Suicide within five years of hospital-treated self-harm: A data linkage cohort study

BACKGROUND

Hospital-treated self-harm is a strong predictor of suicide and hospital contacts may include missed opportunities for suicide prevention. We conducted a data linkage study to identify factors associated with suicide in people treated in hospital for self-harm in Victoria, Australia.

METHOD

We undertook a cohort study following 14,307 people treated in hospital for an episode of self-harm (i.e., either admitted or non-admitted ED presentations) over the period 2011 and 2012 and used data from the Victorian Suicide Register to identify suicides within 5 years. We estimated unadjusted hazard ratios (HRs) for suicide using survival analysis for each exposure variable and then computed adjusted HRs using a multivariate model that included all exposure variables.

RESULTS

Among females, the risk of suicide was higher in those aged 50-74 years (HR 1.78; Cl: 1.02, 3.10), residing in areas of least disadvantage (HR 2.58; Cl: 1.21, 5.50), who used hanging as a method of self-harm (HR 5.17; Cl: 1.86, 14.35) and with organic disorders (HR 6.71; Cl: 2.61, 17.23) or disorders of adult personality and behaviour (HR 2.10; Cl: 1.03, 4.27). In males, the risk of suicide was higher in those who used motor vehicle exhaust gas (MVEG) as a method of self-harm (HR 3.48; Cl: 1.73, 7.01), and with disorders due to psychoactive substance abuse (HR 1.75; Cl: 1.14, 2.67).

CONCLUSION

Although all patients should be routinely assessed for risk and needs following hospital-treated self-harm including appropriate follow-up care, people who use MVEG or hanging as methods of self-harm are obvious candidates for close follow-up.

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.

Association of real-time assessed mood, affect and suicidal ideation in psychiatric inpatients with unipolar depression

Previous research provided preliminary support of a potential reinforcing effect of suicidal ideation demonstrating reduced negative affect and increased positive affect after thinking about suicide. The present study therefore sought to investigate the role of mood and affect as a proximal risk factor of suicidal ideation in a high-risk sample. Seventy-four psychiatric inpatients (72% female) with unipolar depression and current and/or lifetime suicidal ideation aged 18 to 85 years (M = 37.6, SD = 14.3) took part in an ecological momentary assessment (EMA) over 6 days. Multilevel analyses were calculated. Analyses revealed negative valence of mood and low positive affect to be predictors of subsequent intensity of suicidal ideation (active, passive) as well as predictors of change in suicidal ideation (active, passive) since the last measurement. High negative affect only predicted intensity of passive suicidal ideation. Suicidal ideation (active, passive) was prospectively associated with subsequent negative valence of mood and lower positive affect as well as with higher intensity of negative affect. Suicidal ideation (active, passive) also predicted the change in valence of mood, positive affect and negative affect since the last measurement. Mood and affect should be taken into account as important proximal risk factors of active and passive suicidal ideation. The results do not support the idea of a reinforcing effect of suicidal ideation. In fact, they show a pattern of reduced subsequent positive affect, negative valence of mood and increased negative affect. Replication studies with larger samples and longer EMA follow-ups are needed.

Personal growth initiative as a buffer against suicide ideation severity in psychotherapy outpatients with depressive symptoms

OBJECTIVE

Many people who die by suicide experience major depressive disorder (MDD), but most people with MDD do not die by suicide and many do not report thoughts of death or suicide. This cross-sectional study examined the potential of personal growth initiative (PGI) skills to protect against suicide ideation among adult psychotherapy outpatients.

METHOD

Adult outpatients (N = 178) completed measures of suicide ideation severity (SI), depressive symptom severity (DEP), and PGI skills (PGI) at intake.

RESULTS

Although higher DEP significantly correlated with higher suicide ideation, a significant DEP × PGI interaction, indicated significant positive relations between DEP and SI only when PGI was at or below the mean for this sample.

CONCLUSIONS

PGI skills may function as a protective factor against the development of suicide ideation even in the presence of severe depressive symptoms. This suggests that training PGI skills might prevent or reduce suicide ideation among depressed patients.

CALM gatekeeper training is associated with increased confidence in utilizing means reduction approaches to suicide prevention among college resident assistants

BACKGROUND

Most suicide prevention programs focus on increasing knowledge regarding the problem of suicide, yet many fail to include information on the science and application of means reduction approaches. In an attempt to address this gap in practice, the Counseling on Access to Lethal Means (CALM) program was developed to educate clinicians on the importance of means reduction interventions.

METHODS

In the current study, a gatekeeper CALM training was delivered to 167 resident assistants. Confidence levels regarding suicide prevention and means reduction skills were assessed at baseline, post-training, and after a 6-week follow-up.

RESULTS

Results were suggestive of medium to large training effects. Though there was a small decay of training effects at follow-up, the effects were durable when compared to baseline levels.

CONCLUSION

Given these findings, future gatekeeper trainings should be provided more consistently to help sustain the effects and data on the implementation of CALM principles should be measured during follow-up assessments.

Factors Related to Suicide Attempts: The Roles of Childhood Abuse and Spirituality

Objectives: The purpose of this article was to identify independent factors associated with suicide attempts in patients with depression and/or anxiety. Background and Aims: This study was conducted in order to examine whether risk and protective psychological factors influence the risk of suicide attempts among outpatients with anxiety and/or depressive disorders. In this regard, explanatory models have been reported to detect high-risk groups for suicide attempt. We also examined whether identified factors serve as mediators on suicide attempts. Materials and Methods: Patients from 18 to 65 years old from an outpatient clinic at Seoul St. Mary's Hospital were invited to join clinical studies. From September 2010 to November 2017, a total of 737 participants were included in the final sample. The Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Childhood Trauma Questionnaire (CTQ), Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp-12), and Functional Social Support Questionnaire (FSSQ) were used to assess psychiatric symptoms. An independent samples t-test, a chi-square test, hierarchical multiple regression analyses, and the Baron and Kenny's procedures were performed in order to analyze data. Results: Young age, childhood history of emotional and sexual abuse, depression, and a low level of spirituality were significant independent factors for increased suicide attempts. Depression was reported to mediate the relationship between childhood emotional and sexual abuse, spirituality, and suicide attempts. Conclusions: Identifying the factors that significantly affect suicidality may be important for establishing effective plans of suicide prevention. Strategic assessments and interventions aimed at decreasing depression and supporting spirituality may be valuable for suicide prevention.

Is suicidal behaviour a stronger predictor of later suicide than suicidal ideation? A systematic review and meta-analysis

OBJECTIVE

Suicidal ideation and suicidal behaviour are both regarded as important risk factors for suicide, but it is usually believed that suicidal ideation is less strongly linked to suicide than suicidal behaviours. In this study, we assessed and compared the strengths of the associations that suicidal ideation and suicidal behaviour have with later suicide using meta-analysis of primary studies reporting both these independent variables and the dependent variable of suicide.

METHODS

A total of 51 English language publications describing cohort or controlled studies that reported on both the association between suicidal ideation and suicide and the association between suicidal behaviours and suicide were located using searches for titles in PubMed containing variants of the word suicide (suicid*). Suicides were considered to include reported suicides and open verdicts from mortality registers. The strengths of the two associations were examined in separate random effects meta-analyses and were then compared using mixed effects meta-regression. Subgroups were examined according to study characteristics including the definitions of suicidal ideation or behaviour used, setting (psychiatric or non-psychiatric), diagnostic mix of the study population, study design (cohort or control) and study quality.

RESULTS

Suicidal ideation (odds ratio = 3.11, 95% confidence interval = 2.51, 3.86) and suicidal behaviours (odds ratio = 4.09, 95% confidence interval = 3.05, 5.49) were both significantly associated with suicide but there was no significant difference in the strengths of association (p = 0.14). Nor were there significant differences in the strengths of the two associations in multiple subgroup analyses.

CONCLUSION

Suicidal ideation and suicidal behaviour are both moderately associated with suicide. Existing data cannot conclusively demonstrate that suicidal behaviours are more strongly associated with suicide than suicidal ideation. Clinicians should not strongly prioritise suicidal behaviour over suicidal ideation when considering suicide risk.

Wiser Reasoning and Less Disgust Have the Potential to Better Achieve Suicide Prevention

Background: High school and university teachers need to advise students against attempting suicide, the second leading cause of death among 15-29-year-olds. Aims: To investigate the role of reasoning and emotion in advising against suicide. Method: We conducted a study with 130 students at a university that specializes in teachers' education. Participants sat in front of a camera, videotaping their advising against suicide. Three raters scored their transcribed advice on "wise reasoning" (i.e., expert forms of reasoning: considering a variety of conditions, awareness of the limitation of one's knowledge, taking others' perspectives). Four registered psychologists experienced in suicide prevention techniques rated the transcripts on the potential for suicide prevention. Finally, using the software Facereader 7.1, we analyzed participants' micro-facial expressions during advice-giving. Results: Wiser reasoning and less disgust predicted higher potential for suicide prevention. Moreover, higher potential for suicide prevention was associated with more surprise. Limitations: The actual efficacy of suicide prevention was not assessed. Conclusion: Wise reasoning and counter-stereotypic ideas that trigger surprise probably contribute to the potential for suicide prevention. This advising paradigm may help train teachers in advising students against suicide, measuring wise reasoning, and monitoring a harmful emotional reaction, that is, disgust.

Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value

BACKGROUND

The expression of suicidal ideation is considered to be an important warning sign for suicide. However, the predictive properties of suicidal ideation as a test of later suicide are unclear.AimsTo assess the strength of the association between suicidal ideation and later suicide measured by odds ratio (OR), sensitivity, specificity and positive predictive value (PPV).

METHOD

We located English-language studies indexed in PubMed that reported the expression or non-expression of suicidal ideation among people who later died by suicide or did not. A random effects meta-analysis was used to assess the pooled OR, sensitivity, specificity and PPV of suicidal ideation for later suicide among groups of people from psychiatric and non-psychiatric settings.

RESULTS

There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, OR = 3.41, 95% CI 2.59-4.49, 95% prediction interval 0.42-28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P ≤0.001). Studies conducted in primary care and other non-psychiatric settings had similar pooled odds to studies of current and former psychiatric patients (OR = 3.86 v. OR = 3.23, P = 0.7). The pooled sensitivity of suicidal ideation for later suicide was 41% (95% CI 35-48) and the pooled specificity was 86% (95% CI 76-92), with high between-study heterogeneity. Studies of suicidal ideation expressed by current and former psychiatric patients had a significantly higher pooled sensitivity (46% v. 22%) and lower pooled specificity (81% v. 96%) than studies conducted in non-psychiatric settings. The PPV among non-psychiatric cohorts (0.3%, 95% CI 0.1%-0.5%) was significantly lower (Q-value = 35.6, P &lt; 0.001) than among psychiatric samples (3.9%, 95% CI 2.2-6.6).

CONCLUSIONS

Estimates of the extent of the association between suicidal ideation and later suicide are limited by unexplained between-study heterogeneity. The utility of suicidal ideation as a test for later suicide is limited by a modest sensitivity and low PPV.Declaration interestM.M.L. and C.J.R. have provided expert evidence in civil, criminal and coronial matters. I.B.H. has been a Commissioner in Australia's National Mental Health Commission since 2012. He is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to Headspace. I.B.H. has previously led community-based and pharmaceutical industry-supported (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) projects focused on the identification and better management of anxiety and depression. He is a Board Member of Psychosis Australia Trust and a member of Veterans Mental Health Clinical Reference group. He was a member of the Medical Advisory Panel for Medibank Private until October 2017. He is the Chief Scientific Advisor to, and an equity shareholder in, InnoWell. InnoWell has been formed by the University of Sydney and PricewaterhouseCoopers to administer the $30 M Australian Government Funded Project Synergy. Project Synergy is a 3-year programme for the transformation of mental health services through the use of innovative technologies.

Adolescent Predictors of Incidence and Persistence of Suicide-Related Outcomes in Young Adulthood: A Longitudinal Study of Mexican Youth

In recent years, Mexico has seen one of the largest increases in suicide rates worldwide, especially among adolescents and young adults. This study uses data from the 1,071 respondents who participated in a two-wave longitudinal study when they were between 12 and 17 years of age, and again when they were between 19 and 26 years of age. The World Mental Health Composite International Diagnostic Interview assessed suicidal behavior and DSM-IV mental disorders. We used Cox regressions to evaluate which sociodemographic and psychiatric factors and life events predicted the incidence and remission of suicide ideation, plan, and attempt throughout the 8-year span. The 8-year incidence of suicide ideation, plan, and attempt was 13.3%, 4.8%, and 5.9%, respectively. We found that the number of traumatic life events during childhood, no longer being in school, and tobacco use predicted which adolescents developed suicide behaviors as they transitioned into young adulthood. Psychiatric disorders, particularly anxiety disorders, played a larger role in the persistence of those who already had suicidal behaviors, while behavioral disorders played a role in the transition from ideation to attempt. This distinction may be useful for clinicians to assess the risk of suicide.

Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis

AIMS

Several authors claimed that expression of suicidal ideation is one of the most important predictors of completed suicide. However, the strength of the association between suicidal ideation and subsequent completed suicide has not been firmly established in different populations. Furthermore, the absolute suicide risk after expression of suicidal ideation is unknown. In this meta-analysis, we examined whether the expression of suicidal ideation predicted subsequent completed suicide in various populations, including both psychiatric and non-psychiatric populations.

METHODS

A meta-analysis of cohort and case-control studies that assessed suicidal ideation as determinant for completed suicide in adults. Two independent reviewers screened 5726 articles for eligibility and extracted data of the 81 included studies. Pooled risk ratios were estimated in a random effects model stratified for different populations. Meta-regression analysis was used to determine suicide risk during the first year of follow-up.

RESULTS

The risk for completed suicide was clearly higher in people who had expressed suicidal ideation compared with people who had not, with substantial variation between the different populations: risk ratio ranging from 2.35 (95% confidence interval (CI) 1.43-3.87) in affective disorder populations to 8.00 (95% CI 5.46-11.7) in non-psychiatric populations. In contrast, the suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients (risk 1.40%, 95% CI 0.74-2.64) than in non-psychiatric participants (risk 0.23%, 95% CI 0.10-0.54). Past suicide attempt-adjusted risk ratios were not pooled due to large underreporting.

CONCLUSIONS

Assessment of suicidal ideation is of priority in psychiatric patients. Expression of suicidal ideation in psychiatric patients should prompt secondary prevention strategies to reduce their substantial increased risk of suicide.

Alcohol, cannabis and other drugs and subsequent suicide ideation and attempt among young Mexicans

OBJECTIVE

To report results from a follow-up study of alcohol, cannabis and other drugs on suicidal behavior.

METHOD

We estimated prospective associations of substance use as a risk factor for incident suicide ideation and attempt, from a follow-up conducted in 2013 (n = 1071) of the original Mexican Adolescent Mental Health Survey conducted in 2005.

RESULTS

Cannabis use before age 15 (ideation risk ratio (RR) = 3.97; 95% confidence interval (CI) = 1.43-11.03; attempt RR = 5.23; 95% CI = 1.17-23.32), early onset of DSM-IV drug use disorder (DUD) among cannabis users (ideation RR = 3.30; 95% CI = 1.11-9.84; attempt RR = 4.14; 95% CI = 1.28-13.36), high frequency of cannabis use (RR for attempts = 4.60; 1.03-20.60) and recent DSM-IV-DUD among cannabis users (RR for attempts = 4.74; 1.09-20.57) increased the RR. For "other drug use", significant results were found among those with high frequency use of other drugs such that they had a higher RR of suicide attempt (5.04; 1.03-24.64). For alcohol, only those who initiated alcohol before age 15 had higher RRs of suicide attempt (1.79; 1.00-3.20).

DISCUSSION

Those who used cannabis at an early age, early onset of DSM-IV-DUD, and those with heavy cannabis use and recent DSM-IV-DUD among cannabis users in the last 12-months had increased risk of suicide ideation and attempt. Drugs other than cannabis showed some of these associations, but to a lesser degree. Prevention of substance use and treatment of those already engaged in drug use, by decreasing suicide ideation and attempt, may help to prevent suicide in Mexico.