Preventing suicide and premature death by education and treatment

Assessing age invariance of the Male Depression Risk Scale-22 in younger and older adult males

OBJECTIVES

Women are twice as likely to be diagnosed with major depressive disorder as men. Yet suicide rates are four times higher in men than women, increasing to six times when comparing older men to older women. Investigators have begun researching if depression presents differently in individuals who adhere to masculine norms, leading to the conceptualization of masculine depression. Despite validity evidence for the Male Depression Risk Scale-22 (MDRS-22) in mixed-age samples, few studies have investigated the possibility of age-related differences in masculine depression. The present study aimed to test for age invariance of the MDRS-22.

METHOD

Age invariance for the MDRS-22 was tested via a multi-group confirmatory factor analysis with groups of younger (18-64 years) and older (65+ years) males (N = 469).

RESULTS

Age invariance for the MDRS-22 was not established, ΔX2 = 451.47, Δdf = 16, p < 0.001.

CONCLUSION

Results of the study indicate that masculine depression may present differently between younger and older men. To fully understand the construct of masculine depression, it is important to investigate how symptoms may present in individuals of all ages. Overall, the study highlights the importance of investigating how masculine depression may present differently in older men.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

Objective

The authors sought to identify scalable evidence-based suicide prevention strategies.

Methods

A search of PubMed and Google Scholar identi- fied 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

Results

Training primary care physicians in depression rec- ognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active out- reach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are under-studied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

Conclusions

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physi- cian settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.Reprinted from Am J Psychiatry 2021; 178:611-624, with permission from American Psychiatric Association Publishing. Copyright © 2021.

Trends in suicide methods in Switzerland from 1969 to 2018: an observational study

BACKGROUND

Suicide is a serious societal and health problem. We examined changes in rates of completed suicides in Switzerland between 1969-2018 with particular regard to different methods of suicide used in different subgroups of the resident population.

METHODS

We used data of the Swiss cause of death statistics and Poisson regression models to analyse annual incidence rates and calendar time trends of specific suicide methods used in population subgroups by sex (men vs women), age (10-29, 30-64, >64 years), and nationality (Swiss vs other citizenship).

RESULTS

There were 64,996 registered suicides between 1969 and 2018. Across these 5 decades, the overall suicide rate was higher in men than in women (incidence rate ratio [IRR] 2.62, 95% confidence interval [CI] 2.58-2.67), in Swiss citizens than in foreigners (IRR 2.02; 95% CI 1.97-2.07), and in older residents (>64 years) than in the age groups 30-64 years (IRR 1.35, 95% CI 1.32-1.37) and 10-29 years (IRR 2.37, 95% CI 2.32-2.43). After peaking in the 1980s, the overall suicide rate had declined in all of these population subgroups, with flattening trends over most recent years. The most common specific methods of suicide were hanging (accounting for 26.7% of all suicides) and firearms (23.6%). The rates of the specific suicide methods were usually higher in men, in Swiss citizens and in older residents, and they had typically declined over most recent decades in the population subgroups examined. However, some methods diverged from this general pattern, at least in some population subgroups. For instance, railway suicides most recently increased in younger and in male residents whereas suicides by gas and by drowning were only at a low level after rapid declines in the last millennium.

CONCLUSIONS

Restricting access to lethal means (e.g., detoxification of domestic gas), improvements in health care and media guidelines for responsible reporting of suicides are possible explanations for the generally declining suicide rates in Switzerland. Whereas some methods (e.g., poisoning by gases or drowning) had become rare, others continue to account for many suicides every year, at least in some population subgroups (e.g., firearms in older Swiss men or railway suicides in younger and in male residents). As different methods of suicide are chosen by different people or subgroups of the population, preventive efforts should include differentiated strategies and targeted measures to further reduce suicides in Switzerland and elsewhere.

[Suicide prevention in the context of assisted suicide]

The verdict of the German Federal Constitutional Court from 26 February 2020 made it clear that every person is granted the right to end his or her own life, provided it is the person's own free will. It is also within his or her rights to utilize assistance in doing so, if such assistance is offered. This freedom to end one's life and to utilize assistance is not limited to terminal illnesses or situations of unbearable suffering. However, the High Court has also demanded that lawmakers ensure the safety of vulnerable people by making certain that the decision for suicide is in fact made out of the person's own free will. This free decision-making capability can be substantially impaired by acute psychosocial stressors, by mental illnesses but also by third party influence. Therefore, a liberalization of assisted suicide must unconditionally be accompanied by a massive strengthening of suicide prevention measures, which clearly prioritize the help to live over the help to die. This article reviews the scientifically established methods for suicide prevention and makes demands to lawmakers to comprehensively implement such measures.

Suicide prevention training: self-perceived competence among primary healthcare professionals

Objective: The aim is to report the outcomes of the suicide prevention training in terms of the self-perceived impact on the participants.Design: The three-hour training consisted areas of risk and protective factors, screening and evaluating suicide risk, raising concerns and confronting suicidal patients, and treating suicidal ideation in primary healthcare and the associated referral processes.Subjects: The studied participants consisted of general practitioners, nurses, public health nurses and social work professionals.Main outcome measures: Participants assessed their own competence on online form regarding four training areas prior to and two weeks after the training.Results: The response rate was 25%. The self-perceived competence of the healthcare professionals increased in all training areas and in all occupational groups. The healthcare professionals' competence regarding the risk and protective factors training area saw the greatest increase across all professional groups except nurses. There were, however, differences between the groups.Conclusion: Suicide prevention training for primary healthcare professionals did increase the self-perceived competence of the participants in all areas covered by the training. Regular follow-up training is required in order for these improvements to be further developed and retained.Key pointsAfter the suicide prevention training all participants self-perceived increase in their competence in all training areas.The GPs self-perceived most increase in risk and protective factors and nurses in raising concerns and confronting suicidal patients.The GPs' lowest increase was in the area of treating suicidal ideation in primary health care and the referral processes.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

OBJECTIVE

The authors sought to identify scalable evidence-based suicide prevention strategies.

METHODS

A search of PubMed and Google Scholar identified 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

RESULTS

Training primary care physicians in depression recognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are understudied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

CONCLUSIONS

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physician settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.

Men's Psychotherapy Use, Male Role Norms, and Male-Typical Depression Symptoms: Examining 716 Men and Women Experiencing Psychological Distress

Men as compared to women are half as often affected by depressive and anxiety disorders and seek significantly less help for mental health issues than women. Adherence to traditional male role norms (AtTMRN) may hinder men from describing prototypical depression symptoms and from seeking psychotherapy. The current study compared whether AtTMRN, gender role identity, or the experience of prototypical or male-typical externalizing mental health symptoms were associated with psychotherapy use in men and women. In an anonymous online survey, 716 participants (37% men) reporting to currently experience psychological distress were examined. Information was obtained on psychotherapy use, depression and anxiety symptoms, gender role identity, and traditional male role norms. Although experiencing similar levels of depression, men compared to women showed a reduction in psychotherapy use by 29%. Masculine role identity was directly associated with reduced psychotherapy use in men (β = −0.41, p = 0.029), whereas AtTMRN was not (men: β = −0.04, p = 0.818; women: β = −0.25, p = 0.064). Higher externalizing depression symptomatology (β = −0.68, p = 0.005), but not prototypical depression symptomatology (β = −0.02, p = 0.499), was associated with reduced psychotherapy use in men but not women (p > 0.05). Interactions revealed that men, but not women, with high AtTMRN use psychotherapy only when exhibiting elevated symptom levels. The results corroborate previous reports showing reduced psychotherapy use in men as compared to women and identify elevated masculine role identity and male-typical externalizing depression symptomatology as direct factors associated with reduced psychotherapy use in psychologically distressed men. AtTMRN interacts with mental health symptoms to predict psychotherapy use, indicating that men with high AtTMRN only use psychotherapy when exhibiting high symptomatology.

Deficiencies in healthcare prior to suicide and actions to deal with them: a retrospective study of investigations after suicide in Swedish healthcare

OBJECTIVES

The overall aim of this study was to aggregate the conclusions of all investigations conducted after suicides reported to the supervisory authority in Sweden in 2015, and to identify deficiencies in healthcare found in these investigations; the actions proposed to deal with the deficiencies; the level of the organisational hierarchy (micro-meso-macro) in which the deficiencies and actions were situated; and outcomes of the supervisory authority's decisions.

DESIGN AND SETTING

This is a retrospective study of all reports from Swedish primary and secondary healthcare after suicide to the regulatory authority in Sweden in 2015.

RESULTS

In 55% (n=240) of cases, healthcare providers reported healthcare deficiencies that contributed to suicide; these deficiencies were primarily in 'suicide risk assessment' and 'treatment'. Actions aimed at preventing new suicides were proposed in 80% of cases (n=347). By far, the most frequent actions were 'education and competence', present in 52% of cases (n=227) and did not much correspond with identified deficiencies. Sixty-five per cent of the deficiencies and actions were at microlevel, while the remainders were at mesolevel. In 65% (n=284) of cases, the supervisory authority approved the investigation without further requirements.

CONCLUSIONS

The most common identified deficiencies were related to care in the immediate interface between patient and staff. Actions proposed to prevent new suicides were centred on single educational interventions without distinctive sustainable effects in the organisations and usually did not correspond with the identified deficiencies. Future research should examine if application of a framework based on knowledge of the suicide process, suicide prevention strategies and patient safety would enable more sophisticated investigations that could facilitate progress on suicide prevention.

[Antidepressants and Suicidality: A Contradiction?]

Antidepressants and Suicidality: A Contradiction? Abstract. In 2004, the European and American authorities released a black-box warning on antidepressants indicating an association with an increased risk of suicidality (suicidal ideation and behavior) in young people. Until today, this issue remained controversial. The present review gives an overview on the relationship between antidepressant therapy and the risk of suicide and suicidality, respectively: there is no evidence of an increased risk of suicide, but of an increased rate of suicidality during the first period after starting an antidepressant treatment in young patients. Importantly, this risk was not higher than before treatment initiation. However, an intensified supervision is needed especially during the first weeks of treatment. Finally, the risk posed by untreated depression is far greater than a risk associated with antidepressant treatment.

Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and Adolescents

OBJECTIVE

The rate of adolescent suicide and suicidal behavior has risen dramatically in the past decade. The title of this article comes from the classic coming-of-age novel by J.D. Salinger, The Catcher in the Rye. Its protagonist, Holden Caulfield, is a precocious adolescent who, in the face of his inability to cope with his own self-destructives urges, imagines himself saving "little kids playing some game in this big field of rye." He is standing on the edge of a cliff trying to catch "thousands of little kids" before they fall to their demise. This vignette from The Catcher in the Rye provides a useful metaphor for the relationship between mental health professionals and youth at risk for suicide, and suggests more efficient and effective alternative interventions to prevent youth suicide compared to standing by a cliff.

METHOD

These four alternative approaches are described, namely: (1) leading youth away from the cliff (ie, prevention); (2) going to where youth are (ie, improving access to care); (3) working with others to change the rules in the field (ie, changing the way care is delivered); and (4) putting a fence around the cliff (ie, restriction of access to lethal agents). The evidence to support the utility and cost-effectiveness of each of these approaches is reviewed.

CONCLUSION

There are extant, empirically supported, cost-effective approaches to the prevention and management of adolescent suicidal behavior that, if implemented widely, are likely to significantly reverse the decade-long rise in adolescent suicide.

The future of population medicine: Investigating the role of advanced practice providers and simulation education in special patient populations

Advanced practice providers (APPs) have come to play an increasingly significant role in the United States healthcare system in the past five decades, particularly in primary care. The first portion of this paper will explore the utilization of APPs in specific patient populations: pediatrics, obstetrics, geriatrics, and psychiatry. After a brief discussion of the demand for these specialties, the authors will outline the educational preparation and competencies that nurse practitioners and physician assistants must achieve before working with these special populations. Finally, the authors will discuss the current and future roles of APPs in pediatric, obstetric, geriatric, and psychiatric populations. Simulated patient interactions and scenarios have become integrated into clinical education for many health care providers. Although traditionally utilized only in emergency medicine education, medical simulation has grown to become a staple of training in nearly every area of medicine. Healthcare providers of all levels can benefit from both individual and team-based training designed to improve everything from patient communication to procedural competence. The flexible nature of simulation training allows for customized teaching that is directly relevant to a specific specialty. The second half of this paper will demonstrate simulation's versatilite applications in the specialty areas of urgent care, pediatrics, mental health, geriatrics, and obstetrics.

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths

South Asia accounts for the majority of the world's suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to 'fate' and personality characteristics such as 'stubbornness' and 'egoism'; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.

The androgen model of suicide completion

Suicide is a devastating public health issue that imposes severe psychological, social, and economic burdens not only for the individuals but also for their relatives, friends, clinicians, and the general public. Among the different suicidal behaviors, suicide completion is the worst and the most relevant outcome. The knowledge of biological etiopathological mechanisms involved in suicide completion is limited. Hitherto, no objective markers, either alone or in combination, can reliably predict who will complete a suicide. However, such parameters are strongly needed to establish and optimize prediction and prevention. We introduce here a novel ideation-to-completion framework in suicide research and discuss the problems of studies aiming at identifying and validating clinically useful markers. The male gender is a specific risk factor for suicide, which suggests that androgen effects are implicated in the transition from suicidal ideation to suicide completion. We present multiple lines of direct and indirect evidence showing that both an increased prenatal androgen load (with subsequent permanent neuroadaptations) and increased adult androgen activity are involved in suicide completion. We also review data arguing that modifiable maternal behavioral traits during pregnancy contribute to the offspring's prenatal androgen load and increase the risk for suicide completion later in life. We conclude that in utero androgen exposure and adult androgen levels facilitate suicide completion in an synergistic manner. The androgen model of suicide completion provides the basis for the development of novel predictive and preventive strategies in the future.

Mental illness in Sweden (1896-1905) reflected through case records from a local general hospital

Mental illness in a hospital in a medium-sized town in Sweden was studied. Consecutive case records from 1896 to 1905, and also from 2011, were selected. In the historical sample, neurasthenia was the most common diagnosis, followed by affective disorders and alcohol abuse. ICD-10 diagnoses corresponded well with the historical diagnoses. Melancholia resembled modern criteria for depression. Mania, insania simplex and paranoia indicated more severe illness. Abuse was more common among men and hysteria among women. Those with a medical certificate for mental hospital care were very ill and showed no gender difference. There were no diagnoses for abuse, but 17% had a high level of alcohol consumption. The pattern of signs and symptoms displayed by patients does not appear to change with time.

Effectiveness of General Practitioner training to improve suicide awareness and knowledge and skills towards depression

BACKGROUND

General Practitioners (GPs) are well placed as gatekeepers for managing depression and suicidal ideation but not always well prepared. Capacity building has therefore been recommended as a useful strategy for suicide prevention. This study aimed to examine whether GPs' knowledge and attitudes towards and confidence to deal with depression and suicide improve after following a training program.

METHODS

As part of the OSPI-Europe multilevel intervention, a standardized training on depression and suicide was provided to 208 GPs in three European countries. Core outcomes were assessed using the Depression Attitude Questionnaire, the Attitude towards Suicide Prevention Scale, and the Morriss Confidence Scale. Data were collected before and after training, and at three to six months follow-up.

RESULTS

At baseline, GPs demonstrated various stigmatizing attitudes towards depression and low optimism about the therapeutic treatment of depression. They showed moderately positive attitudes towards suicide prevention but felt little confident in dealing with depression and suicide in daily practice. The training resulted in improved knowledge, attitudes and confidence regarding depression and suicide and their prevention and treatment. At follow-up, only the increase in confidence to deal with depression and suicide was sustained.

LIMITATIONS

The Depression Attitude Questionnaire has rather weak psychometric properties. Other external factors may have contributed to the observed training effects as the study included no control group.

CONCLUSIONS

The OSPI-Europe training program was able to improve the GPs' attitudes towards suicide prevention, several attitudes towards depression and its treatment as well as the GPs' confidence to deal with depression and suicide in everyday practice. At follow, only the GPs' confidence to deal with depression and suicide was preserved.

Development of a 2-h suicide prevention program for medical staff including nurses and medical residents: A two-center pilot trial

BACKGROUND

Suicide is a crucial global health concern and effective suicide prevention has long been warranted. Mental illness, especially depression is the highest risk factor of suicide. Suicidal risk is increased in people not only with mental illness but also with physical illnesses, thus medical staff caring for physically-ill patients are also required to manage people with suicidal risk. In the present study, we evaluated our newly developed suicide intervention program among medical staff.

METHODS

We developed a 2-h suicide intervention program for medical staff, based on the Mental Health First Aid (MHFA), which had originally been developed for the general population. We conducted this program for 74 medical staff members from 2 hospitals. Changes in knowledge, perceived skills, and confidence in early intervention of depression and suicide-prevention were evaluated using self-reported questionnaires at 3 points; pre-program, immediately after the program, and 1 month after program.

RESULTS

This suicide prevention program had significant effects on improving perceived skills and confidence especially among nurses and medical residents. These significant effects lasted even 1 month after the program.

LIMITATIONS

Design was a single-arm study with relatively small sample size and short-term follow up.

CONCLUSIONS

The present study suggests that the major target of this effective program is nurses and medical residents. Future research is required to validate the effects of the program with control groups, and also to assess long-term effectiveness and actual reduction in suicide rates.

Neuroendocrinology of a Male-Specific Pattern for Depression Linked to Alcohol Use Disorder and Suicidal Behavior

Epidemiological studies show low rates of diagnosed depression in men compared to women. At the same time, high rates of alcohol use disorders (AUDs) and completed suicide are found among men. These data suggest that a male-specific pattern for depression may exist that is linked to AUDs and suicidal behavior. To date, no underlying neuroendocrine model for this specific pattern of male depression has been suggested. In this paper, we integrate findings related to this specific pattern of depression with underlying steroid secretion patterns, polymorphisms, and methylation profiles of key genes in order to detail an original neuroendocrine model of male-specific depression. Low circulating levels of sex steroids seem to increase the vulnerability for male depression, while concomitant high levels of glucocorticoids further intensify this vulnerability. Interactions of hypothalamus-pituitary-gonadal (HPG) and hypothalamus-pituitary-adrenocortical (HPA) axis-related hormones seem to be highly relevant for a male-specific pattern of depression linked to AUDs and suicidal behavior. Moreover, genetic variants and the epigenetic profiles of the androgen receptor gene, well-known depression related genes, and HPA axis-related genes were shown to further interact with men's steroid secretion and thus may further contribute to the proposed male-specific pattern for depression. This mini-review points out the multilevel interactions between the HPG and HPA axis for a male-specific pattern of depression linked to AUDs and suicidal behavior. An integration of multilevel interactions within the three-hit concept of vulnerability and resilience concludes the review.

Social Stigma Toward Suicide: Effects of Group Categorization and Attributions in Korean Health News

The purpose of this study is to examine the influence of health news content on the stigma of suicide. In particular, this study tested whether the onset controllability and group categorization had a causal effect on people's stigma toward suicide. The results indicated that stigma scores were lower for those who read an article explaining the causes of suicide as uncontrollable than for those who read an article explaining the causes as controllable. Also, lower stigma scores were observed for those who read an article depicting suicidal people as the in-group compared to those who read an article depicting suicidal people as the out-group. Furthermore, stigma scores were the highest for those exposed to an article with the out-group categorization combined with the controllable causes of suicide.

Suicide prevention competencies among urban Indian physicians: A needs assessment

INTRODUCTION

India accounts for the highest estimated number of suicides in the World. In 2012, more than 258,000 of the 804,000 suicide deaths worldwide occurred in India. Early identification and effective management of suicidal ideation and behavior are paramount to saving lives. However, mental health resources are often scarce and limited. Throughout India, there is a severe shortage in mental health professions trained, which results in a treatment gap of about 90%. A comprehensive needs assessment was undertaken to identify the nature of the deficits in suicide prevention training for physicians in three Indian cities: Mumbai, Ahmedabad, and Mysore.

MATERIALS AND METHODS

The study was carried out in several concurrent phases and used a mixed-method approach of converging quantitative and qualitative methodologies. Data were collected using survey questionnaires, focus groups, consultations, and environmental scans. A total of 46 physicians completed the questionnaire. Focus groups were conducted in Mumbai and Ahmedabad with 40 physicians. Consultations were carried out with psychiatrists and psychiatric residents from hospitals and clinics in Mumbai, Ahmedabad, and Mysore.

RESULTS

Training gaps in suicide prevention exist across the health care professions. Existing training lacks in both quality and quantity and result in critical deficits in core competencies needed to detect and treat patients presenting with suicidal ideation and behavior. Only 43% of the surveyed physicians felt they were competent to treat suicidal patients. The majority of surveyed physicians believed they would greatly benefit from additional training to enhance their suicide risk assessment and intervention skills.

CONCLUSIONS

There is a dire need for medical schools to incorporate suicide prevention training as a core component in their medical curricula and for continuing medical education training programs for physicians to enhance competencies in early detection and management of suicidal behavior.

Gender differences in a cohort of major depressive patients: further evidence for the male depression syndrome hypothesis

BACKGROUND

Previous studies have shown that major depressive patients may differ in several features according to gender, but the existence of a specific male depressive syndrome remains controversial.

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 125 (27.7%) were of male gender, whereas 317 (72.3%) were female, after exclusion of bipolar I patients.

RESULTS

Compared to women, men were more often married, had more associated mixed features, with more bipolar disorder NOS, more hyperthymic temperaments, and less depressive temperaments. Women had an earlier age at onset of depression, more depressive episodes and suicide attempts. A higher family loading was shown in men for bipolar disorder, alcohol use disorder, impulse control disorders and suicide, whereas their family loading for major depressive disorder was lower. Men displayed more comorbidities with alcohol use, impulse control, and cardiovascular disorders, with lower comorbidities with eating, anxiety and endocrine/metabolic disorders. The following independent variables were associated with male gender: hyperthymic temperament (+), alcohol use disorder (+), impulse control disorders (+), and depressive temperament (-).

LIMITATIONS

The retrospective design and the lack of specific tools to assess the male depressive syndrome.

CONCLUSION

Study findings may lend support to the male depression syndrome concept and draw attention to the role of hyperthymic temperament, soft bipolarity as well as comorbidities as determinants of this syndrome. The latter could help recognize an entity which is probably underdiagnosed, but conveys a high risk of suicide and cardiovascular morbidity.

Public mental health: the time is ripe for translation of evidence into practice

Public mental health deals with mental health promotion, prevention of mental disorders and suicide, reducing mental health inequalities, and governance and organization of mental health service provision. The full impact of mental health is largely unrecognized within the public health sphere, despite the increasing burden of disease attributable to mental and behavioral disorders. Modern public mental health policies aim at improving psychosocial health by addressing determinants of mental health in all public policy areas. Stigmatization of mental disorders is a widespread phenomenon that constitutes a barrier for help-seeking and for the development of health care services, and is thus a core issue in public mental health actions. Lately, there has been heightened interest in the promotion of positive mental health and wellbeing. Effective programmes have been developed for promoting mental health in everyday settings such as families, schools and workplaces. New evidence indicates that many mental disorders and suicides are preventable by public mental health interventions. Available evidence favours the population approach over high-risk approaches. Public mental health emphasizes the role of primary care in the provision of mental health services to the population. The convincing evidence base for population-based mental health interventions asks for actions for putting evidence into practice.

Health care contacts in the year before suicide death

BACKGROUND

Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.

OBJECTIVE

To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed.

DESIGN

Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states.

PARTICIPANTS

In all, 5,894 individuals who died by suicide, and were health plan members in the year before death.

MAIN MEASURES

Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site.

KEY RESULTS

Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means.

CONCLUSIONS

This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Development and preliminary validation of the male depression risk scale: furthering the assessment of depression in men

BACKGROUND

The last decade has seen the burgeoning publication of male-specific depression rating scales designed to assess externalising depression symptoms (e.g., substance use, risk-taking, and aggression). These symptoms are theorised to reflect the behavioural manifestation of depression amongst men who rigidly conform to masculine norms. To date, research findings from these scales have been mixed, and each scale is limited by psychometric shortcomings or constrained assessment of symptom sub-domains.

METHODS

The Male Depression Risk Scale (MDRS-22) was developed from online, non-clinical, community samples. Following best-practice recommendations, initial scale items were subject to expert review. Study 1 (male n=386) reduced the item pool via exploratory factor analysis while Study 2 (male n=499, female n=291) refined and validated the factor structure using confirmatory factor analysis. Sex and masculinity comparisons were evaluated.

RESULTS

Goodness of fit indices validated the six-factor solution with subscales assessing: emotional suppression, drug use, alcohol use, anger and aggression, somatic symptoms and risk-taking. Between-groups analyses indicated higher MDRS-22 scores for males reporting higher conformity to masculine norms.

LIMITATIONS

Data were drawn from an online community sample without use of diagnostic interview. Test-retest correlations were not evaluated. Future research should look to examine longitudinal typical-externalising symptom trajectories across a range of clinical and non-clinical settings.

CONCLUSIONS

The MDRS-22 reports satisfactory preliminary psychometric properties with validated subscales enabling multidimensional assessment of theorised externalising symptom sub-domains. MDRS-22 scale brevity may facilitate use in primary care settings enabling better identification of at-risk males.

Psychosocial factors associated with suicidal ideation in clinical patients with depression

BACKGROUND

Depression is a major risk factor for suicide, but few studies have examined psychosocial risk factors for suicide in clinical patients with depression. The purpose of this study was to investigate psychosocial factors which could be associated with suicidal ideation in clinical patients with depression including: sick-leave, help-seeking behavior, and reluctance to admit mental health problems.

METHODS

A multi-center cross-sectional survey using self-report questionnaire was conducted at 54 outpatient psychiatric clinics in Tokyo in 2012. Adult outpatients who were diagnosed by psychiatrists as mood disorders (F30-F39) in the International Classification of Diseases-10 (ICD-10) were included in the study. Those who met the criteria for current hypomanic or manic episode were excluded from the study.

RESULTS

A total of 189 patients with depression participated in the survey. Multivariable logistic regression analysis showed that taking sick-leave and having sought help from family were associated with decreased odds of current suicidal ideation. Moderate or more severe depression was associated with increased odds of suicidal ideation, and reluctance to admit own mental health problem tended to increase odds of suicidal ideation.

LIMITATIONS

Living status and suicidal ideation before consultation with psychiatrist were not investigated. Severity of suicidal ideation and comorbid psychiatric disorders were not assessed.

CONCLUSIONS

Importance of treatment of more severe depression for suicide prevention was confirmed. Industrial health staffs should consider the possibility of positive effect of taking sick-leave when they see employees with depression. Promoting help-seeking for family and reducing stigma of mental illness may be effective for suicide prevention.

Correlates of suicide stigma and suicide literacy in the community

Public knowledge and attitudes toward suicide may influence help-seeking for suicidality. This study aimed to identify correlates of suicide attitudes and knowledge. Australian adults were invited to complete an online survey, with 1,286 responders. Less exposure to suicide, older age, male gender, less education, and culturally diverse backgrounds were associated with poorer knowledge; while younger age, male gender, and culturally diverse backgrounds were associated with more stigmatizing attitudes toward people who die by suicide. The results suggest suicide literacy and stigma reduction programs would benefit community members, particularly males and individuals from culturally diverse backgrounds.

Efficient interventions on suicide prevention: a literature review

AIM

This review focuses on interventions to prevent suicide. It excludes psychotherapy evaluations and pharmaceutical clinical trials. The aim of this article is to provide useful input to the reflection on and the development of actions for professionals who may be concerned by suicide prevention.

METHOD

This research is based on 41 published evaluation studies presenting results on at least one of the three following outcomes: completed suicides, suicide attempts, and suicidal ideations. These studies have been classified into seven categories of preventive action.

RESULTS

According to data from the literature selected for our analysis, the three most efficient categories of intervention seem to be the limitation of access to lethal means, the preservation of contact with the patients hospitalized for a suicide attempt after hospitalization, and the implementation of emergency call centers. The four other categories of intervention examined in this study - the training of general practitioners, the reorganization of care, programs in schools, and information campaigns - have not yet shown sufficient proof of their efficacy. Nevertheless, these interventions, under certain conditions, can also contribute significantly to the prevention of suicide.

CONCLUSION

The majority of effective interventions minister to people already suffering from psychological disorders, but health promotion initiatives prior to situations of psychological disorders also deserve to be considered, in particular the implementation of services for the isolated elderly.

Teaching therapeutic assessment for self-harm in adolescents: training outcomes

OBJECTIVES

To describe the teaching programme of Therapeutic Assessment (TA), a brief intervention at the point of initial assessment for adolescents with self-harm; to describe trainees' preferences and choices regarding their use of specific aspects of TA.

DESIGN

This is a comparative study investigating the differences in the TA skills before and after training. This design was chosen to establish whether or not TA training is efficacious.

METHODS

 Twenty-four clinicians volunteered to participate in five half-day TA training sessions. Their scores on the Therapeutic Assessment Quality Assurance Tool (TAQAT, primary outcome measure) were compared before and after training. Satisfaction with training and therapeutic strategy choices as well as ability to perform TA in an RCT were investigated.

RESULTS

Clinicians who participated in TA training had significantly increased scores on TAQAT after training. The clinicians who achieved the required quality of TA post assessments were likely to be able to carry out TA in an RCT with high fidelity. In addition, prior to training, significant differences in the quality of assessments as measured by TAQAT were identified depending on the experience of the clinician. This discrepancy was no longer present post training. Therapeutic strategy based on solution-focused brief therapy (SFBT) was the option of choice post training.

CONCLUSIONS

TA training is feasible and associated with improved quality of self-harm assessment.

PRACTITIONER POINTS

TA is a brief intervention associated with improved treatment engagement. TA training is feasible and is associated with improved quality of self-harm assessment. SFBT-based exit is the most commonly used strategy in TA.

Combined effects of neuroticism and extraversion: findings from a matched case control study of suicide in rural China

Neuroticism and extraversion are potentially important markers of personality vulnerability to suicide. Whereas previous studies have examined these traits independently, we examined their combined effects. Data were collected from family members and/or friends of individuals 18 years or older who died by suicide (n = 64) in rural China and from age-, sex-, and geographically matched controls (n = 64). Personality was assessed with the NEO-Five Factor Inventory. Individuals with a personality style characterized by high neuroticism and low extraversion were at 3.07 (95% confidence interval [CI], 1.44-6.55) times greater risk for suicide than were individuals without this personality style; in contrast, a style characterized by low neuroticism and high extraversion conferred decreased suicide risk (odds ratio, 0.41; 95% CI, 1.44-6.55). We conclude that it may be clinically inadequate to conceptualize neuroticism, by itself, as a risk marker for suicide. However, when the negative affect characteristic of neuroticism is combined with the joylessness, pessimism, and hopelessness characteristic of low extraversion, risk for suicide is elevated.

Can the Holmes-Rahe Social Readjustment Rating Scale (SRRS) be used as a suicide risk scale? An exploratory study

The objective of this research was to examine whether the Holmes-Rahe Social Readjustment Rating Scale, a life event scale, can be used to identify suicide attempters. The Holmes-Rahe Social Readjustment Rating Scale's ability to identify suicide attempters was tested in 1183 subjects (478 suicide attempters, 197 psychiatric inpatients, and 508 healthy controls) using the Fisher Linear Discriminant Analysis and traditional psychometric methods. The Fisher Linear Discriminant Analysis outperformed traditional psychometric approaches (area under the curve: 0.85 vs. 0.78; p < 0.05) and indicated that this scale may be used to identify suicide attempters. The life events that better characterized suicide attempters were change in frequency of arguments, marital separation, and personal injury. The Holmes-Rahe Social Readjustment Rating Scale may help identify suicide attempters.

Strategies for quantifying the relationship between medications and suicidal behaviour: what has been learned?

In recent years there has been considerable concern that certain classes of drugs, for example antidepressants, may increase the risk of suicide. In this current opinion article, we examine the literature on methodological and statistical approaches to the design and analysis of suicidal event studies. Experimental, ecological and observational studies of the relationship between drugs and suicidal events (thoughts, attempts and completion) are discussed. Areas considered include analysis of spontaneous reporting system data, ecological trends in national and/or small area (e.g. county) suicide rates, meta-analyses of randomized clinical trials, and large-scale medical claims data. New statistical and experimental strategies for investigating possible associations between drugs and suicide are highlighted, and we suggest directions for future statistical/methodological research. To put this into context, we then review the most recent literature on the relationship between drugs (antidepressants, antiepileptics, varenicline, montelukast and antipsychotics) and suicidal events. Overall, there appears to be little evidence that drugs increase the risk of suicide and related behaviour. Numerous lines of evidence in adults clearly demonstrate that inadequate treatment of depression (pharmacotherapy and/or psychotherapy) is associated with increased risk of suicidal behaviour. In children, the results are less clear and further study is required to better delineate which children benefit from treatment and who may be at increased risk as a consequence of treatment. From a statistical and methodological perspective, the field of pharmacoepidemiology is a fertile area for statistical research, both in theory and in application. In general, methods have been adopted from other areas such as general epidemiology, despite the singular nature of many of the problems that are unique to drug safety in general, in particular the study of rare events. Finally, there is considerable debate concerning the communication of risk. For suicide, regulatory action has been taken largely on the basis of evidence suggesting increased risk of suicidal thoughts. However, suicidal thoughts are quite common, particularly among patients with depression, and may have little relationship to suicidal behaviour and/or completion.

Suicide From the Perspectives of Older Men Who Experience Depression

Depression can be a pathway to older men’s suicide, yet the mechanisms by which this can occur are poorly understood. A qualitative study of 22 older men who self-identified or were formally diagnosed with depression was conducted to describe the connections between masculinity, depression, and suicide. Analyses of individual interviews revealed that cumulative losses around social bonds were central to older men’s depression, apathy for living, and thoughts about suicide. Prominent were men’s self-assessments of failing to fulfill breadwinner roles, judgments that led participants to ruminate on their shortcomings amid recognizing their older age as limiting opportunities for redemption. Stigma featured as a barrier for men acting on their suicidal thoughts, and guilt about the pain their suicide would evoke on family and friends was a strong deterrent for men’s self-harm. Overall, participants’ alignment to masculine ideals influenced both the connectedness and detachment between older men’s depression and suicide.

Crucial elements in suicide prevention strategies

Ways of conceptualizing suicide prevention are reviewed briefly, and the preventive model: Universal, Selected, and Indicated prevention (USI) is chosen as the structure for the literature review, and the discussion. Universal preventive interventions are directed toward entire population; selective interventions are directed toward individuals who are at greater risk for suicidal behaviour; and indicated preventions are targeted at individuals who have already begun self-destructive behaviour. On the universal prevention level, an overview of the literature is presented with focus on restrictions in firearms and carbon monoxide gas. At the selective prevention level, a review of risk of suicide in homelessness and schizophrenia and risk factors for suicide in schizophrenia is conducted and possible interventions are mentioned together with the evidence for their effect. Suicide rate and preventive measures in affective disorder are also touched upon. At the indicated prevention level, studies of fatal and non-fatal suicide acts after suicide attempt are mentioned. The evidence of preventive measures to reduce repetition rates is presented. Finally, the state of the art is discussed with regard to prevention at the universal, the selected and the indicated level and clinical and research implications are outlined.

Outcomes of a two-tiered multifaceted elderly suicide prevention program in a Hong Kong Chinese community

OBJECTIVES

1) To compare the 2-year completed suicide and reattempt rates in a preintervention group of Hong Kong Chinese suicide attempters (aged 65 years and older) who received standard care and a postintervention group enrolled in a regional elderly suicide prevention program (ESPP) that adopts a two-tiered multifaceted care management model and 2) to examine the trend of suicide rates in older adults aged 65 years and older in the pre- and postintervention periods.

DESIGN

The first part is an observational cohort study with baseline, follow-up, and outcome data being identified from a clinical electronic registry. The second part examines changes in suicide rates from official mortality statistics.

SETTING

A government-funded suicide intervention program serving catchment population (852,796 people aged 65 years and older) in Hong Kong, China.

PARTICIPANTS

Suicide attempters (aged 65 years and older) presenting to old-age psychiatric service in the pre- and postintervention phases.

MEASUREMENTS

1) Two-year rates of completed suicide and suicide reattempt and 2) changes in population suicide rates in the pre- and postintervention periods.

RESULTS

The 2-year completed suicide rate was 7.58% in the preintervention group (N = 66) and 1.99$% in the ESPP group (N = 351) Χ = 6.192; p value: 0.028; df = 1). Reattempt rates were not different. At a population level, suicide rate dropped significantly only in women aged 85 years and older, relative to the preintervention period.

CONCLUSIONS

The ESPP was associated with a reduced rate of completed suicide in old-age suicide attempters and might have contributed to a fall of suicide rate in women aged 85 years and older.

Suicide prevention training for professionals in the public health network in a large Brazilian city

The objective of this study was to improve health professionals' knowledge and attitudes toward suicide prevention. A suicide prevention training of 18 hours duration was conducted with 270 health professionals, mainly primary care workers, who were routinely involved with patients at high risk for suicide. Questionnaires were used to assess changes in attitudes and knowledge. The score in the knowledge questionnaire, with 21 points as maximum value, increased from 8.9 to 13 points (p < .001, significance level of 95%). Of the 25 questionnaire items representing attitudes, 18 showed significant change after the training. This training model has enhanced knowledge and attitudes toward suicide prevention in healthcare workers.

Suicide attempters in the emergency department before hospitalization in a psychiatric ward

PURPOSE

The study aims to compare the current suicidal risk of mood disorder patients who had just attempted suicide, as compared with those who had not attempted suicide, admitted to an emergency department (ED), and then hospitalized in a psychiatric unit.

METHOD

One hundred sixty-one mood disorder patients admitted to the ED were studied. A total of 22.4% of the participants were admitted for a suicide attempt. Patients were assessed for psychopathology and diagnosis.

FINDINGS

Suicide attempters were nearly 12 times more likely to report ongoing suicidal ideation during the psychiatric evaluation in the ED than nonattempters. Men and women did not differ for current and previous suicide attempts or for ongoing suicidal ideation.

PRACTICAL IMPLICATIONS

It is important to conduct a suicide risk assessment when individuals are admitted to an ED.

Effects of training program on recognition and management of depression and suicide risk evaluation for Slovenian primary-care physicians: follow-up study

AIM

To implement and evaluate an educational program for primary care physicians on recognition and treatment of depression and suicide prevention.

METHOD

The study was conducted in 3 Slovenian neighboring regions (Celje, Ravne na Koroskem, and Podravska) with similar suicide rates and other health indicators. All primary care physicians from Celje (N=155) and Ravne na Koroskem (N=35) were invited to participate in the educational program on depression treatment and suicide risk recognition. From January to March 2003, approximately half of them (82 out of 190; educational group) attended the program, whereas the other half (108 out of 190; control group 1) and physicians from the Podravska region (N=164; control group 2) did not attend the program. The prescription rates of antidepressants and anxiolytics before and after the intervention were compared between the studied regions. Also, suicide rates three-years before and after the intervention were compared.

RESULTS

From 2002 to 2003, there was a 2.33-fold increase in the rate of antidepressant prescriptions in the educational group (P<0.05) and only 1.28-fold (P<0.05) and 1.34-fold (P<0.05) increase in control groups 1 and 2, respectively. However, the 12% decrease in suicide rate in the intervention regions was not significantly greater than the 4% decrease in the non-intervention region (P>0.05).

CONCLUSION

Our training program was beneficial for primary care physicians' ability to recognize and manage depression. However, there was no significant decrease in local suicide rates.

Reducing suicides through an alliance against depression?

BACKGROUND

Since 2003, the Regensburg Alliance Against Depression, the regional partner of the German Alliance Against Depression, has been conducting a four-level intervention program to improve early detection and treatment of patients with depression, which was successfully piloted in the framework of the German Research Network on Depression and Suicidality.

METHODS

After 5 years of campaign, the suicide rates before and after the intervention were evaluated in comparison with two control regions and with the German overall rate.

FINDINGS

The results show that only the suicide rate in Regensburg fell significantly during the intervention period. The drop in the suicide rate was due to a significant decrease in male suicides.

INTERPRETATION

An intensive community-based campaign could be effective in lowering suicide rates. Especially, the combination of continuing medical educations (CMEs) for general practitioners focusing on 'male depression' and low-threshold campaigns for the general public seems to reach male depressive patients.

"You feel like you can't live anymore": suicide from the perspectives of Canadian men who experience depression

Severe depression is a known risk factor for suicide, yet worldwide men's suicide rates continue to outnumber reported rates of men's depression. While acknowledging that the pathways to suicide are diverse, and being mindful of the complex challenges inherent to studying suicide, we interviewed men who experienced depression as a means to better understanding the processes they used to counter and contemplate suicide. This novel qualitative study provides insights on how masculine roles, identities and relations mediate depression-related suicidal ideation in a cohort of 38 men in Canada, ranging in age from 24 to 50 years-old. Constant comparative analyses yielded the core category of reconciling despair in which men responded to severe depression and suicidal ideation by following two pathways. To counter suicide actions, connecting with family, peers and health care professionals and/or drawing on religious and moral beliefs were important interim steps for quelling thoughts about suicide and eventually dislocating depression from self-harm. This pathway revealed how connecting with family through masculine protector and father roles enabled men to avoid suicide while positioning help-seeking as a wise, rational action in re-establishing self-control. The other pathway, contemplating escape, rendered men socially isolated and the overuse of alcohol and other drugs were often employed to relieve emotional, mental and physical pain. Rather than providing respite, these risky practices were the gateway to men's heightened vulnerability for nonfatal suicidal behaviour. Men on this pathway embodied solitary and/or risk taker identities synonymous with masculine ideals but juxtaposed nonfatal suicidal behaviours as feminine terrain.

A Community-Based Survey and Screening for Depression in the Elderly

Background: In addition to implementing a depression screening program, conducting a survey beforehand might contribute to suicide risk reduction for the elderly. Aims: This study evaluates outcomes of a community-based program to prevent suicide among individuals aged 60 and over, using a quasiexperimental design with an intervention region (41,337 residents, 35.1% aged 60 and over) and a neighboring reference region. Methods: Our 2-year intervention program included an anonymous survey by random sample in the entire intervention region and, in the second year, a depression screening with follow-up by a psychiatrist in the higher-risk districts. Changes in the risk of completed suicide were estimated by the incidence-rate ratio (IRR). Results: The risk for men in the intervention region was reduced by 61% (age-adjusted IRR = 0.39; 90% CI = 0.18–0.87), whereas there was a (statistically insignificant) 51% risk reduction for women in the intervention region, and no risk reduction for either men or women in the reference region. The ratio of the crude IRR for elderly men in the intervention region to that for all elderly men in Japan was estimated at 0.42 (90% CI = 0.18–0.92), showing that the risk reduction was greater than the national change. Conclusions: The management of depression through a combination of an initial survey and subsequent screening holds clear promise for prompt effectiveness in the prevention of suicide for elderly men, and potentially for women.

Screening for suicide ideation among older primary care patients

OBJECTIVES

Older adults have high rates of suicide and typically seek care in primary medical practices. Older adults often do not directly or spontaneously report thoughts of suicide, which can impede suicide prevention efforts. Therefore, the use of additional approaches to suicide risk detection is needed, including the use of screening tools. The objective of this study was to assess whether brief screens for depression have acceptable operating characteristics in identifying suicide ideation among older primary care patients and to examine potential sex differences in the screen's accuracy.

METHODS

We administered the 15-item Geriatric Depression Scale (GDS), which includes a 5-item GDS subscale (GDS-SI) designed to screen for suicide ideation, to a cross-sectional cohort of 626 primary care patients (235 men, 391 women) 65 years of age or older in the Northeastern United States. We assessed presence of suicide ideation with items from the Hamilton Rating Scale for Depression and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

RESULTS

Patients expressing suicide ideation (n = 69) scored higher on the GDS and GDS-SI than those who did not (n = 557). A GDS cut score of 4 maximized sensitivity (0.754) and specificity (0.815), producing an area under the curve of 0.844 (P < .001) and positive and negative predictive values of 0.335 and 0.964, respectively. Optimal cut scores were 5 for men and 3 for women. A GDS-SI cut score of 1 was optimal for the total sample and for both men and women.

CONCLUSIONS

The GDS and GDS-SI accurately identify older patients with suicide ideation. Research is needed to examine their acceptability and barriers to routine use in primary care.

Completed suicide and marital status according to the Italian region of origin

Completed suicide is associated with marital status; being unmarried is associated with a higher suicide rate as compared with being married or living with a partner. Moreover, the region of origin may be particularly important when trying to explain major inequalities in suicide rates across a country. Data were obtained from the Italian Database on Mortality, collected by the Italian Census Bureau (ISTAT) and processed by the Italian National Institute of Health-Statistics Unit. The Italian population in the last Italian census (October 2001) was used to estimate age-standardized mortality rates from suicide by marital status (ICD-9 revision: E950-959) and "natural" causes (ICD-9 revision: 0-280; 320-799). Rate Ratios and 95% confidence intervals were calculated using married individuals as a reference. All analyses were conducted separately for men and women for 2000-2002, the most recent years with data available. Logistic regression analysis was used to compare differences by marital status for suicide versus death from natural causes. There are major inequalities in suicide rates in Italy. The North region has the highest suicide rates both for married and non-married individuals. Sardinia Island has the highest male suicide rate in Italy-23.07 per 100,000 per year-compared with the average national male suicide rate of 13.80, a difference which is significantly higher by 67% (RR: 1.67; 95%CI = 1.40-1.99). In contrast, Sardinia has one of the lowest female suicide rates among the Italian regions, close to that of the South and the Center regions. The North-East is the only region where the suicide rate among divorced men is significantly higher than that of married men. In the South, widowers have the highest suicide rate, with a rate 6-times that of married men (RR = 5.66; 95%CI = 4.46-7.18). Major inequalities in suicide rates by region may derive from different socio-cultural backgrounds, confirming the notion that suicide is a multifaceted phenomenon. The results of the present study indicate that suicide prevention must take into account the social and cultural characteristics of different communities. Moreover, these findings support the notion that marital status may play a central role in influencing suicide.

Characteristics and effects of suicide prevention programs: comparison between workplace and other settings

The present study reviews the literature on suicide prevention programs conducted in the workplace and other settings, namely school, the community, medical facilities, jail, and the army, by conducting an electronic literature search of all articles published between 1967 and November 2007. From a total of 256 articles identified, various contents of suicide prevention programs were determined, and in 34 studies, the effect of programs was evaluated. A review of the literature reveals that the common contents of suicide prevention programs in the workplace and other settings are education and training of individuals, development of a support network, cooperation from internal and external resources, as well as education and training of managers and staff. Although the characteristic contents of suicide prevention programs at the workplace aimed at improving personnel management and health care, screening and care for high-risk individuals, as well as improvement of building structures, were not described. Although a reduction in undesirable attitudes and an increase in mental health knowledge and coping skills in the workplace are in agreement with findings in other settings, suicide rate, suicide-associated behavior, and depression, which were assessed in other settings, were not evaluated in the three studies targeting the workplace.

Suicide trends diverge by method: Swiss suicide rates 1969-2005

We examined the change in Swiss suicide rates since 1969, breaking down the rates according to the method used. The descriptive analyses of the main suicide methods are presented. The suicide rates reached a peak in the late 1970s/early 1980s and declined in more recent years. Firearm suicides and suicides by falls were the exception and sustained their upwards trend until the 1990s. Suicide by vehicle exhaust asphyxiation showed a rapid decline following the introduction of catalytic converters in motor vehicles. No substantial method substitution was observed. Suicide by poisoning declined in the 1990s but rose again following an increase in assisted suicide in somatically incurable patients. Suicide is too often regarded as a homogeneous phenomenon. With regard to the method they choose, suicide victims are a heterogeneous population and it is evident that different suicide methods are chosen by different people. A better understanding of the varying patterns of change over time in the different suicide methods used may lead to differentiated preventive strategies.

Training mental health professionals to assess and manage suicidal behavior: can provider confidence and practice behaviors be altered?

Remarkably little systematic research has studied the effects of clinical suicidology training on changing practitioner attitudes and behaviors. In the current study we investigated whether training in an empirically-based assessment and treatment approach to suicidal patients administered through a continuing education workshop could meaningfully impact professional practices, clinic policy, clinician confidence, and beliefs posttraining and 6 months later. At the 6 month follow-up we found that 44% of practitioners reported increased confidence in assessing suicide risk, 54% reported increased confidence in managing suicidal patients, 83% reported changing suicide care practices, and 66% reported changing clinic policy. These results suggest that a brief and carefully developed workshop training experience can potentially change provider perceptions and behaviors with a possible impact on clinical care therein.

Factors associated with antidepressant, anxiolytic and hypnotic use over 17 years in a national cohort

BACKGROUND

In the general population, most individuals with mental disorders are not treated with psychotropic medications. The objective of this study was to identify factors associated with psychotropic medication use over a 17 year period in a birth cohort.

METHOD

Members of the 1946 British birth cohort (n=2,928 in 1999) reported psychotropic medication use in 1982 at age 36, in 1989 at age 43, and in 1999 at age 53. At each of the three time points, several factors were investigated for their association with antidepressant, anxiolytic or hypnotic medication use.

RESULTS

After adjusting for severity of symptoms of depression and anxiety, clinical factors such as suicidal ideation, sleep difficulty and poor physical health were strongly associated with antidepressant, anxiolytic or hypnotic medication use in 1982 and 1989, but not in 1999. Non-clinical factors were infrequently associated with antidepressant, anxiolytic or hypnotic medication use in 1982 and 1989 after adjusting for severity of symptoms, however several non-clinical factors were associated with antidepressant, anxiolytic or hypnotic medication use in 1999 including being female (OR=1.4, 95% CI: 1.0, 1.9), unemployment (OR=2.9, 95% CI: 2.1, 4.1), living alone (OR=2.6, 95% CI: 1.7, 3.9), and being divorced, separated or widowed (OR=1.5, 95% CI: 1.1, 2.3).

LIMITATIONS

Data were not available on help-seeking behaviour.

CONCLUSIONS

Treatment of mental disorder with psychotropic medications is strongly associated with clinical factors. However, non-clinical factors continue to be significant, and may influence both treatment-seeking and prescribing behaviour.

Effect of community-based intervention using depression screening on elderly suicide risk: a meta-analysis of the evidence from Japan

A systematic review was undertaken to quantify the effect of community-based depression screening (CDS) with follow-up on the completed suicide risk for residents aged 65 and over. Five quasi-experimental studies in Japanese regions with high suicide rates were included in the meta-analysis. Combined incidence rate ratios (95% confidence intervals) by the Mantel-Haenszel method and by the DerSimonian-Laird method in two homogenous studies implementing the follow-up conducted by psychiatrists were 0.30 (0.13-0.68) and 0.33 (0.14-0.80) in men, and 0.33 (0.19-0.58) and 0.33 (0.19-0.60) in women, respectively; and those in three homogenous studies implementing the follow-up conducted by general practitioners were 0.73 (0.45-1.18) and 0.74 (0.45-1.23) in men, and 0.36 (0.21-0.60) and 0.39 (0.22-0.66) in women, respectively. There are very few studies included, however, to demonstrate an association between CDS and the reduced risk, suggesting gender difference in the effectiveness.