The profile of suicide: changing or changeable?

Age and sex differences in the annual and seasonal variation of Australia's suicide rate, 2000-2020

Suicide is a major public health concern both globally and in Australia. But in Australia the extent of substantive annual and seasonality trends since 2000 through the first two decades of the 21st Century, by age and sex, has not been formally reported. The current paper sought to identify annual and within-year (seasonality) trajectories in age-sex standardized suicide rates between 2000 and 2020. The annual and within-year (seasonality) trajectories of suicide were estimated from generalised regression analyses of Australia's mortality database. No systematic variation in Australia's suicide rate since 2000 was reported and was consistent between sex and age cohorts. Seasonal variation in rates were identified, with peaks in the new year (January), declines in late Summer/Autumn, stability in Winter, increases in Spring, but with a notable decline in early summer (November-December). These trends were driven men only. Interpretation of current suicide rates need to consider systematic long-term historical context. Despite a historical focus on youth suicide especially, working-aged and very old men have consistently reported higher standardized suicide rates over the first two decades of the 21st Century. Seasonal variation was reported but only reported by men, potentially because across the lifespan, suicide rates for females were a comparatively low incidence event. Particularly after recent successive national and international crises, we emphasise that surveillance and interpretation of current suicide rate requires careful consideration as to the extent any immediate variation may otherwise fall within otherwise normal historical norms.

Advancing early detection of suicide? A national study examining socio-demographic factors, antecedent stressors and long-term history of self-harm

BACKGROUND

A range of factors including mental disorders, adverse events and history of self-harm are associated with suicide risk. Further examination is needed of the characteristics of suicides which occur without established risk factors, using national surveillance systems.

METHODS

Data on all suicides in Ireland from 2015 to 2017 were drawn from the Irish Probable Suicide Deaths Study (IPSDS). Variables examined included socio-demographics, psychiatric history and precipitant stressors. Suicide data were linked with data on prior self-harm from the National Self-Harm Registry Ireland (NSHRI). Latent Class Analysis (LCA) was used to identify sub-groups of suicide cases.

RESULTS

Of the 1809 individuals who died by suicide, 401 (22.2 %) had a history of hospital-treated self-harm. Four distinct profiles of suicides were identified. One group was marked by high levels of prior self-harm and mental health conditions. Two of the groups included few individuals with a history of self-harm but had notably high levels of mental health conditions. These two groups had relatively high levels of reported chronic pain or illness but differed in terms of socio-demographics. The final group, predominantly male, had markedly low levels of mental health conditions or self-harm but high levels of personal stressors and substance use.

LIMITATIONS

The use of coronial data may be limited by bias in the collecting of information from the deceased's family members.

CONCLUSIONS

A sub-group of suicide cases exists without any psychiatric or self-harm history but with salient occupational or health-related proximal stressors. Suicide prevention interventions should include occupational settings and should promote mental health literacy.

The socio-ecological determinants of help-seeking practices and healthcare access among young men: a systematic review

Delayed engagement with health services is a key contributor to poorer health outcomes experienced by men. Patterns of health service usage which reduce the opportunity for disease prevention and health promotion appear to be especially prominent amongst young men. To identify the multiple and intersecting determinants of young men's help-seeking practices and health services usage, this review uses the social ecological model (SEM) to guide a critical synthesis of the literature on barriers and facilitators experienced by young men in accessing health services. A systematic review was conducted across five databases (MEDLINE, Embase, PsychINFO, CINAHL and Scopus). Included studies presented primary data regarding young men's (12-24 years) barriers and/or facilitators to seeking and accessing health care. Thirty-one studies (24 qualitative and 7 quantitative) underwent data extraction, quality appraisal and thematic analysis under the guiding framework of the SEM. Seven key themes were constructed, encapsulating the perceived barriers and facilitators to help-seeking and accessing health care experienced by young men, including masculine attitudes, health literacy, social pressure, service accessibility, economic factors, service characteristics and cultural attitudes. These findings highlight the complex interplay between the individual, interpersonal, organizational and societal factors impacting young men's healthcare engagement. They also illuminate avenues for multifaceted, context-specific interventions to enhance healthcare accessibility for this group, including addressing health literacy gaps, providing culturally sensitive care and reducing cost barriers.

Cross-national presence and sociodemographic correlates of the suicide crisis syndrome

BACKGROUND

The Suicide Crisis Syndrome (SCS) has been proposed as an acute, pre-suicidal mental state that precedes imminent suicidal behavior; however, its cross-national applicability and sociodemographic correlates have not yet been determined. The present study assessed the presence and severity of the SCS in ten countries and examined several potential sociodemographic correlates (i.e., age, gender, marital status, race/ethnicity) of the SCS.

METHODS

5528 community-based adults across 10 participating countries provided information on their SCS symptoms and sociodemographic characteristics in an anonymous online survey obtained via convenience sampling during the first year of the COVID-19 pandemic.

RESULTS

The SCS occurred cross-nationally, with rates ranging from 3.6% (Israel) to 16.2% (Poland). Those in the United States, South Korea, Poland, and Turkey had the highest severity of symptoms. Participants who were older, identified as cisgender men, and married tended to have lower rates of the SCS than their respective counterparts. There were minimal differences in the SCS by race/ethnicity.

LIMITATIONS

These data were both cross-sectional and collected via convenience sampling, limiting generalizability of findings and information about the SCS's predictive utility.

CONCLUSIONS

These findings support the cross-national presence of the SCS during the COVID-19 pandemic. Sociodemographic correlates aligned with those of suicidal behavior more generally, providing additional evidence for the concurrent/predictive validity of the SCS.

Irritable Mood and Subthreshold Hypomanic Episodes Correlate with More Severe Major Depression

INTRODUCTION

Irritable mood (IM) and subthreshold hypomanic symptoms are reported in half and two-fifths of major depressed subjects respectively, but their clinical and prognostic meanings remain unclear. The aim of this study was to test the clinical usefulness of 2 specifiers in DSM-IV major depressive disorder (MDD): IM occurring during an index episode (IM+) and lifetime episodes of elated mood or IM with at least 2 concurrent hypomanic symptoms (subthreshold hypomanic episodes [SHEs]).

METHOD

We included 482 outpatients with MDD participating in the Combining Medications to Enhance Depression Outcome study (mean age 43.14 ± 12.46 years, 144 males - 30%). The main aim of the original study was to test whether 2 different medications when given in combination as the first treatment step, compared to 1 medication, would improve antidepressant response.

RESULTS

IM + subjects (N = 349; 70%) were younger and more often females, with a more severe depression, a more marked social impairment, and more psychiatric comorbidities. The IM + group was also characterized by higher levels of suicidal ideation and more cases of emotional abuse. The combination of IM+ and SHEs was associated with an even more severe clinical picture. Limitations include the post hoc method, incomplete assessment of bipolar validators (e.g., family history of bipolar illness), personality disorders and suicide attempts.

CONCLUSIONS

The presence of IM and SHEs in MDD correlate with an overall more severe clinical condition.

Factors associated with suicidal behavior among university students in Bangladesh after one year of COVID-19 pandemic

BACKGROUND

The COVID-19 outbreak spillovers mental health burden where suicide is a common psychological public health issue that affects people all over the world. This study aimed to explore the factors associated with suicidal behavior among university students in Bangladesh after one year of the COVID-19 outbreak.

METHODS

An online cross-sectional survey was conducted among 2100 Bangladeshi university students aged ≥18 years from April 29 to May 15, 2021. The survey questionnaire contained socio-demographic information, COVID-19 related physical and psychosocial factors (CRPPF), preventive response to psychological stress, and the Suicidal Behaviors Questionnaire-Revised (SBQ-R) scale. Descriptive statistics along with logistic regression were performed for statistical analysis.

RESULTS

About 47.90% of the students were at risk of suicidal behavior, and female students were very likely to be at risk of suicidal behavior than their male counterparts (AOR = 2.28; 95% CI: 1.86 to 2.81). Keeping distance from friends or family (AOR = 1.66; 95% CI: 1.34 to 2.04), having relationship problems (AOR = 2.20; 95% CI: 1.79 to 2.70), feeling own selves as burden to families (AOR = 2.50; 95% CI: 2.02 to 3.11), and being stressed of lockdown (AOR = 1.56; 95% CI: 1.19 to 2.03) were highlighted as some of the significant factors associated with increased risk of suicidal behavior.

CONCLUSION

University students were exposed to several factors that impose the risk of developing suicidal behavior. Concerned authorities should design & implement appropriate strategies for ensuring suicidal prevention besides their mental well-being.

Comparison of Suicide Attempts and Suicide Deaths by Jumping from a High Place in Korean Children and Adolescents

Jumping from a high place is the most common method of suicide among Korean children and adolescents. The aim of this study was to examine the personal, family, and school life of Korean children and adolescents who chose jumping from a high place, among suicide attempts and suicide deaths, based on teachers’ reports. Data on suicide attempts and suicide deaths by jumping from a high place in children and adolescents were collected through the Ministry of Education in South Korea from 2016 to 2018. We compared sociodemographic variables, suicide-related variables, emotional and behavioral status, school life related variables, and variables related to family problems among suicide deaths (n = 262), actual suicide attempts (n = 50), and interrupted or aborted suicide attempts (n = 210). There were differences in educational stage (p < 0.001), place of suicide (p < 0.001), presence of suicide note (p < 0.05) and previous suicide attempt (p < 0.001) among the three groups. The total difficulty score on the Strength Difficulty Questionnaire of interrupted or aborted suicide attempts was higher than that of the other two groups. Our study suggests that the suicide death group tend to present fewer personal and family pathologies and better school adjustment than the suicide attempt group.

A Case Series Study of Help-Seeking among Younger and Older Men in Suicidal Crisis

Due to the continuing high suicide rates among young men, there is a need to understand help-seeking behaviour and engagement with tailored suicide prevention interventions. The aim of this study was to compare help-seeking among younger and older men who attended a therapeutic centre for men in a suicidal crisis. In this case series study, data were collected from 546 men who were referred into a community-based therapeutic service in North West England. Of the 546 men, 337 (52%) received therapy; 161 (48%) were aged between 18 and 30 years (mean age 24 years, SD = 3.4). Analyses included baseline differences, symptom trajectories for the CORE-34 Clinical Outcome Measure (CORE-OM), and engagement with the therapy. For the CORE-OM, there was a clinically significant reduction in mean scores between assessment and discharge (p < 0.001) for both younger and older men. At initial assessment, younger men were less affected by entrapment (46% vs. 62%; p = 0.02), defeat (33% vs. 52%; p = 0.01), not engaging in new goals (38% vs. 47%; p = 0.02), and positive attitudes towards suicide (14% vs. 18%; p = 0.001) than older men. At discharge assessment, older men were significantly more likely to have an absence of positive future thinking (15% vs. 8%; p = 0.03), have less social support (45% vs. 33%; p = 0.02), and feelings of entrapment (17% vs. 14%; p = 0.02) than younger men. Future research needs to assess the long-term effects of help-seeking using a brief psychological intervention for young men in order to understand whether the effects of the therapy are sustainable over a period of time following discharge from the service.

"Time to Try Something New" - Professionals' Experiences and Reflections on Suicide Prevention in Norway

Background: The suicide rate in Norway has remained relatively stable despite 25 years of government-funded suicide prevention efforts. Aim: We aimed to gather experiences of the professionals responsible for implementing suicide prevention action plans and guidelines and/or involved in relevant research. Method: We conducted semistructured interviews with 22 professionals about their reflections on the priorities and work done so far as well as where to go next. Data were analyzed by means of thematic analysis. Results: The participants described conflicting understandings and a monopolization of "the truth" within the suicide prevention community. They perceived the dominant biomedical understanding of suicidality and appurtenant approach to suicide prevention as too narrow. Thus, they found the suicide prevention work and collaboration challenging and recommend that it is time to try something new. Limitations: This study was conducted in a Norwegian context. A biomedical approach to suicide prevention is, however, common internationally. Conclusion: Participants described several challenges in the suicide prevention work. The contemporary "regime of truth" limits how suicide is understood and studied, as well as how suicide prevention is approached. A more open approach to suicide prevention, emphasizing the importance of relationships, context, and collaboration between sectors, is recommended.

Performance, Cost-Effectiveness, and Representativeness of Facebook Recruitment to Suicide Prevention Research: Online Survey Study

BACKGROUND

Researchers are increasingly using social media advertisements to recruit participants because of their many advantages over traditional methods. Although there is growing evidence for the effectiveness and cost-effectiveness of social media recruitment in the health sciences, no studies have yet examined this in the context of suicide prevention, which remains to be a highly stigmatized and sensitive topic.

OBJECTIVE

This study aims to recruit a general community sample to complete a survey on suicide literacy, stigma, and risk via Facebook advertisements. Specifically, we aim to establish the performance of the advertisements, cost-effectiveness, sample representativeness, and the impact of gender-specific advertising on recruiting men into the study.

METHODS

From June 2017 to March 2019, we released Facebook advertisements targeted at adults 18 years or older, residing in the New South Wales (NSW) trial or control regions, and involved in the LifeSpan suicide prevention trial. Cost-effectiveness was examined descriptively using metrics provided by Facebook. Chi-square analyses were conducted to determine demographic differences between our sample and the general NSW population as well as the impact of gender-specific advertisements on gender engagement.

RESULTS

The 14 Facebook advertisement campaigns reached a total of 675,199 people, yielding 25,993 link clicks and resulting in 9603 individuals initiating the survey (7487 completions) at an overall cost of Aus $2.81 (US $2.01) per participant. There was an overrepresentation of younger (P=.003), female (P=.003), highly educated (P<.001) participants and mental health conditions (P<.001) compared with the total NSW population. The use of male-specific advertisements resulted in a significantly higher proportion of men completing the survey relative to gender-neutral advertisements (38.2% vs 24.6%; P<.001).

CONCLUSIONS

This study demonstrates the potential of Facebook to be an effective, low-cost strategy for recruiting a large sample of general community participants for suicide prevention research. Strategies to improve sample representativeness warrant further investigation in future research.

Suicidal Behavior in Adolescents: A Latent Class Analysis

The main goal of the present study was to identify and validate latent classes of suicidal behavior in a representative sample of adolescents. The sample comprised a total of 1506 students, including 667 males (44.3%), selected through a sample stratified by clusters. The mean age was 16.15 years (SD = 1.36). The instruments used evaluated suicidal behavior, positive and negative affect, emotional and behavioral problems, prosocial behavior, and subjective well-being. Using the Paykel Suicide Scale, the latent class analysis identified four homogeneous subgroups: “low risk”, “suicidal act”, “suicidal ideation”, and “high risk for suicide”. These subgroups presented a differential pattern in terms of their social-emotional adjustment. The subgroups with the highest theoretical risk showed lower scores on subjective well-being and positive affect as well as higher scores on emotional and behavioral problems and negative affect compared to the non-risk subgroups. This study contributes to an understanding of the typologies of suicidal behavior among adolescents and the relationship with psychopathological adjustment. Ultimately, these findings may promote the development or improvement of early detection and prevention strategies in the suicidal behavior field in order to reduce the socio-economic burdens associated with suicide in young populations.

Identifying Typologies of Persons Who Died by Suicide: Characterizing Suicide in Victoria, Australia

The objective of the study was to determine whether people who died by suicide form groups based on demographic, psychosocial, mental and physical health factors and exposure to stressors. A retrospective case series review of 2,839 individuals who died by suicide in Victoria, Australia over the period 2009-2013 was conducted. A two-stage cluster analysis was performed. Diagnosis of mental illness was present in 52% of cases and initial cluster analysis determined two groups with the main predictor of group membership being the presence of diagnosed mental illness. Further analysis identified four subgroups within the mental illness group and two within the non-mental illness group. The study demonstrates that suicide does not always occur in the context of mental illness; people who die by suicide cannot be considered a homogenous group.

Hospital-presenting self-harm and ideation: Comparison of incidence, profile and risk of repetition

OBJECTIVE

The aim of this study was to describe presentations to hospital as a result of self-harm or suicidal ideation and to examine patterns of repetition.

METHOD

Presentations made to hospital emergency departments in Northern Ireland following self-harm and ideation between April 2012 and March 2017 were recorded by the Northern Ireland Registry of Self-harm. Person-based rates per 100,000 were calculated using national population estimates. Risk of repeat attendance to hospital was examined using Kaplan-Meier analyses.

RESULTS

A total of 62,213 presentations to emergency departments following self-harm or with ideation were recorded. The rate of self-harm was more than twice the rate of hospital-presenting ideation. Rates of ideation were higher among men, and both self-harm and ideation rates peaked for girls aged 15-19 and men aged 20-24 years. The cumulative probability of repeat attendance to hospital was higher following ideation (52% after 12 months), primarily because 12% of ideation presentations were followed by a subsequent self-harm presentation, whereas 4% of self-harm presentations were followed by ideation.

CONCLUSIONS

Our findings indicate that hospital presenters with ideation are at high risk of future self-harm. The transition from ideation to suicidal behaviour is important to consider and research could inform effective and early intervention measures.

Clinical assessment of suicide risk and suicide attempters' self-reported suicide intent: A cross sectional study

This study explored medical doctors’ clinical assessment of suicide risk and suicide attempters’ self-reported suicide intent. Three years of archival assessment records related to suicide attempters who were admitted to the emergency department of a large teaching hospital in Singapore were subjected to analysis. Records related to 460 suicide attempters (70.4% females; 28.6% males) were analysed using logistic regressions. Their ages ranged from 12 to 85 (M = 29.08, SD = 12.86). The strongest predictor of suicide intent was habitual poor coping, followed by serious financial problems, and expressed regret. The strongest predictor of suicide risk was hiding the attempt followed by prior planning. The findings were discussed in regards to implications in clinical assessments and suicide prevention efforts.

Use of prescription medication prior to suicide in Norway

BACKGROUND

The use of psychotropic medications in relation to mental disorders is considered central to preventing suicide. However, few studies have addressed prescription patterns at different time points within the last year prior to suicide and compared these with those of the general population.

METHODS

We use data covering the period from 2010 to 2011 from the Norwegian Cause of Death Registry and the Norwegian Prescription Database to examine dispensing patterns of prescription medication within 12 months and within 30 days of suicide. Our data includes all registered suicides in Norway among individuals aged 15 years and older in 2011 (n = 594), 434 men and 160 women. Dispensing of prescription medication in the general population (n ≈ 4 million) are used for comparison.

RESULTS

Dispensing of any prescription medication were high and varied from 95.6% for females and 83.2% for males within 12 months of suicide, to 64.4% for females and 47.2% for males within 30 days of suicide, respectively. The percentages with dispensed prescription medication increased with age. A similar sex and age pattern was observed for the dispensing of psychotropic medications. Within the last 30 days, close to one in two were dispensed psychotropic medications. The dispensing of antidepressants, hypnotics and sedatives was more common than the dispensing of other categories of psychotropics. The percentages with dispensed prescription medication among the population controls were considerably lower, in particular the dispensing of psychotropics.

CONCLUSION

Dispensing of prescription medications, including psychotropic medications, is common prior to suicide. The percentage with dispensed prescription medication increases with age and are higher for females than for males.

Relative risk of suicide following exposure to recent stressors, Victoria, Australia

OBJECTIVE

This study aimed to identify stressors over-represented in the 12 months prior to death among 553 Victorian adults who died by suicide.

METHODS

Age- and sex-specific suicide rates and relative risks of suicide were calculated using numerator data on suicides occurring in 2013 by people with a given exposure sourced from the Victorian Suicide Register and denominator data on the total Victorian population with that exposure sourced from the 2014 Australian Bureau of Statistics General Social Survey.

RESULTS

Mental illness was associated with increased suicide risk among people of all age groups and both sexes. Alcohol and/or other drug problems were associated with increased risk for males and females of all ages, with the exceptions of the oldest males and females, and the youngest females. Trouble with the police was associated with increased risk among all but the oldest males, whereas among females it was associated with elevated risk in those aged 25-44 years and 65+ years. Conclusions and Implications for public health: Males experiencing mental illness and alcohol and other drug problems should be a particular priority for suicide prevention initiatives but people exposed to other stressors such as contact with the police and divorce/relationship separation also warrant attention.

Differences in Characteristics and Exposure to Stressors Between Persons With and Without Diagnosed Mental Illness Who Died by Suicide in Victoria, Australia

Background: Mental illness is an established risk factor for suicide. To develop effective prevention interventions and strategies, the demographic characteristics and stressors (other than, or in addition to, mental illness) that can influence a person's decision to die by suicide need to be identified. Aim: To examine cases of suicide by the presence or absence of a diagnosed mental illness (mental illness status) to identify differences in factors associated with suicide in the groups. Method: Logistic regression analyses were used to investigate mental illness status and exposure to stressors among 2,839 persons who died by suicide in Victoria, Australia (2009-2013), using the Victorian Suicide Register. Results: Females, metropolitan residents, persons treated for physical illness/injury, those exposed to stressors related to isolation, family, work, education, and substance use and those who had made a previous suicide attempt had increased odds of having a diagnosed mental illness. Employed persons had decreased odds of having a diagnosed mental illness. Limitations: The retrospectivity of data collection as well as the validity and reliability of some of the data may be questionable owing to the potential for recall bias. Conclusion: The point of intervention for suicide prevention cannot always be a mental health professional; some people who die by suicide either do not have a mental illness or have not sought help.

To die or not to die: a qualitative study of men's suicidality in Norway

BACKGROUND

Previous research has shown that men who adhere to traditional beliefs about masculinity have increased health risks compared to those who do not. Single marital status, unemployment, retirement, and physical illness are commonly known risk factors for male suicidal behavior. Most men struggling with these risk factors are, however, not suicidal. To find out more about what makes some men vulnerable to suicidal behavior, risk factors must be analyzed in light of men's life history as well as the social context where they live their masculinity.

METHOD

We conducted semi-structured qualitative in-depth interviews with 15 men (20-76 years old) who were admitted to hospital after a suicidal act. We analyzed the data by means of qualitative content analysis with a directed approach. The analysis was directed by the participants' reports on whether they had wanted to die or not at the time of the suicidal act. On this basis, they were divided into two groups: a "to die" and a "not to die" group. We then analyzed each group separately before comparing them.

RESULTS

In both groups, the main reason or trigger for the suicidal act were problems in intimate relationships. These problems were complex and connected to the men's lived masculinity, ranging from shame, or tainted masculine honor, to taking responsibility as a man for the wife. Some men pointed to pain and ennui as reasons or triggers for their suicidal act. Only one in the "not to die" group took full responsibility for the suicidal act, whereas all but one did the same in the "to die" group. The men not taking responsibility described the suicidal act as involuntary because of either alcohol or a kind of "black-out". Not taking responsibility for the act may be a way of preserving masculine identity.

CONCLUSION

Relationship problems are the main reason or trigger of the suicidal act for most participants, but in very different ways, mirroring lived masculinity. The most striking finding is the uniqueness of each story, questioning the utility of standardized suicide prevention efforts.

Barriers toward help-seeking among young men prior to suicide

This study explores barriers to help-seeking among young men prior to suicide. We analyzed 61 in-depth interviews with parents, siblings, friends, and ex-partners of 10 young men (aged 18-30) with no record of mental illness, as well as 6 suicide notes, using interpretative phenomenological analysis. Three barriers emerged: (a) a total defeat; (b) no room for weakness; and (c) fear of mental disorder. The shame from falling short of standards (own/significant male others') could be a considerable barrier to help-seeking in a suicidal crisis.

Suicidal ideation and behavior in institutions of higher learning: A latent class analysis

Suicide is the second leading cause of death among undergraduate students, with an annual rate of 7.5 per 100,000. Suicidal behavior (SB) is complex and heterogeneous, which might be explained by there being multiple etiologies of SB. Data-driven identification of distinct at-risk subgroups among undergraduates would bolster this argument. We conducted a latent class analysis (LCA) on survey data from a large convenience sample of undergraduates to identify subgroups, and validated the resulting latent class model on a sample of graduate students. Data were collected through the Interactive Screening Program deployed by the American Foundation for Suicide Prevention. LCA identified 6 subgroups from the undergraduate sample (N = 5654). In the group with the most students reporting current suicidal thoughts (N = 623, 66% suicidal), 22.5% reported a prior suicide attempt, and 97.6% endorsed moderately severe or worse depressive symptoms. Notably, LCA identified a second at-risk group (N = 662, 27% suicidal), in which only 1.5% of respondents noted moderately severe or worse depressive symptoms. When graduate students (N = 1138) were classified using the model, a similar frequency distribution of groups was found. Finding multiple replicable groups at-risk for suicidal behavior, each with a distinct prevalence of risk factors, including a group of students who would not be classified as high risk with depression-based screening, is consistent with previous studies that identified multiple potential etiologies of SB.

Suicide and mental disorders: A discourse of politics, power, and vested interests

One of the most well-established truths in suicidology is that mental disorders play a significant role in at least 90% of suicides, and a causal relationship between the two is often implied. In this article, the authors argue that the evidence base for this truth is weak and that there is much research questioning the 90% statistic. Based on numerous examples, they also argue that ideology, politics, power, and vested interests among influential professionals in the field obstruct argument-based discussion of this issue. The authors also discuss unfortunate consequences of the constant reiteration of the 90% statistic.

Prediction of Lethality in Suicide Attempts: Gender Matters

This study explores gender differences in lethality of suicide attempts. Three years of medical records related to suicide attempters (N = 666) were subjected to analysis. Of the sample, 69.2% were female, 30.8% male; 63.8% Chinese, 15.8% Indian, and 15.0 % Malay. Ages ranged from 10 to 85 years old (M = 29.7, SD = 16.1). More males than females made attempts with high perceived lethality (χ²= 12.10, p < .0001) and high medical lethality (χ²= 10.59, p < .0001). Available variables were subjected to regression analyses. The regression models predicted more than 60% of high medical lethality suicide attempts and more than 80% of high perceived lethality attempts. Suicide intent and opportunity for rescue were significant predictors for both measures of lethality. Gender differences were examined. Findings were discussed in regard to implications in suicide assessments and interventions.

Does ethnicity matter in risk and protective factors for suicide attempts and suicide lethality?

This study explored ethnic differences in risk and protective factors for suicide attempts, for the major ethnic groups in Singapore, and ethnic differences in prediction of lethality. Three years of medical records related to suicide attempters (N = 666) who were admitted to the emergency department of a large teaching hospital in Singapore were subjected to analysis. Of the sample, 69.2% were female, 30.8% male; 63.8% Chinese, 15.8% Indian, and 15.0% Malay. Indians were over-represented in this sample, as compared with the ethnic distribution in the general population. Ages ranged from 10 to 85 years old (M = 29.7, SD = 16.1). Ethnic differences were found in risk and protective factors, and perceived lethality of suicide attempts. All available variables were subjected to regression analyses for Chinese, Indian and Malay attempters to arrive at parsimonious models for prediction of perceived lethality. The findings were discussed in regards to implications in assessment of suicide risk and primary prevention for the multiethnic society in Singapore.

Neuropsychological Markers of Suicidal Risk in the Context of Medical Rehabilitation

While great strides have been made to advance the understanding of the neurobiology of suicidal behavior (SB), the neural and neuropsychological mechanisms associated with SB are not well understood. The purpose of the current study is to identify neurocognitive markers of SB in the context of medical rehabilitation. The performances of 39 patients at a medical rehabilitation center, aged 21-78, were examined on a series of neurocognitive executive tasks-decision-making (Iowa Gambling Task - IGT), mental flexibility (WCST), response inhibition (SST) and working memory (digit span). Self-report questionnaires were administered, for Suicidal behaviors, depression, Anxiety, and PTSD as well as perceived social support. Suicidal participants performed more poorly on the IGT. A mediation analysis presented a significant direct effect of decision making on suicidal risk (p < 0.14) as well as significant indirect effect of decision making on suicidal risk that was mediated by the depressive symptoms (95% BCa CI [-0.15, -0.018]) with a medium effect size (κ² = 0.20, 95% BCa CI [0.067, 0.381]). Despite the complexity of relationship between decision-making and suicidal risk, these results suggest that clinicians should routinely assess decision-making abilities in adults at risk for suicide due to the fact that impaired decision-making may increase suicidal risk above and beyond that conferred by depression.

Compositional, Contextual, and Collective Community Factors in Mental Health and Well-Being in Australian Rural Communities

There are disproportionately higher and inconsistently distributed rates of recorded suicides in rural areas. Patterns of rural suicide are well documented, but they remain poorly understood. Geographic variations in physical and mental health can be understood through the combination of compositional, contextual, and collective factors pertaining to particular places. The aim of this study was to explore the role of "place" contributing to suicide rates in rural communities. Seventeen mental health professionals participated in semi-structured in-depth interviews. Principles of grounded theory were used to guide the analysis. Compositional themes were demographics and perceived mental health issues; contextual themes were physical environment, employment, housing, and mental health services; and collective themes were town identity, community values, social cohesion, perceptions of safety, and attitudes to mental illness. It is proposed that connectedness may be the underlying mechanism by which compositional, contextual, and collective factors influence mental health and well-being in rural communities.

Collaborative Assessment and Management of Suicidality (CAMS) compared to treatment as usual (TAU) for suicidal patients: study protocol for a randomized controlled trial

Background

Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that appears promising to reduce suicidal ideation and suicidal cognition. CAMS has not previously been evaluated in a standard specialized mental health care setting for patients with suicidal problems in general. In this pragmatic randomized controlled trial (RCT) we will investigate if CAMS is more effective than treatment as usual (TAU) in reducing suicidal thoughts and behaviors. Effects will also be investigated on mental health and symptom relief in general and upon readmissions to inpatient units.

Methods/design

The study is a multicenter, observer-blinded, superiority, two-armed RCT which will include patients from four clinical departments at Vestre Viken Hospital Trust, Norway. We aim to include 100 patients with moderate to strong suicidal problems, as defined by a score of 13 or more on Beck’s Scale for Suicide Ideation - Current. Patients are included regardless of diagnosis. Randomization will be performed using a stratified four-block procedure with treatment unit as the stratification variable. The duration of treatment will vary depending on patients’ needs and clinical assessments. Patients are interviewed by research staff at four checkpoints: baseline, 2 weeks, 6 months, and 12 months. Central outcome measures are the Beck Scale for Suicide Ideation - Current, Outcome Questionnaire – 45, and Suicide Attempt Self-Injury Count.

Discussion

This pragmatic trial is effectuated within the Public Health Care System in Norway, where patients have multiple problems and diagnoses and therapists have a high work load. Results from this trial are highly generalizable to a typical everyday clinical setting, and one should expect similar results if CAMS is implemented in the future as a standard component in specialized mental health care systems.

Trial registration

Open Science Framework: DOI 10.17605/OSF.IO/JHRM2. Registered 5 July 2015. ClinicalTrials.gov: NCT02685943. Registered on 8 February 2016.

The Role of Self-Esteem in Suicides Among Young Men

This study explores self-esteem in suicide among young males with no earlier history of suicide attempt(s) or treatment in mental health services. The data come from an ongoing psychological autopsy study; 10 cases of young men aged 18 to 30, were selected to generate a phenomenologically based understanding of the psychological mechanisms and processes involved in the suicidal process. The analyses are based on in-depth interviews with 61 closely connected individuals, as well as suicide notes. We used Interpretative Phenomenological Analysis. For these young men, the transition to young adulthood, a period of major life challenges, seemed to be associated with personal defeats. According to their significant others, the deceased seemed to have experienced intolerable discrepancies between their actual performances and their ideal self standards. Four themes emerged from the analysis: (a) striving to find a viable path to life as an adult man; (b) experiencing a sense of failure according to own standards; (c) emotional self-restriction in relationships; and (d) strong feelings of loneliness and rejection of self. Improved understanding of suicides outside the mental illness paradigm may have important implications for preventive strategies.

Assisting Australians with mental health problems and financial difficulties: a Delphi study to develop guidelines for financial counsellors, financial institution staff, mental health professionals and carers

Background

There is a strong association between mental health problems and financial difficulties. Therefore, people who work with those who have financial difficulties (financial counsellors and financial institution staff) need to have knowledge and helping skills relevant to mental health problems. Conversely, people who support those with mental health problems (mental health professionals and carers) may need to have knowledge and helping skills relevant to financial difficulties. The Delphi expert consensus method was used to develop guidelines for people who work with or support those with mental health problems and financial difficulties.

Methods

A systematic review of websites, books and journal articles was conducted to develop a questionnaire containing items about the knowledge, skills and actions relevant to working with or supporting someone with mental health problems and financial difficulties. These items were rated over three rounds by five Australian expert panels comprising of financial counsellors (n = 33), financial institution staff (n = 54), mental health professionals (n = 31), consumers (n = 20) and carers (n = 24).

Results

A total of 897 items were rated, with 462 items endorsed by at least 80 % of members of each of the expert panels. These endorsed statements were used to develop a set of guidelines for financial counsellors, financial institution staff, mental health professionals and carers about how to assist someone with mental health problems and financial difficulties.

Conclusions

A diverse group of expert panel members were able to reach substantial consensus on the knowledge, skills and actions needed to work with and support people with mental health problems and financial difficulties. These guidelines can be used to inform policy and practice in the financial and mental health sectors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0868-2) contains supplementary material, which is available to authorized users.

Electronic protocol for suicide risk management in research participants

OBJECTIVE

To describe an electronic, telephone-delivered, suicide risk management protocol (SRMP) that is designed to guide research staff and safely triage study participants who are at risk for self-harm.

METHODS

We tested the SRMP in the context of the NIH-funded randomized clinical trial "Bypassing the Blues" in which 302 patients who had undergone coronary artery bypass graft surgery (CABG) were screened for depression and assessed by telephone 2-weeks following hospital discharge and at 2-, 4-, and 8-month follow-up. We programmed the SRMP to assign different risk levels based on patients' answers from none to imminent with action items for research staff keyed to each of them. We describe frequency of suicidal thinking, SRMP use, and completion of specific steps in the SRMP management process over the 8-month follow-up period.

RESULTS

Suicidal ideation was expressed by 74 (25%) of the 302 study participants in 139 (13%) of the 1069 blinded telephone assessments performed by research staff. The SRMP was launched in 103 (10%) of assessments, and the suicidal risk level was classified as moderate or high in 10 (1%) of these assessments, thereby necessitating an immediate evaluation by a study psychiatrist. However, no hospitalizations, emergency room visits, or deaths ascribed to suicidal ideation were discovered during the study period.

CONCLUSION

The SRMP was successful in systematically and safely guiding research staff lacking specialty mental health training through the standardized risk assessment and triaging research participants at risk for self-harm.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00091962 (http://clinicaltrials.gov/ct2/show/NCT00091962?term=rollman+cabg&rank=1).

Maladaptive Perfectionism

This study aimed to explore how the life history of suicide victims with no history of treatment in mental health care or of attempted suicide seemed to presdispose them to maladaptive perfectionism. The study is part of an ongoing psychological autopsy study. It aimed to produce a phenomenological understanding of the vulnerability to suicide related to perfectionism, based on the life history of six male suicide victims aged 22 to 58. Interpretative Phenomenological Analysis was used to analyze the interview data of 41 key informants. Three main themes emerged: (a) exposure to high expectations combined with little recognition and warmth; (b) reduced ability to cope with failures and weaknesses; and (c) fear of emotional rejection. Together these themes illustrate that feelings of shame, mainly resulting from an unfulfilled need for attachment, a desire for love and recognition may relate to maladaptive perfectionism, which influences the suicidal process. The results may have important implications for suicide prevention programs.

Suicide After Nonfatal Self-Harm

Background: Nonfatal self-harm is the strongest predictor of suicide, with some of the risk factors for subsequent suicide after nonfatal self-harm being similar to those for suicide in general. However, we do not have sufficient information regarding the medical care provided to nonfatal self-harm episodes preceding suicide. Aims: Our study sought to explore hospital care and predictive characteristics of the risk of suicide after nonfatal self-harm. Method: Individuals with history of nonfatal self-harm who died by suicide were compared with those who had a nonfatal self-harm episode but did not later die by suicide. Cases were identified by cross-linking data collected through a self-harm monitoring project, 2000–2007, and comprehensive local data on suicides for the same period. Results: Dying by suicide after nonfatal self-harm was more common for male subjects than for female subjects (OR = 3.3, 95% CI = 1.7–6.6). Self-injury as the method of nonfatal self-harm was associated with higher risk of subsequent suicide than was self-poisoning (OR = 2.0, 95% CI = 1.04–3.9). More urgent care at the emergency department (OR = 2.7, 95% CI = 1.1–6.3) and admission to hospital (OR = 2.0, 95% CI = 1.0–4.0) at the index episode were related to a heightened risk of suicide. Conclusion: The findings of our study could help services to form assessment and aftercare policies.

From a cracking façade to a total escape: maladaptive perfectionism and suicide

This study explored the final stages of the suicide process among six men characterized as maladaptive perfectionists. These men, aged 22 to 58, had no history of suicide attempts or mental health treatment. In-depth interviews with 5 to 9 informants for each person were analyzed by using interpretative phenomenological analysis. Three themes emerged from the analysis: (a) a cracking façade; (b) a total loss of coping ability; and (c) a total escape. Suicide was related to a shameful defeat that was not reversible, and a loss of the ability to handle such feelings of defeat and shame.

Suicide and Perfectionism: A Psychological Autopsy Study of Non-Clinical Suicides

This study explores suicide in relation to perfectionism among individuals who died by suicide with no history of treatment in mental health care or of suicide attempts. The study is part of an ongoing psychological autopsy study (PA-study). It aimed to produce a phenomenological understanding of the dynamics/processes from perfectionism to suicide among 6 men aged 22 to 58. Interpretative Phenomenological Analysis (IPA) was used to analyze the interview data of 41 key informants. Based on the informants' narratives, it seemed that perfectionism left these men less able to cope with their (self-perceived) inability to meet their high expectations. Four themes emerged from analysis: 1) striving for success; 2) fear of failure; 3) keeping up the facade; and 4) rigidity. The results may be important in the prevention of nonclinical suicides, a group that is particularly difficult to identify, especially if the deceased have been regarded as very successful in many areas.

Exploring vulnerability to suicide in the developmental history of young men: a psychological autopsy study

This study explores the developmental history of ten young men who completed suicide in the transition to adulthood. The young men, aged 18-30, had no previous history of suicide attempts or treatment in mental health. In-depth interviews with four to eight informants for each suicide were analyzed using Interpretative Phenomenological Analysis. Three developmental issues from early age onwards emerged: (a) unsuccessful in becoming independent; (b) weakened competence to deal with shame; and (c) trapped in anger. The capacity to regulate emotions like shame and anger could make certain men vulnerable to suicide when facing adult challenges and defeats.

Deliberate self-harm before psychiatric admission and risk of suicide: survival in a Danish national cohort

PURPOSE

Psychiatric illness and deliberate self-harm (DSH) are major risk factors of suicide. In largely 15% of psychiatric admissions in Denmark, the patient had an episode of DSH within the last year before admission. This study examined the survival and predictors of suicide in a suicidal high-risk cohort consisting of hospitalized psychiatric patients with recent DSH.

METHODS

This national prospective register-based study examined all hospitalized psychiatric patients who self-harmed within a year before admission. All admitted patients, in the time period 1998-2006, were followed and survival analyses techniques were used to identify predictors of suicide.

RESULTS

The study population consisted of 17,257 patients; 520 (3%) died by suicide during follow-up; 50% of the suicides occurred within a year from the index admission. A rate of 1,645 suicides per 100,000 person-years in the first year after psychiatric admission was found. Adjusted analyses showed that a higher degree of education, having DSH within a month before psychiatric admission and contact with a private psychiatrist increased the risk of suicide.

CONCLUSIONS

Psychiatric hospitalized patients with recent DSH revealed high suicide rates, even during hospitalization. When discharging psychiatric patients with recent DSH careful arrangement of follow-up treatment in the outpatient setting is recommendable.

Gender differences in completed suicides in Istanbul, Turkey

BACKGROUND

Psychological autopsy studies have been widely used to identify the cause of suicide. However, gender is one of the most frequently replicated predictors for suicide. To identify further the significant risk factors for suicide among males and females separately.

METHOD

Data were obtained from The Turkish-Istanbul Forensic Medicine Institute Morgue Department for all suicides deaths from April to August 2002 in Istanbul. 124 completed suicides were included in the study.

RESULTS

This study findings suggest that unemployed, not married or in a de facto relationship, previous suicide attempt, and alcohol or substance abuse were common amongst those who died by suicide. Most of the victims were male; the most frequent suicide methods were hanging and jumping down a high building followed by firearms. Both males and females were most frequently affected by psychiatric disorders. It was found that 108 cases that did not receive psychiatric care attempted suicide for the first time and committed suicide.

CONCLUSION

This finding suggests that suicides should be investigated by an expert team and not by the police and victims' relatives only to determine whether they are really suicides or not.