11.2% of men, 76.5% of suicides) compared with 19/81 (2.0% of women, 23.5% of suicides). Of dead index attempters, 72.9% used guns, yielding an odds ratio for gunshot death, compared with all other methods, of 140 (95% CI=60-325). When adjusted for covariates, survivors given follow-up psychiatric appointments had significantly lower likelihood of subsequent suicide (odds ratio=0.212, 95% CI=0.089-0.507).

CONCLUSIONS

At 5.4%, completed suicide prevalence in this community cohort of suicide attempters was almost 59% higher than previously reported. An innovative aspect of this study explains the discrepancy: by including index attempt deaths-approximately 60% of total suicides-suicide prevalence more than doubled. We contend that counting both index and subsequent attempt deaths more accurately reflects prevalence. Our findings support suicide attempt as an even more lethal risk factor for completed suicide than previously thought. Research should focus on identifying risk factors for populations vulnerable to making first attempts and target risk reduction in those groups.

Death of a Close Relative and the Risk of Suicide in Sweden-A Large Scale Register-Based Case-Crossover Study

Background

Bereavement is thought to be a risk factor for suicide but the association has not been thoroughly investigated according to specific sensitive time periods and risk groups using a self-matched design. We aimed to 1) determine the risk of suicide within the first year after death of a close relative, 2) investigate if and how the risk changes within this time window and 3) determine if sex, age, and type of relationship, affect this association.

Methods

A self-matched, case-crossover study was performed by linking Swedish registers. In total, 31 059 individuals with suicide between 1990 and 2011 were included. Different periods within the year prior to the suicide were compared with corresponding periods one year earlier in the same individual’s life. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for suicide after death of a close relative.

Results

Increased ORs of suicide were seen during the first month, OR 1·77 (95% CI 1·35–2·34), and the first half-year, 1·27 (1·13–1·43). An even higher OR was found within the first week, 3·43 (1·89–6·22). Patterns were similar for women and men and across age groups. Death of a partner or child but not death of a sibling or parent was associated with a significantly increased suicide risk. The strongest association was seen after death of a partner in individuals aged 45 and older.

Discussion

These findings provide knowledge of sensitive time periods and at-risk groups in the early period of bereavement. Due to the use of a self-matched study design, methodological challenges of unmeasured residual confounding could be overcome.

Characteristics of suicide completers and attempters in rural Chinese population

OBJECTIVE

This study aimed to compare the similarities and differences between suicide completers and attempters in rural China.

METHODS

Two paired case-control studies of completed suicide and suicide attempts were conducted in rural Shandong, China. This analysis included 409 suicide attempters (SA) with a mean age of 43.90 (SD=13.31), 117 suicide completers (SC) with a mean age of 50.38 (SD=13.02) and their controls matched by gender, age (within 3years), and residence. Logistic regression models were used to examine risk factors of suicide attempts and completed suicide and the differences between SA and SC.

RESULTS

Compared to their matched controls, suicide attempters and completers shared the following common risk factors: low levels of education (middle school or under) (OR, 95% CI: 2.79, 1.40-5.55 for SA and 16.98, 1.59-181.60 for SC), negative life events (OR, 95% CI: 7.37, 4.73-11.50 for SA and 21.08, 4.74-93.71 for SC), and mental disorders (OR, 95% CI: 7.52, 3.85-14.69 for SA and 22.39, 2.65-189.60 for SC). Compared to suicide attempts, completed suicide was associated with the following risk factors: male gender (OR, 95% CI: 1.75, 1.06-2.90), advancing age (OR, 95% CI: 1.02, 1.00-1.04), poor family economic status (OR, 95% CI: 6.74, 3.22-14.13), prior suicide attempts (OR, 95% CI: 2.43, 1.18-4.97), family suicide history (OR, 95% CI: 2.59, 1.33-5.06), high suicide intent (OR, 95% CI: 1.15, 1.05-1.27), and highly lethal methods (OR, 95% CI: 13.65, 6.51-28.59).

CONCLUSIONS

Although suicide completers and attempters share some common risk factors, suicide completers are more likely to have prior suicide attempts, family suicide history, and higher suicidal intent, and to use highly lethal methods in rural Chinese.

[Follow-up interventions after suicide attempt. What tools, what effects and how to assess them?]

After attempting suicide, 60 to 70% of patients are discharged from emergency departments and referred to outpatient treatment which entails psychosocial strategies, pharmacological strategies or a combination. The main objective of outpatient care consists in preventing recurrent suicidal behavior. Yet suicide attempters have been found to be very difficult to engage in treatment. Between 11% and 50% of attempters refuse outpatient treatment or drop out of outpatient therapy very quickly. In order to address this extremely serious issue, for the past 20 years monitoring or follow up interventions has been presented as a promising approach. Follow-up intervention is defined as a service that aims at both increased access to and engagement in care as well as to prevent suicide and related behaviors. This approach consists in "stay in contact" or "connectedness" protocols using phone calls or tele-assistance, sending letters, email or mobile phone messages and medical visits or nursing at home. From one study to another these tools have been used separately, associated to one another or reinforced by motivational interviewing or brief psychotherapy. To our knowledge, since 1993 16 controlled and randomized controlled studies assessed the effectiveness of diverse follow-up. Four studies assessing telephone follow up reported a significant decrease in suicide reattempt while one study evaluating a sending letters strategy reported positive results. Among five studies assessing engagement in healthcare, only two (one using phone follow up and the other sending letters reported significantly positive results. The refusal rate of monitoring strategies has not exceeded 11% attesting to the high applicability of these methods. Despite several positive results, we cannot draw firm conclusions on replicability of these results. This is largely due to methodological issues: lack of standardization of interventions, lack of consensus on definition of the main measured variables (recurrent suicidal behavior, engagement in healthcare) but also to the confounding effect of other care approaches frequently associated with follow up intervention services. Further studies and research should be conducted as follow-up intervention services are increasingly used in suicide prevention because of their good acceptability and usefulness.

[Suicide mortality in Colombia and México: Trends and impact between 2000 and 2013]

INTRODUCTION

Suicides are one of the main public health issues globally. Objective: To analyze the trends and impact of suicide mortality in Colombia and México between 2000 and 2013, nationally, by sex and age groups. Materials and methods: Mortality vital statistics from the Colombian Departamento Administrativo Nacional de Estadística and the Mexican Instituto Nacional de Estadística y Geografía were used. We conducted a descriptive and cross sectional study for which we calculated standardized mortality rates and years of life lost in people between 0 and 100 years of age. Results: In Colombia, the suicide mortality rate decreased between 2000 and 2013 for both sexes (28% for men and 38% for women); an opposite trend was observed in México (with an increase of 34% for males and 67% for females). In 2013, the years of life lost in Colombia were 0,32 among men and 0,15 among women, with a decreasing trend since 2000, whereas in México a level of 0,42 was observed in men and 0,2 in women, with an increasing trend since 2000. The age groups where suicides had a bigger impact were those of men 15 to 49 years of age in both countries, while suicides were more uniformly distributed among women between 15 and 84 years of age.

CONCLUSION

 Suicide mortality increased gradually in México, whereas in Colombia an opposite trend was observed. Suicides can be prevented, so it is fundamental to implement public health policies focused on timely identification, comprehensive prevention strategies and the study of associated risk factors.