A population-based longitudinal study of suicide risk in male schizophrenia patients: Proximity to hospital discharge and the moderating effect of premorbid IQ

Association between childhood cognitive skills & adult suicidal behavior: A systematic review and meta-analysis

BACKGROUND

It is unclear whether cognitive skill deficits during childhood carry risk for suicide attempt or mortality later in adulthood at the population level. We conducted a systematic review and meta-analysis of population-based studies examining the association between childhood cognitive skills and adult suicidal behavior, namely attempt and mortality.

METHOD

We systematically searched databases for articles then extracted study characteristics and estimates on the association between childhood cognitive skills (i.e., IQ or school performance at age ≤ 18 years) and later suicide attempt and mortality. Random-effect meta-analysis was used to quantify this association across all studies with available data.

RESULTS

Twenty-three studies met the inclusion criteria and suggest an association between lower childhood cognitive skills and increased risk of suicidal behavior. Meta-analysis of the adjusted estimates from 11 studies (N = 2,830,191) found the association to be small but statistically significant. Heterogeneity was significant but moderate, and results were unlikely to be influenced by publication bias. In subgroup analyses, associations were significant only for males. No difference in effect size was found between suicide attempt and suicide mortality.

LIMITATIONS

Cognitive skills were measured with different cognitive subtests. Heterogeneity in the age of cognitive skills assessment. Meta-regression and subgroup analyses were based on a relatively low number of studies.

CONCLUSIONS

Individuals with lower cognitive skills in childhood have a greater risk of suicidal behavior in adulthood, especially males. Although the association was small, interventions improving cognitive skills may yield large effects on suicide prevention at the population level if the association is causal.

The Importance of Suicide Risk Formulation in Schizophrenia

Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25-50% of patients with schizophrenia attempt suicide in their lifetime. Evidence points to numerous individual, clinical, social, and psychological risk factors for suicide in patients with schizophrenia. Although recognizing suicidal risk factors in schizophrenia is extremely important in suicidal risk assessment, we have recently witnessed a change in suicide risk management that shifts the focus from suicide risk assessment to suicide risk formulation. Suicide risk formulation is dependent on the data gathered in the suicide risk assessment and assigns a level of suicide risk that is indispensable for the choice of treatment and the management of patients with a high suicidal risk. In this article, we extend the suicide risk formulation model to patients with schizophrenia. Suicide risk formulation results from four different areas that help clinicians collect as much information as possible for the management of suicidal risk. The four distinct judgments comprise risk status (the risk relating to the specific group to which the patient belongs), risk state (the risk for the person compared with his baseline or another reference point in the course of his life), available resources (on whom the person can count during a crisis) and foreseeable events (which can exacerbate the crisis). In schizophrenia, the suicide risk formulation model allows the clinician to evaluate in depth the clinical context of the patient, the patient's own history and patient-specific opportunities for better choosing and applying suicide prevention strategies.

Suicidal Risk Following Hospital Discharge: A Review

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate risk of suicide and suicide attempts following psychiatric hospitalization• Assess the relationship between suicide attempts and completed suicides BACKGROUND: Suicidal risks among psychiatric patients appear to be especially high soon after hospitalization. Given the importance of such outcomes, and the lack of recent reviews of post-discharge suicide attempt risks, we evaluated reported findings on the risk of suicide and attempts following psychiatric hospitalization.

METHODS

With systematic, computerized searching, we identified 48 studies (1964-2017) involving 1,700,785 subjects. Follow-up was limited to ≥12 months after discharge from psychiatric hospitalization to avoid inflation of annualized rates due to shorter exposure times.

RESULTS

The overall observed pooled, annualized rate of completed suicide was 241 (confidence interval, 238-243) per 100,000 person-exposure years in 41 studies, and for attempts, 722 (698-746) in 13 studies. In six studies (64,848 subjects) reporting on both suicides and attempts, the ratio of annualized rates for attempts/completed suicides was 8.79 (6.63-12.0). Among all 48 studies, cumulative distribution of suicidal events included 26.4% (25.9-26.9) within the initial month, 40.8% (40.2-41.4) within 3 months, and 73.2% (72.7-73.7) within 12 months of discharge.

CONCLUSIONS

Among patients recently discharged from psychiatric hospitalization, rates of suicide deaths and attempts were far higher than in the general population or even in unselected clinical samples of comparable patients, with a strong inverse association with time post-discharge. Improved monitoring and care of patients discharged from psychiatric hospitalization are needed, ideally with detailed planning and implementation of aftercare prior to discharge.

Self-Reported Suicidal Ideation as a Predictor of Suicidal Behavior Among Outpatients With Diagnoses of Psychotic Disorders

OBJECTIVE

Individuals with psychotic disorders are at high risk of suicidal behavior. The study examined whether response to item 9 of the Patient Health Questionnaire (PHQ-9), which asks about thoughts of death or self-harm, predicts suicidal behavior among outpatients with diagnoses of psychotic disorders.

METHODS

Electronic health records (EHRs) from seven large integrated health systems were used to identify all outpatient visits by adults with a diagnosis of schizophrenia spectrum psychosis or unspecified psychosis from January 1, 2009, to June 30, 2015, during which a PHQ-9 was completed (N=32,982 visits by 5,947 patients). Suicide attempts over the 90 days following each visit were ascertained from EHRs and insurance claims. Suicide deaths were ascertained from state death certificate files.

RESULTS

Risk of suicide attempt within 90 days of an outpatient visit was .8% among patients reporting no thoughts of death or self-harm and 3.5% among those reporting such thoughts "nearly every day." Over 90 days of follow-up, 47% of suicide attempts occurred among those who reported any recent thoughts of death or self-harm at the sampled visit. Also, 59% of attempts occurred among those reporting thoughts of death or self-harm at the index visit or any visit in the prior year. The number of suicide deaths within 90 days (N=10) was too small to accurately assess the relationship between PHQ-9 item 9 response and subsequent suicide death.

CONCLUSIONS

Among outpatients with psychotic disorders, response to item 9 of the PHQ-9 accurately identified those at increased short-term risk of a suicide attempt.

Epidemiology of Suicide and the Psychiatric Perspective

Suicide is a worldwide phenomenon. This review is based on a literature search of the World Health Organization (WHO) databases and PubMed. According to the WHO, in 2015, about 800,000 suicides were documented worldwide, and globally 78% of all completed suicides occur in low- and middle-income countries. Overall, suicides account for 1.4% of premature deaths worldwide. Differences arise between regions and countries with respect to the age, gender, and socioeconomic status of the individual and the respective country, method of suicide, and access to health care. During the second and third decades of life, suicide is the second leading cause of death. Completed suicides are three times more common in males than females; for suicide attempts, an inverse ratio can be found. Suicide attempts are up to 30 times more common compared to suicides; they are however important predictors of repeated attempts as well as completed suicides. Overall, suicide rates vary among the sexes and across lifetimes, whereas methods differ according to countries. The most commonly used methods are hanging, self-poisoning with pesticides, and use of firearms. The majority of suicides worldwide are related to psychiatric diseases. Among those, depression, substance use, and psychosis constitute the most relevant risk factors, but also anxiety, personality-, eating- and trauma-related disorders as well as organic mental disorders significantly add to unnatural causes of death compared to the general population. Overall, the matter at hand is relatively complex and a significant amount of underreporting is likely to be present. Nevertheless, suicides can, at least partially, be prevented by restricting access to means of suicide, by training primary care physicians and health workers to identify people at risk as well as to assess and manage respective crises, provide adequate follow-up care and address the way this is reported by the media. Suicidality represents a major societal and health care problem; it thus should be given a high priority in many realms.

The association between attempted suicide and stock price movements: Evidence from Taiwan

This study is the first comprehensive analysis to investigate the potential association between stock market fluctuations and attempted suicide events as measured by self-inflicted injuries treated in hospitalization. Using nationwide, 15-year population-based data from 1998 through 2012, we observe that the occurrences for the hospitalizations of attempted suicides are apparently predicted by stock price movements. A low stock price index, a daily fall in the stock index, and consecutive daily falls in the stock index have been shown to be associated with increased risk of hospitalization in patients with attempted suicide. More specifically, stock price index is found to be significant impact on attempted suicide in the 45-54 age groups of both genders, whilst daily change is significant for both genders in the 25-34 and 55-64 age groups and accumulated change is only significant in female aged 25-44 and above 65. On the basis of the results, relevant organizations should consider the suicidal factors that relate prime-working-age and near-retirement-age people to better carry out specific suicide prevention measures, and, meanwhile, encourage those people to pay less attention towards daily stock price movements.

Health and functioning of adolescents conceived by assisted reproductive technology

OBJECTIVE

To evaluate the general health, mental health, and cognitive ability of assisted reproductive technology (ART)-conceived adolescents.

DESIGN

A nested case-control study within a historic cohort.

SETTING

Not applicable.

PATIENT(S)

A total of 253 ART-conceived adolescents born between 1982 and 1993 and 253 matched references according to birth year, gender, and the high-school they attended.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Medical and psychiatric diagnoses, and cognitive ability recorded at the military preinduction screening (ages 16-17 years) and doctor's appointments throughout the military service.

RESULT(S)

No differences were detected in general and mental health of ART adolescents or cognitive ability, compared with the reference group. Similar results were obtained after stratification for gender and singleton births. The ART adolescents had fewer cases of discharge from military service due to health reasons (4% vs. 8.3%). Follow-up during the military service revealed that male ART adolescents had significantly more doctor's appointments compared with the reference group (23.80 ± 15.59 vs. 19.95 ± 13.79).

CONCLUSION(S)

Our preliminary results provide reassurance that in the long-run health and functioning of ART-conceived adolescents is not compromised. Further studies with larger cohorts are needed to confirm these results.

Dimensional psychotic experiences in adolescence: Evidence from a taxometric study of a community-based sample

Psychotic experiences of varying severity levels are common in adolescence. It is not known whether beyond a certain severity in the general population, psychotic experiences represent a categorically distinct phenomena to milder psychotic experiences. We employed taxometric analytic procedures to determine whether psychotic experiences in adolescence are taxonic (i.e. categorical) or dimensional. Six different psychotic experiences were assessed in a community sample of approximately 5000 adolescents. Three taxometric procedures were conducted. Across all procedures, there was no evidence of a taxon (i.e. a separate latent population) underlying psychotic experiences in adolescence. Rather, a dimensional structure was supported. The results support the notion that psychotic experiences are continuously distributed throughout the general population, and there is no clear discontinuity between milder and more severe psychotic experiences. Thus, these findings support the use of dimensional approaches to understanding psychotic experiences in etiological studies. In clinical practice, categorical cut-offs are needed: the present findings show that a 'natural' break point is not present for identifying severe psychotic experiences, and it is likely therefore that other criteria (such as general functioning) might better aid decision-making with regards to identifying individuals with severe psychotic experiences in need of care during adolescence.