Prediction of repeated parasuicide after 1-12 months

Multidimensional variability in ecological assessments predicts two clusters of suicidal patients

The variability of suicidal thoughts and other clinical factors during follow-up has emerged as a promising phenotype to identify vulnerable patients through Ecological Momentary Assessment (EMA). In this study, we aimed to (1) identify clusters of clinical variability, and (2) examine the features associated with high variability. We studied a set of 275 adult patients treated for a suicidal crisis in the outpatient and emergency psychiatric departments of five clinical centers across Spain and France. Data included a total of 48,489 answers to 32 EMA questions, as well as baseline and follow-up validated data from clinical assessments. A Gaussian Mixture Model (GMM) was used to cluster the patients according to EMA variability during follow-up along six clinical domains. We then used a random forest algorithm to identify the clinical features that can be used to predict the level of variability. The GMM confirmed that suicidal patients are best clustered in two groups with EMA data: low- and high-variability. The high-variability group showed more instability in all dimensions, particularly in social withdrawal, sleep measures, wish to live, and social support. Both clusters were separated by ten clinical features (AUC = 0.74), including depressive symptoms, cognitive instability, the intensity and frequency of passive suicidal ideation, and the occurrence of clinical events, such as suicide attempts or emergency visits during follow-up. Initiatives to follow up suicidal patients with ecological measures should take into account the existence of a high variability cluster, which could be identified before the follow-up begins.

The association between reattempted suicide and incoming calls to the brief contact intervention service, VigilanS: a study of the clinical profile of callers

BACKGROUND

Suicide is a major health problem globally. As attempted suicide is a major risk factor for suicide, specific prevention strategies have been designed for use thereafter. An example is the brief contact intervention (BCI). In this regard, France employs a composite BCI, VigilanS, which utilizes three types of contact: phone calls, postcards and a 'who to contact in a crisis' card. Previous studies have found that this system is effective at preventing suicide. Nevertheless, VigilanS was not effective in the same way for all the patients included. This observation raises the question of specific adaptation during follow-up for populations that were less receptive to the service. In consideration of this issue, we identified one study which found that incoming calls to the service were linked with a higher risk of suicide reattempts. However, this study did not document the profiles of the patients who made these calls. Better understanding of why this population is more at risk is important in terms of identifying factors that could be targeted to improve follow-up. This research therefore aims to bring together such data.

METHODS

We performed a retrospective analysis of 579 patients referred to VigilanS by Toulouse University Hospital (France). We examined the sociodemographics, clinical characteristics, and follow-ups in place and compared the patients who made incoming calls to the service versus those who did not. Subsequently, we conducted a regression analysis using the significantly associated element of patients calling VigilanS. Then, in order to better understand this association, we analyzed the factors, including such calls, that were linked to the risk of suicide reattempts.

RESULTS

We found that 22% of the patients in our sample called the VigilanS service. These individuals: were older, at 41.4 years versus 37.9 years for the non-callers; were more likely to have a borderline personality disorder (BPD) diagnosis (28.9% versus 19.3%); and had a history of suicide attempts (71.9% versus 54.6%). Our analysis confirmed that incoming calls to VigilanS (OR = 2.9) were associated with reattempted suicide, as were BPD (OR = 1.8) and a history of suicide attempts (OR = 1.7).

CONCLUSION

There was a high risk that the patients calling VigilanS would make another suicide attempt. However, this association was present regardless of the clinical profile. We postulate that this link between incoming calls and reattempted suicide may arise because this form of contact is, in fact, a way in which patients signal that a further attempt will be made.

Excess mortality by suicide in high-risk subgroups of suicide attempters: a prospective study of standardised mortality rates in suicide attempters examined at a medical emergency inpatient unit

OBJECTIVES

The primary aim of the present study was to investigate the putative excess mortality by suicide in suicide attempters. As a secondary aim, we investigate excess mortality in specific, clinically relevant subgroups: individuals with repeated suicide attempts (RA); individuals who used violent method at the attempt (VA); and those who scored high on the Suicide Intent Scale (HS) at the time of the baseline attempt. Finally, we investigate excess mortality in men and women separately and within 5 years and over 5 years after hospital admission for attempted suicide.

DESIGN

Prospective register-based follow-up for 21-32 years. Standardised mortality ratio (SMR) was calculated for suicide using national census data. Clinically relevant subgroups were investigated separately.

SETTING

Medical emergency inpatient unit in the south of Sweden.

PARTICIPANTS

1039 individuals who were psychiatrically assessed at admission to medical inpatient care for attempted suicide between 1987 and 1998.

OUTCOME MEASURE

Suicide.

RESULTS

The overall SMR for suicide was 23.50 (95% CI 18.68 to 29.56); significantly higher (p<0.001) among women (30.49 (95% CI 22.27 to 41.72)) than men (18.61 (95% CI 13.30 to 26.05)). Mortality was highest within the first 5 years after the index suicide attempt (48.79 (95% CI 35.64 to 66.77)) compared with those who died after 5 years (p<0.001) (14.74 (10.53 to 20.63)). The highest independent SMR was found for VA (70.22 (95% CI 38.89 to 126.80)). In a regression model including RA, VA and HS all contributed significantly to excess suicide mortality.

CONCLUSIONS

An elevated risk of premature death by suicide was found in suicide attempters compared with the general population. Assessment of previous suicide attempts is important, even though the attempt/s may have occurred decades ago. When assessing suicide risk, clinicians should consider repeated attempts and whether the attempts involved high suicidal intent and violent method. Healthcare interventions may benefit from targeting identified subgroups of attempters.

Longitudinal Development of Reasons for Living and Dying With Suicide Attempters: A 2-Year Follow-Up Study

BACKGROUND

Clinical interventions for patients after a suicide attempt might include a focus on Reasons for Living (RFL) and/or Reasons for Dying (RFD). The present study examined the longitudinal development of RFL and RFD in patients with and without a suicide-specific intervention - the Attempted Suicide Short Intervention Program (ASSIP).

METHODS

In this secondary analysis of a 2-year follow-up randomized controlled study, participants completed the Suicide Status Form II to assess RFL and RFD, at baseline, as well as at 6-, 12-, 18-, and 24-months follow-up. Growth models and latent class analysis were used to investigate longitudinal developments in RFL and RFD. Regression models were used to test the association between RFL, RFD and suicidal reattempts and ideation.

RESULTS

Cross-sectionally and longitudinally, RFD, but not RFL, were associated with suicide reattempts and suicidal ideation. The number of RFD decreased significantly across the 24 month period (from 1.90 at t1 to 1.04 at t5 in the control group and from 2.32 at t1 to 0.51 at t5 in the intervention group), and this decrease was stronger (b = -0.02; p = 0.004) in the ASSIP group than in the control group. There was no overall change in RFL. Three latent trajectories of RFD were identified: a decreasing (n = 77), a steady high (n = 17) and a trajectory with first increasing and then decreasing RFD (n = 26). The proportion of patients in the ASSIP intervention was highest in the decreasing trajectory and lowest in the steady high trajectory. Patients in the steady high trajectory were characterized by worse mental health and fewer social obligations (partner, children) at baseline.

CONCLUSION

The results confirm the importance of RFD within the suicidal process and show that the number of RFD can be further reduced over the period of 24 months with short interventions such as ASSIP. The relevance of number of RFL in the suicidal process, as protective factor, was not confirmed. In the subgroup of patients whose RFD did not decrease over a long period of time, there is a particularly high risk of suicidal ideation/behavior. Clinical interventions should focus more closely on RFD, their etiology and maintenance.

SMS SOS: a randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging

BACKGROUND

Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia.

METHODS/DESIGN

Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge.

DISCUSSION

This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense.

TRIAL REGISTRATION AND ETHICS APPROVAL

This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370 . Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).

The Effect of Active Treatment and Visit Compared to Conventional Treatment, on Preventing Recurrent Suicidal Attempts: A Randomized Controlled Clinical Trial

BACKGROUND

Suicide is a major problem, and its prevention is a global priority. In many cases, suicide attempter attempts to do it again after the rescue. In current study we aimed to compare active visit and treatment of patients in a periodic manner with treatment as usual, in the prevention of recurrent suicidal attempts.

MATERIALS AND METHODS

This study was a randomized controlled clinical trial which was conducted in Isfahan Noor Hospital's Emergency Center on 60 patients in 2013-2014. The samples were selected using simple random sampling and they were assigned into two groups: The conventional treatment group (treatment as usual) (30 patients), and visit and active treatment (30 patients). In the intervention group, there were ten follow-ups by a face-to-face visit over 12 months, and six follow-ups by phone call in control group. Through the completion of the initial and follow-up questionnaire evaluation was performed. The data were analyzed using Cochran test, and repeated measure (ANOVA).

RESULTS

During the 12-month follow-up visit and active treatment, significant difference in reducing suicidal thoughts (P = 0.003) was observed and an increase in the life expectancy (P = 0.001), interest and motivation in life (P = 0.001) was found in the intervention group, and also nonsignificant reduction was found in the rate of suicidal attempts.

CONCLUSION

Visit and active treatment is useful in suicide attempters and it can helps in preventing recurrent suicide attempt as a preventive program by increasing hope and reducing suicidal thoughts.

Effect of telephone follow-up on repeated suicide attempt in patients discharged from an emergency psychiatry department: a controlled study

BACKGROUND

Attempted suicide is a major public health problem, and the efficacies of current postvention protocols vary. We evaluated the effectiveness of telephone follow-up of patients referred to an emergency psychiatric unit for attempted suicide on any further attempt/s over the following year.

METHOD

In a single-center, controlled study with intent to treat, we evaluated the efficacy of a protocol of telephone follow-up of 436 patients at 8, 30, and 60 days after they were treated for attempted suicide. As controls for comparison, we evaluated patients with similar social and demographic characteristics referred to our emergency psychiatric unit in the year prior to the study who did not receive telephone follow-up after their initial hospitalization. Data were analyzed using logistic regression.

RESULTS

Very early telephone follow-up of our patients effectively reduced recidivism and seemed to be the only protective factor against repeated suicide attempt.

CONCLUSIONS

Implementing a protocol of early telephone follow-up after attempted suicide could help prevent repeated attempt/s. More controlled studies are needed to assess optimal techniques to prevent such repetition.

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.

Clinical and Psychosocial Profiles of Asian Immigrants Who Repeatedly Attempt Suicide: A Mixed-Method Study of Risk and Protective Factors

BACKGROUND

Persons who repeatedly attempt suicide comprise a highly distressed population that warrants the understanding of risk and protective factors in assessment and treatment. There is a dearth of literature on Asian immigrants' suicidal behavior.

AIMS

The study aimed to capture the clinical and psychosocial profiles of Asian immigrants who made repeated suicide attempts.

METHOD

We utilized retrospective chart reviews (n = 44) and in-person interviews (n = 12) in two urban public hospitals.

RESULTS

The study samples shared major suicide risk factors identified in studies of other populations. Participants of the interview sample suffered from a pervasive sense of hopelessness stemming from social isolation, self-stigma, feelings of failure in their life roles, and perceptions of rejection by their families. Conversely, psychological well-being--feeling cared for and able to reciprocate care for others--appeared to be a protective factor for participants who improved in their functioning and recovery.

CONCLUSION

The study lays the groundwork for further research on suicide risk and protective factors.

Effect of phone call versus face-to-face follow-up on recurrent suicide attempts prevention in individuals with a history of multiple suicide attempts

BACKGROUND

To evaluate the efficacy of different ways of communications on prevention of suicidal reattempt, we compared the efficacy of phone call versus face-to-face follow-up in patients with previous attempt.

MATERIALS AND METHODS

In a randomized controlled clinical trial, 55 suicide reattempters who were admitted to the poisoning emergency were divided into phone call (29 patients) and face-to-face (26 patients) groups randomly. They were followed at 8 occasions: 2^nd and 4^th weeks, and the 2^nd, 3^rd, 4^th, 5^th, 6^th, and 8^th months. The suicidal reattempt, suicidal thought, hope, and interest of the patients were assessed on each occasion, and the patients were guided to visit by a therapist, if needed. The findings were analyzed by Mann-Whitney, Chi-square, Cochran, Friedman, and independent t-tests using SPSS 20.

RESULTS

The status of "hope" and "interest" improved in both groups, but it showed more significant difference in the face-to-face group. Suicidal thoughts in both groups decreased over time, and this was more significant in the face-to-face group. However, we did not found any significant difference in the frequency of the suicidal reattempts between two groups.

CONCLUSION

Face-to-face versus phone call follow-up of suicide attempters can significantly alleviate suicidal thoughts and improve hopes and interests.

OSTA program: A French follow up intervention program for suicide prevention

Attempted suicide is a strong risk factor for subsequent suicidal behavior. In recent years, a particular interest has been given to follow-up interventions as a potential effective strategy in preventing recurrent suicidal behavior. We developed a follow-up intervention program called OSTA (organization of a suitable monitoring for suicide attempters) aimed at addressing this issue and tested its effectiveness in a 1-year randomized controlled trial. Individuals who attempted suicide and were admitted to the emergency department (ED) of Bicêtre Hospital (n=320) were randomly allocated to receive either the OSTA program or a control treatment. On an intention to treat basis, the proportion of patients who reattempted suicide did not differ significantly between the interventional group (IG) 14.5% (22/152) and the control group (CG) 14% (21/150). There were also no significant differences, between the two arms, in the number of suicide attempts. Although no significant difference has been found between the OSTA program and the control treatment concerning the rate of suicide reattempts, we believe that further studies should be conducted to test the effectiveness of more standardized follow-up studies in suicide prevention.

Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review

Suicidal thoughts and behaviors are highly prevalent public health problems with devastating consequences. There is an urgent need to improve our understanding of risk factors for suicide to identify effective intervention targets. The aim of this meta-analysis was to examine the magnitude and clinical utility of anxiety and its disorders as risk factors for suicide ideation, attempts, and deaths. We conducted a literature search through December 2014; of the 65 articles meeting our inclusion criteria, we extracted 180 cases in which an anxiety-specific variable was used to longitudinally predict a suicide-related outcome. Results indicated that anxiety is a statistically significant, yet weak, predictor of suicide ideation (OR=1.49, 95% CI: 1.18, 1.88) and attempts (OR=1.64, 95% CI: 1.47, 1.83), but not deaths (OR=1.01, 95% CI: 0.87, 1.18). The strongest associations were observed for PTSD. Estimates were reduced after accounting for publication bias, and diagnostic accuracy analyses indicated acceptable specificity but poor sensitivity. Overall, the extant literature suggests that anxiety and its disorders, at least when these constructs are measured in isolation and as trait-like constructs, are relatively weak predictors of suicidal thoughts and behaviors over long follow-up periods. Implications for future research priorities are discussed.

Patterns of presentation for attempted suicide: analysis of a cohort of individuals who subsequently died by suicide

All suicides and related prior attempts occurring in Northern Ireland over two years were analyzed, focusing on number and timing of attempts, method, and mental health diagnoses. Cases were derived from coroner's records, with 90% subsequently linked to associated general practice records. Of those included, 45% recorded at least one prior attempt (with 59% switching from less to more lethal methods between attempt and suicide). Compared with those recording one attempt, those with 2+ attempts were more likely to have used less lethal methods at the suicide (OR = 2.77: 95% CI = 1.06, 7.23); and those using less lethal methods at the attempts were more likely to persist with these into the suicide (OR = 3.21: 0.79, 13.07). Finally, those with preexisting mental problems were more likely to use less lethal methods in the suicide: severe mental illness (OR = 7.88: 1.58, 39.43); common mental problems (OR = 3.68: 0.83, 16.30); and alcohol/drugs related (OR = 2.02: 0.41, 9.95). This analysis uses readily available data to highlight the persisting use of less lethal methods by visible and vulnerable attempters who eventually complete their suicide. Further analysis of such conditions could allow more effective prevention strategies to be developed.

Switching suicide methods as a predictor of completed suicide in individuals with repeated self-harm: a community cohort study in northern Taiwan

OBJECTIVE

Repetition of suicide attempts is common, but little is known about the relationship between switching methods of suicide attempt and the probability of completed suicide. This study aimed to determine the transition of methods chosen by individuals who repeat suicide attempts, and how the switched methods of suicide attempts influence the risk of suicide death.

METHOD

All consecutive individuals (n = 2052) with an episode of non-fatal suicide attempt registered in a surveillance database provided by the Department of Health of the Keelung City Government from 1 January 2006 to 31 December 2010 were enrolled and followed up until the end of 2011. The earliest attempt recorded in the database was defined as the index attempt. Data on the time of subsequent completed suicide and methods chosen for repeated self-harm during the follow-up period were analyzed by performing a Cox proportional hazards regression.

RESULTS

Of the total subjects, 374 (18.2%) had at least one other attempted suicide and 50 (2.4%) eventually died by suicide. Subjects who used highly lethal methods in the index self-harm tended to switch methods in the next suicide attempt (p<0.001). Switching to a more lethal method was a significant predictor of completed suicide (adjusted hazard ratio (aHR) 7.05, 95% confidence interval (CI) 3.52-14.14). In addition, subjects who used charcoal-burning in the index self-harm attempt had a higher risk of subsequent suicide death (aHR 3.47, 95% CI 1.57-7.68).

CONCLUSIONS

The findings in this study give us some insight into the patterns of methods in repeat suicide attempters. The intent behind switching methods of suicide attempt might be considered as an important item of clinical assessment of the seriousness of suicidal behavior.

SIAM (Suicide intervention assisted by messages): the development of a post-acute crisis text messaging outreach for suicide prevention

BACKGROUND

Suicidal behaviour and deliberate self-harm are common among adults. Research indicates that maintaining contact either via letter or postcard with at-risk adults following discharge from care services can reduce reattempt risk. Feasibility trials demonstrated that intervention through text message was also effective in preventing suicide repetition amongst suicide attempters. The aim of the current study is to investigate the effect of text message intervention versus traditional treatment on reducing the risk of suicide attempt repetition among adults after self-harm.

METHODS/DESIGN

The study will be a 2-year multicentric randomized controlled trial conducted by the Brest University Hospital, France. Participants will be adults discharged after self-harm, from emergency services or after a short hospitalization. Participants will be recruited over a 12-month period. The intervention is comprised of an SMS that will be sent at h48, D7, D15 and monthly. The text message enquires about the patients' well-being and includes information regarding individual sources of help and evidence-based self help strategies. Participants will be assessed at the baseline, month 6 and 13. As primary endpoint, we will assess the number of patients who reattempt suicide in each group at 6 months. As secondary endpoints, we will assess the number of patients who reattempt suicide at 13 month, the number of suicide attempts in the intervention and control groups at 6 and 13 month, the number of death by suicide in the intervention and control groups at month 6 and 13. In both groups, suicidal ideations, will be assessed at the baseline, month 6 and 13. Medical costs and satisfaction will be assessed at month 13.

DISCUSSION

This paper describes the design and deployment of a trial SIAM; an easily reproducible intervention that aims to reduce suicide risk in adults after self-harm. It utilizes several characteristics of interventions that have shown a significant reduction in the number of suicide reattempts. We propose to assess its efficacy in reducing suicide reattempt in the suicide attempter (SA) population.

TRIAL REGISTRATION

The study was registered on Clinical Trials Registry (clinicaltrials.gov): NCT02106949, registered on 06 June 2014.

The efficacy of telephonic follow up in prevention of suicidal reattempt in patients with suicide attempt history

Background:

prevention of suicide is one of priority world health. Suicide is one of the preventable causes of death. The aim of this study is evaluation of telephone follow up on suicide reattempt.

Materials and Methods:

This randomized controlled clinical trial is a prospective study which has been done in Noor Hospital of Isfahan-Iran, at 2010. 139 patients who have suicide attempt history divided in one of two groups, randomly, 70 patients in” treatment as usual (TAU)” and 69 patients in “brief interventional control (BIC). Seven telephone contact with BIC group patients have been done “during six months” and two questionnaires have been filled in each session. The data has been analyzed by descriptive and Chi-square test, under SPSS.

Results:

No significant differences of suicide reattempt has been found between two groups (P = 0.18), but significant reduction in frequency of suicidal thoughts (P = 0.007) and increase in hope at life (P = 0.001) was shown in intervention group.

Conclusion:

Telephones follow up in patients with suicide history decrease suicidal thought frequency” and increase hope in life, significantly.

Methods of suicide predict the risks and method-switching of subsequent suicide attempts: a community cohort study in Taiwan

OBJECTIVE

Suicide is a major public health concern. This study aimed to determine the predictors of repeated suicide attempts, focusing on whether lethality level of the suicidal method predicts the risk of subsequent suicide attempts.

METHODS

All consecutive individuals (N=2,070) with an episode of nonfatal self-harm registered in a surveillance database provided by the Department of Health of Keelung City Government in Taiwan from January 1, 2006 to December 31, 2010 were enrolled and followed up until the end of 2011. The earliest attempt recorded in the database was defined as the index attempt. Subjects were classified according to suicide method into low-lethal and high-lethal groups. Data on time of and methods chosen for subsequent suicide attempts during the follow-up period were analyzed.

RESULTS

Of the total people screened for the study, 18.1% made a repeated suicide attempt. Subjects in the high-lethal group were more likely to be male; aged 35-64 years; and single, divorced, or widowed. Compared to other time intervals, most subsequent suicide attempts occurred within 6 months from the index attempt. The independent predictors for repeated suicide attempts were the use of low-lethal methods in the index attempt and being 35-49 years old. Using high-lethal methods and being older than 50 years were associated with changing suicide method for the second attempt.

CONCLUSION

Lethality level of former suicidal method could predict repeated suicide attempts and changing of suicide methods. Further clarification is needed on whether a higher risk of repeat attempts is associated with higher rates of suicide mortality.

Suicide reattempters: a systematic review

The aim of this study is to identify the characteristic features of suicide reattempters. The recognition of the suicide reattempters population as a distinct clinical population may encourage future preventive and clinical work with this high-risk subgroup and thus reduce deaths. A systematic literature review was carried out in order to identify the key demographic, psychological, and clinical variables associated with the repetition of suicide attempts. In addition, we wished to analyze the operational definitions of the repetition of suicide attempts proposed in the scientific literature. Studies published from 2000 to 2012 were identified in PubMed, PsycINFO, and Web of Science databases and were selected according to predetermined criteria. We examined a total of 1480 articles and selected 86 that matched our search criteria. The literature is heterogeneous, with no consensus regarding the operational definitions of suicide reattempters. Comparison groups in the literature have also been inconsistent and include subjects making a single lifetime attempt and subjects who did not reattempt during a defined study period. Suicide reattempters were associated with higher rates of the following characteristics: unemployment, unmarried status, diagnosis of mental disorders, suicidal ideation, stressful life events, and family history of suicidal behavior. Additional research is needed to establish adequate differentiation and effective treatment plans for this population.

Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review

OBJECTIVES

This review aimed to identify the evidence for predictors of repetition of suicide attempts, and more specifically for subsequent completed suicide.

METHODS

We conducted a literature search of PubMed and Embase between January 1, 1991 and December 31, 2009, and we excluded studies investigating only special populations (eg, male and female only, children and adolescents, elderly, a specific psychiatric disorder) and studies with sample size fewer than 50 patients.

RESULTS

The strongest predictor of a repeated attempt is a previous attempt, followed by being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other variables examined (Caucasian ethnicity, having a criminal record, having any mood disorders, bad family environment, and impulsivity) there are indications for a putative correlation as well. For completed suicide, the strongest predictors are older age, suicide ideation, and history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive with a positive correlation (but sustained by very scarce data) for poor impulsivity and a somatic diagnosis.

CONCLUSION

It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or substance abuse/dependence, which are, along with depression, the most consistent predictors for initial nonfatal attempt and suicide, are not consistently reported to be very strong predictors for nonfatal repetition.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

ClinicalTrials.gov NCT00700089.

Subtyping borderline personality disorder by suicidal behavior

Course and outcome of Borderline Personality Disorder (BPD) are favorable for the vast majority of patients; however, up to 10% die by suicide. This discrepancy begs the question of whether there is a high lethality subtype in BPD, defined by recurrent suicidal behavior and increasing attempt lethality over time. In a prospective, longitudinal study, we sought predictors of high lethality among repeat attempters, and defined clinical subtypes by applying trajectory analysis to consecutive lethality scores. Criteria-defined subjects with BPD were assessed using standardized instruments and followed longitudinally. Suicidal behavior was assessed on the Columbia Suicide History, Lethality Rating Scale, and Suicide Intent Scale. Variables discriminating single and repeat attempters were entered into logistic regression models to define predictors of high and low lethality attempts. Trajectory analysis using three attempt and five attempt models identified discrete patterns of Lethality Rating Scale scores. A high lethality trajectory was associated with inpatient recruitment, and poor psychosocial function, a low lethality trajectory with greater Negativism, Substance Use Disorders, Histrionic and/or Narcissistic PD co-morbidity. Illness severity, older age, and poor psychosocial function are characteristics of a poor prognosis subtype related to suicidal behavior.

Prospective predictors of suicidal behavior in borderline personality disorder at 6-year follow-up

OBJECTIVE

Recurrent suicidal behavior is a defining characteristic of borderline personality disorder. Although most patients achieve remission of suicidal behavior over time, as many as 10% die by suicide, raising the question of whether there is a high-risk suicidal subtype. The authors conducted a longitudinal study of suicidal behavior in borderline personality disorder patients to identify prospective predictors of suicide attempts and to characterize those patients at highest risk for suicide completion.

METHOD

Demographic and diagnostic characteristics and clinical and psychosocial risk factors assessed at baseline were examined for predictive association with medically significant suicide attempts using Cox proportional hazards models. The authors defined prospective predictors for participants who completed 6 or more years in the study and compared the data to those of earlier intervals.

RESULTS

Among 90 participants, 25 (27.8%) made at least one suicide attempt in the interval, and most attempts occurred in the first 2 years. The risk of suicide attempt was increased by low socioeconomic status, poor psychosocial adjustment, family history of suicide, previous psychiatric hospitalization, and absence of any outpatient treatment before the attempt. Higher global functioning scores at baseline decreased this risk.

CONCLUSIONS

Risk factors predictive of suicide attempt change over time. Acute stressors such as major depressive disorder were predictive only in the short term (12 months), while poor psychosocial functioning had persistent and long-term effects on suicide risk. Half of borderline patients have poor psychosocial outcomes despite symptomatic improvement. A social and vocational rehabilitation model of treatment is needed to decrease suicide risk and optimize long-term outcomes.

The incidence and repetition of hospital-treated deliberate self harm: findings from the world's first national registry

BACKGROUND

Suicide is a significant public health issue with almost one million people dying by suicide each year worldwide. Deliberate self harm (DSH) is the single most important risk factor for suicide yet few countries have reliable data on DSH. We developed a national DSH registry in the Republic of Ireland to establish the incidence of hospital-treated DSH at national level and the spectrum and pattern of presentations with DSH and repetition.

METHODS AND FINDINGS

Between 2003 and 2009, the Irish National Registry of Deliberate Self Harm collected data on DSH presentations to all 40 hospital emergency departments in the country. Data were collected by trained data registration officers using standard methods of case ascertainment and definition. The Registry recorded 75,119 DSH presentations involving 48,206 individuals. The total incidence rate fell from 209 (95% CI: 205-213) per 100,000 in 2003 to 184 (95% CI: 180-189) per 100,000 in 2006 and increased again to 209 (95% CI: 204-213) per 100,000 in 2009. The most notable annual changes were successive 10% increases in the male rate in 2008 and 2009. There was significant variation by age with peak rates in women in the 15-19 year age group (620 (95% CI: 605-636) per 100,000), and in men in the 20-24 age group (427 (95% CI: 416-439) per 100,000). Repetition rates varied significantly by age, method of self harm and number of previous episodes.

CONCLUSIONS

Population-based data on hospital-treated DSH represent an important index of the burden of mental illness and suicide risk in the community. The increased DSH rate in Irish men in 2008 and 2009 coincided with the advent of the economic recession in Ireland. The findings underline the need for developing effective interventions to reduce DSH repetition rates as a key priority for health systems.

Suicide attempt presentations at the emergency department: outcomes from a pilot study examining precipitating factors in deliberate self-harm and issues in primary care physician management

The aim of this study was to examine the psychosocial precipitating factors of people presenting to the emergency department (ED) due to attempted suicide. Demographic, diagnostic and service use data were collected for a 6-week period. All patients were referred for primary care physician (PCP) management, with a sample followed up for secondary analysis of precipitants to self-harm and follow-up outcomes. Results of the study showed that key psychosocial stressors that triggered suicidality were relationship issues and recent unemployment, with depression present in 92% of cases. While 83% of patients followed attended their first PCP appointment, 50% discontinued by 3 months. The conclusion of this study is that psychosocial crises and depression are key factors in suicide attempts. Assertive crisis intervention, facilitated linkage to community services, and greater monitoring are recommended.

Global functioning and suicide among Chinese rural population aged 15-34 years: a psychological autopsy case-control study

As the relationship between global functioning and young suicide remains unclear in rural China, this study was aimed to explore the relationship between them. Data of 391 rural suicides and 416 controls, all aged 15-34 years in three provinces in China were used for this study. The Global Assessment of Functioning (GAF) scale was adopted to assess global functioning of suicides and controls. The results showed that GAF score was stronger than mental illness in predicting suicide in China. Different correlates of GAF score were found between suicides and controls. Unsurprisingly, GAF score was significantly correlated with mental illness in both suicides and controls. Different characteristics were also found among three types of suicide which were classified using GAF score. Assessing global functioning is useful and GAF scale should be regularly used in suicide prevention practice.

Variables associated with repeated suicide attempt in a criminal justice population

The aim of this study was to identify factors associated with repeated suicide attempts among criminal justice clients examined for substance abuse using the Addiction Severity Index. Among suicide attempters (n=1,404), repeaters (two or more attempts, n=770) were compared to nonrepeaters. In logistic regression, repetition was associated with younger age, opioid analgesics, somatic medication, overdose, maternal psychiatric problems, delirium tremens, cognitive problems, and violent behavior. As in other settings, factors associated with repetition differed from those associated with suicide attempts in general. In this setting, substance use complications and cognitive problems were connected to repetition and should be addressed in risk assessments.

Distinguishing the relevant features of frequent suicide attempters

BACKGROUND

In spite of the high prevalence of suicide behaviours and the magnitude of the resultant burden, little is known about why individuals reattempt. We aim to investigate the relationships between clinical risk factors and the repetition of suicidal attempts.

METHODS

1349 suicide attempters were consecutively recruited in the Emergency Room (ER) of two academic hospitals in France and Spain. Patients were extensively assessed and demographic and clinical data obtained. Data mining was used to determine the minimal number of variables that blinded the rest in relation to the number of suicide attempts. Using this set, a probabilistic graph ranking relationships with the target variable was constructed.

RESULTS

The most common diagnoses among suicide attempters were affective disorders, followed by anxiety disorders. Risk of frequent suicide attempt was highest among middle-aged subjects, and diminished progressively with advancing age of onset at first attempt. Anxiety disorders significantly increased the risk of presenting frequent suicide attempts. Pathway analysis also indicated that frequent suicide attempts were linked to greater odds for alcohol and substance abuse disorders and more intensive treatment.

CONCLUSIONS

Novel statistical methods found several clinical features that were associated with a history of frequent suicide attempts. The identified pathways may promote new hypothesis-driven studies of suicide attempts and preventive strategies.

Crisis intervention at the general hospital: an appropriate treatment choice for acutely suicidal borderline patients

This study investigated whether crisis intervention (CI) at the General Hospital is a suitable management strategy among borderline patients referred to the emergency room (ER) for deliberate self-harm. Two patient cohorts (n=200) meeting DSM-IV Borderline Personality Disorder criteria, were prospectively assessed for repeated deliberate self-harm and service consumption. At ER discharge, 100 subjects received CI, while 100 comparison subjects (recruited before the implementation of CI) were assigned to treatment as usual (TAU). At 3-month follow-up, a high proportion of repeated deliberate self-harm and hospitalization in the global study sample was found. However rates were lower in the CI group: 8% repeated deliberate self-harm and 8% psychiatric hospitalization, versus 17% and 56% in the TAU group. The global expenditure for psychiatric hospitalization was 728,840 Swiss Francs (CHF) for CI and 914,340 for TAU. This study indicates that associated with mean hospitalization/relapse rates, CI may be a suitable management strategy for acutely suicidal borderline patients.

Does the Suicide Assessment Scale predict risk of repetition? A prospective study of suicide attempters at a hospital emergency department

PURPOSE

To determine whether the modified version of the Suicide Assessment Scale (SUAS) can be utilised to predict risk of repeat suicidal behaviour.

SUBJECTS AND METHODS

Hundred and sixty-five patients aged 18 to 68 years who were admitted to emergency wards after a suicide attempt were interviewed. Follow-up interviews (n=96) were carried out after 2 months. Associations between SUAS scores and repeat attempt (fatal/non-fatal) during the following 3 years were analysed and the instrument's ability to predict repetition was assessed.

RESULTS

High SUAS score (>30) was associated with repetition. The ability of the SUAS to correctly predict repeat suicidal behaviour in the entire study group was low (AUC=0.65, 95% CI=0.56-0.74) but better for those (n=42) who reported ongoing psychiatric treatment at follow-up (AUC=0.78, 95% CI 0.63-0.94). Among the latter group, all with baseline SUAS scores >30 made repeats.

CONCLUSION

The modified SUAS performed well as a screening instrument in psychiatric patients.

Formal and informal help during the year after a suicide attempt: a one-year follow-up

AIMS

The aims of this study are threefold: to investigate formal and informal help with clinical and social needs that patients who attempted suicide received during the year after their attempt; to examine whether help from services was estimated to be adequate; and to look at whether patients who repeated suicide attempt(s) during follow-up differed from those who did not.

METHODS

The Camberwell Assessment of Need instrument measuring 22 need areas was used in semi-structured interviews with 140 patients at 1 and 12 months after a suicide attempt.

RESULTS

Help given from services was rated as high at both 1 and 12 months in health-related areas, but lower in areas related to social needs. Informal help was initially frequent, with some exceptions. The amount of help from services did not decrease in any need area during follow-up, neither in repeaters nor in non-repeaters. There were no changes in informal help in repeaters, while in non-repeaters informal help decreased in some areas. At both 1 and 12 months, repeaters and non-repeaters mostly found help from services to be adequate. However, in the areas of information, intimate relationships, psychotic symptoms and sexual expression about half of the patients in both groups did not consider that they had received the right type of help.

CONCLUSIONS

The generally high level of formal help in health-related areas during the first year after a suicide attempt and the high rated adequacy of help given is satisfactory. However, in certain areas lack of formal help was evident. Informal caregivers contributed significantly to the help that patients received. The use of the Camberwell Assessment of Need instrument could improve observation on needs areas and whether help is available. Perhaps this kind of evaluation could be used earlier than after 1 year in such a vulnerable group as suicide attempters.