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

Mental disorders and subsequent suicide events in a representative community population

OBJECTIVE

This study examined the patterns of association between mental disorders and subsequent suicide in a community sample representative of the Canadian household population.

METHODS

This retrospective cohort study used data from the Canadian Community Health Survey 2002 linked to the Death Database 2000-2011 and the Hospitalization Database 1999/2000-2012/2013) (n=27,000). Mental disorders (past year major depressive episodes (MDE), bipolar disorders (BPD), anxiety disorders (AD), and substance dependence (SD)) and subsequent suicide events (deaths or hospitalizations for suicide attempts) were identified. Competing risk regression models were used to analyze the time-to-event data, adjusting for age, sex, marital status, and educational attainment.

RESULTS

Past year mental disorders were diagnosed in 11.38% of the cohort and 0.41% had suicide events. An increased hazard of suicide events associated with MDE, SD and AD weakened over-time, but this was not observed for BPD. For example, the HR of suicide events for MDE was 6.02 (95% confidence interval (CI)=2.65, 13.68) in the first 4 years, whereas, it was 2.03 (95% CI=0.91, 4.53) after 4 years. Whereas, the HRs of suicide events for BPD were 16.95 (95% CI=6.88, 41.75) and 15.81 (95% CI=5.89, 42.45) before and after 4 years.

LIMITATIONS

Diagnostic data are likely to underestimate the prevalence of suicide events.

CONCLUSIONS

The risk of suicide events declined over time for MDE, SA and AD, but remained high for BPD. This may reflect improvement over time in MDE, SA and AD, but indicates that people living with BPD have a persistent elevated hazard of suicide events.

The association between mental disorders and suicide: A systematic review and meta-analysis of record linkage studies

BACKGROUND

There has long been debate about the extent to which mental disorders contribute to suicide. We aimed to examine the evidence on the contribution of mental disorders to suicide among record linkage studies.

METHODS

We performed a systematic search using eight major health databases for English-language studies published between 1 January 2000 and 11 June 2018 that linked collected data on mental disorders and suicide. We then conducted a meta-analysis to assess risk of suicide conferred by mental disorders.

RESULTS

Our search identified 20 articles representing 13 unique studies. The pooled rate ratio (RR) was 13.2 (95% CI 8.6-20.3) for psychotic disorders, 12.3 (95% CI 8.9-17.1) for mood disorders, 8.1 (95% CI 4.6-14.2) for personality disorders, 4.4 (95% CI 2.9-6.8) for substance use disorders, and 4.1 (95% CI 2.4-6.9) for anxiety disorders in the general population. The overall pooled RR for these mental disorders was 7.5 (95% CI 6.6-8.6). The population attributable risk of mental disorders was up to 21%.

LIMITATIONS

The overall heterogeneity between studies was very high.

CONCLUSIONS

Our findings underline the important role of mental disorders in suicide. This suggests that ongoing efforts are required to improve access to and quality of mental health care to prevent suicide by people with mental disorders.

Murderers or thieves at risk? Offence-related suicide rates in adolescent and adult prison populations

Purpose

Prisoners have a higher risk of suicide compared to non-incarcerated individuals. One aim of suicide prevention for prisoners is to identify risk factors in order to put stronger support mechanisms in place for the more vulnerable detainees. This study investigates the suicide risk (SR) in offence-related sub-populations in a representative German sample and differentiates between SR for adolescent and adult prisoners.

Methods

Conducting a national study with data from public German records on the entire prison population from 2000 to 2016 and suicide numbers in German prisons in the same period, SR was calculated for the total male prison population as well as for both subgroups, adolescent and adult male prisoners.

Results

In the study period, male prisoners spent 959.584 life years (LY) in German criminal detention. Among those, 524 prisoners died of suicide. SR was higher for detainees imprisoned for an offence resulting in extensive physical harm for another person, e.g. homicide (suicide rate = 134,8 suicides per 100.000 LY; OR = 2,47; CI95%: 1,98–3,08), bodily injury (suicide rate = 87,3; OR = 1,60; CI95%: 1,29–1,99), and sexual offences (suicide rate = 84,2; OR = 1,54; CI95%: 1,18–2,01) compared with the SR of the total prison population (suicide rate = 54.6). Age differences between offence-related SR were found for theft, with adolescents (suicide rate = 69,3; OR = 1,25; CI95%: 0,85–1,84) showing higher SR than adults (suicide rate = 38,2; OR = 0,7; CI95%: 0,54–0,92).

Conclusion

The index offence of detainees is associated with SR and age-related differences exist. Suicide prevention in prisons should take both into account to determine populations at risk.

[Suicide and suicide tendencies in adolescent detainees]

Following accidents, suicide is the second leading cause of death in adolescence. This stage of life has the most suicide attempts of all age groups. In addition to mentally ill juveniles, adolescent delinquents represent a high-risk group for suicidal behavior and completed suicide. In particular, the population of detainees, an extreme form of juvenile delinquency, have a 16- to 18-fold higher risk of suicidal behavior and suicide compared to the general population. Because the composition of juvenile detainees differs greatly from that of detained adults, age-specific scientific approaches and prevention programs are needed. This task cannot be addressed by juvenile detention staff alone, but rather demands close cooperation between adolescent psychiatrists, psychologists, prison medical staff, legal experts and prison officers to use the opportunity for suicide prevention in juvenile detention facilities.

National cohort study of absolute risk and age-specific incidence of multiple adverse outcomes between adolescence and early middle age

Background

Psychiatric illness, substance misuse, suicidality, criminality and premature death represent major public health challenges that afflict a sizeable proportion of young people. However, studies of multiple adverse outcomes in the same cohort at risk are rare. In a national Danish cohort we estimated sex- and age-specific incidence rates and absolute risks of these outcomes between adolescence and early middle age.

Methods

Using interlinked registers, persons born in Denmark 1966–1996 were followed from their 15^th until 40^th birthday or December 2011 (N = 2,070,904). We estimated sex- and age-specific incidence rates of nine adverse outcomes, in three main categories: Premature mortality (all-causes, suicide, accident); Psychiatric morbidity (any mental illness diagnosis, suicide attempt, alcohol or drug misuse disorder); Criminality (violent offending, receiving custodial sentence, driving under influence of alcohol or drugs). Cumulative incidences were also calculated using competing risk survival analyses.

Results

For cohort members alive on their 15^th birthday, the absolute risks of dying by age 40 were 1.99 % for males [95 % confidence interval (CI) 1.95–2.03 %] and 0.85 % for females (95 % CI 0.83–0.88 %). The risks of substance misuse and criminality were also much higher for males, especially younger males, than for females. Specifically, the risk of a first conviction for a violent offence was highest amongst males aged below 20. Females, however, were more likely than males to have a hospital-treated psychiatric disorder. By age 40, 13.25 % of females (95 % CI 13.16–13.33 %) and 9.98 % of males (95 % CI 9.91–10.06 %) had been treated. Women aged below 25 were also more likely than men to first attempt suicide, but this pattern was reversed beyond this age. The greatest gender differentials in incidence rates were in criminality outcomes.

Conclusions

This is the first comprehensive assessment of the incidence rates and absolute risks of these multiple adverse outcomes. Approximately 1 in 50 males and 1 in 120 females who are alive on their 15th birthday will die by age 40. By examining the same cohort at risk, we compared risks for multiple outcomes without differential inter-cohort biases. These epidemiological profiles will inform further research into the pathways leading to these adverse events and future preventive strategies.

National study of suicide method in violent criminal offenders

BACKGROUND

Gaining a greater knowledge of the mechanisms and means by which violent offenders die by suicide can inform tailored preventive strategies.

METHODS

Using interlinked national Danish registry data we constructed a nested case-control study dataset of all adult suicides during 1994-2006: N=9708 cases and N=188,134 age and gender matched living controls. Completely ascertained International Classification of Diseases 10th revision cause-specific mortality codes were examined, with all criminal charges since 1980, and covariate information on psychiatric treatment and socio-demographics. Self-poisonings were classified as 'nonviolent' suicide and all other methods as being 'violent' ones.

RESULTS

Compared with the general population, risk among male and female violent offenders was strongly and significantly elevated for suicide by either a violent or a nonviolent method, although the relative risk was greater for nonviolent suicide. These patterns were also observed among nonviolent offenders, albeit with smaller effect sizes. Risk was especially raised for self-poisoning with narcotics & hallucinogens. We could only examine the full range of suicide methods in male violent offenders. In these men, hanging was the most frequently used method, although risk was markedly and significantly elevated virtually across the entire range of regularly used suicide methods.

LIMITATIONS

We lacked sufficient statistical power for undertaking a detailed profiling of specific suicide methods among female violent offenders.

CONCLUSIONS

Our findings indicate that comprehensive and broadly-based preventive approaches are needed for tackling the markedly raised risk of suicide by both violent and nonviolent means in this population. Their high relative risk for self-poisoning by illicit or illegal drugs underlines the importance of access to means and of prevailing subculture.

Forging an agenda for suicide prevention in the United States

Suicide prevention must be transformed by integrating injury prevention and mental health perspectives to develop a mosaic of common risk public health interventions that address the diversity of populations and individuals whose mortality and morbidity contribute to the burdens of suicide and attempted suicide. Emphasizing distal preventive interventions, strategies must focus on people and places--and on related interpersonal factors and social contexts--to alter the life trajectories of people before they become suicidal. Attention also must be paid to those in the middle years--the age with the greatest overall burden. We need scientific and social processes that define priorities and assess their potential for reducing what has been a steadily increasing rate of suicide during the past decade.