Long- and Short-Term Risk Factors in the Prediction of Inpatient Suicide

Inpatient suicide in psychiatric settings: Evaluation of current prevention measures

The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.

Problemi della previsione in psichiatria

Sono esaminati vari problemi relativi alla previsione in psichiatria. I dati disponibili mostrano, in modo simile alle scienze sociali, ampi limiti nella capacità previsionale, specie per quanto riguarda il suicidio, la violenza e altri aspetti comportamentali. Vengono esaminate le difficoltà che nascono dal cercare di derivare il futuro della persona dal suo passato, la mancata coerenza fra aspetti di personalità e possibili comportamenti e il privilegio dato a strumenti psicopatologici incentrati sul singolo caso, rispetto a quelli attuariali con valutazioni testistiche e statistiche. Vengono anche evidenziati i numerosi bias cognitivi che distorcono le previsioni, in particolare l'errore fondamentale di attribuzione, che privilegia aspetti personologici rispetto a quelli situazionali. Ma altri bias hanno una importante azione distorsiva, da quelli della rappresentatività a quelli della disponibilità, da quelli statistici, al framing o al priming. Emerge una psichiatria molto legata nelle pratiche ancora al senso comune e alla folk psychology, con la ricchezza ma anche i molti errori che la caratterizzano. Di fatto esiste una modesta capacità previsionale riconosciuta alla psicologia popolare e alla psichiatria, ma è legata più a vincoli situazionali che a modelli personologici e psicopatologici e in ogni caso scarsamente affidabile per la previsione clinica in psichiatria.

The revised suicide crisis inventory (SCI-2): Validation and assessment of prospective suicidal outcomes at one month follow-up

BACKGROUND AND AIM

The Suicide Crisis Syndrome (SCS) is an evidence-based pre-suicidal cognitive and affective state predictive of short-term suicide risk. The most recent SCS formulation, proposed as a suicide-specific DSM diagnosis, features a feeling of Entrapment accompanied by four additional symptom clusters: Affective Disturbance; Loss of Cognitive Control; Hyperarousal; and Social Withdrawal. The aim of the present study was to revise the Suicide Crisis Inventory (SCI; Barzilay et al., 2020), a self-report measure assessing the presence of the SCS,in accordance with the current SCS formulation, as well as to assess the psychometric properties and clinical utility of its revised version, the Suicide Crisis Inventory-2 (SCI-2).

METHODS

The SCI-2, a 61-item self-report questionnaire, was administered to 421 psychiatric inpatients and outpatients at baseline. Prospective suicidal outcomes including suicidal ideation, preparatory acts, and suicidal attempts were assessed after one month. Internal structure and consistency were assessed with confirmatory factor analysis, convergent, discriminant, and current criterion validity. Receiver-operating characteristic (ROC) curves with Area under the Curve (AUC) were used to examine the predictive validity of the SCI-2 to prospective outcomes. Exploratory analyses assessed the predictive validity of the five SCI-2 dimensions.

RESULTS

The SCI-2 demonstrated excellent internal consistency (Cronbach's α = 0.971), good convergent, discriminant, and current criterion validity. The SCI-2 significantly predicted all three outcomes, and was the only significant predictor of suicidal attempts with AUC = 0.883.

DISCUSSION

The results of this study indicate that the SCI-2 is a valid and reliable tool to assess the presence and intensity of the Suicide Crisis Syndrome and to predict short-term prospective suicidal behaviors and attempts among psychiatric outpatients and inpatients regardless of patients' readiness to disclose suicidal ideation.

The role of suicide ideation in assessing near-term suicide risk: A machine learning approach

BACKGROUND

The majority of suicide attempters do not disclose suicide ideation (SI) prior to making an attempt. When reported, SI is nevertheless associated with increased risk of suicide. This paper implemented machine learning (ML) approaches to assess the degree to which current and lifetime SI affect the predictive validity of the Suicide Crisis Syndrome (SCS), an acute condition indicative of imminent risk, for near-term suicidal behaviors (SB ).

METHODS

In a sample of 591 high-risk inpatient participants, SCS and SI were respectively assessed using the Suicide Crisis Inventory (SCI) and the Columbia Suicide Severity Rating Scale (C-SSRS). Two ML predictive algorithms, Random Forest and XGBoost, were implemented and framed using optimism adjusted bootstrapping. Metrics collected included AUPRC, AUROC, classification accuracy, balanced accuracy, precision, recall, and brier score. AUROC metrics were compared by computing a z-score.

RESULTS

The combination of current SI and SCI showed slightly higher predictive validity for near-term SB as evidenced by AUROC metrics than the SCI alone, but the difference was not significant (p<0.05). Current SI scored the highest amongst a chi square distribution in regards to predictors of near-term SB.

CONCLUSION

The addition of SI to the SCS does not materially improve the model's predictive validity for near-term SB, suggesting that patient self-reported SI should not be a requirement for the diagnosis of SCS.

How do distal and proximal risk factors combine to predict suicidal ideation and behaviors? A prospective study of the narrative crisis model of suicide

AIM

The Narrative Crisis Model of suicide posits that when individuals with trait vulnerabilities for suicide face stressful life events, they may develop distorted perceptions of themselves and society that culminate in a sense of no future. Referred to as the suicide narrative, these perceptions makes them more likely to experience the Suicidal Crisis Syndrome, an acute affective condition that increases the risk of engaging in suicidal ideation behaviors. The goal of this study was to assess the stage components of this model.

METHODS

The stage components of the NCM were assessed among adult psychiatric inpatients (N = 223; listwise N = 85) aged 18-65 years old and admitted for suicidal ideation or attempts. Suicidal outcomes were assessed at one month follow-up. Structural equation modeling (SEM) was used to assess the model and its prediction of prospective suicidal outcomes.

RESULTS

The model was supported by the SEM and proved to be a good fit for the data. Each temporal stage was significantly predicted by the precedent stage in the model and 13% of the variance in suicidal ideation and behaviors (when assessed conjointly) were explained by the model. When suicidal ideation and attempts were assessed separately, the amount of variance explained was 10.8% for suicidal ideation and 40.7% for suicidal attempts.

DISCUSSION

The progression from trait vulnerabilities to suicidal outcomes proposed by the NCM was supported by our findings. These findings have clinical implications in the assessment and treatment of suicide risk and will need replication with larger samples.

Suicidal thoughts, suicidal behaviours and self-harm in daily life: A systematic review of ecological momentary assessment studies

Background

Ecological Momentary Assessments (EMA) offer an approach to understand the daily risk factors of suicide and self-harm of individuals through the use of self-monitoring techniques using mobile technologies.

Objectives

This systematic review aimed to examine the results of studies on suicidality risk factors and self-harm that used Ecological Momentary Assessments.

Methods

Pubmed and PsycINFO databases were searched up to April 2020. Bibliographies of eligible studies were hand-searched, and 744 abstracts were screened and double-coded for inclusion.

Results

The 49 studies using EMA included in the review found associations between daily affect, rumination and interpersonal interactions and daily non-suicidal self-injury (NSSI). Studies also found associations between daily negative affect and positive affect, social support, sleep, and emotions and a person's history of suicide and self-harm. Associations between daily suicide thoughts and self-harm, and psychopathology factors measured at baseline were also observed.

Conclusions

Research using EMA has the potential to offer clinicians the ability to understand the daily predictors, or risk factors, of suicide and self-harm. However, there are no clear reporting standards for EMA studies on risk factors for suicide. Further research should utilise longitudinal study designs, harmonise datasets and use machine learning techniques to identify patterns of proximal risk factors for suicide behaviours.

Emotion-Oriented Coping Style Predicts Self-Harm in Response to Acute Psychiatric Hospitalization

Psychiatric hospitalization can cause significant distress for patients. Research has shown that to cope with the stress, patients sometimes resort to self-harm. Given the paucity of research on self-harm among psychiatric inpatients, a better understanding of transdiagnostic processes as predictors of self-harm during psychiatric hospitalization is needed. The current study examined whether coping styles predicted self-harm after controlling for commonly associated factors, such as age, gender, and borderline personality disorder. Participants were 72 patients (mean age = 39.32 years, SD = 12.29, 64% male) admitted for inpatient treatment at a public psychiatric hospital in Sydney, Australia. Participants completed self-report measures of coping styles and ward-specific coping behaviors, including self-harm, in relation to coping with the stress of acute hospitalization. Results showed that younger age, diagnosis of borderline personality disorder, and higher emotion-oriented coping were associated with self-harm. After controlling for age and borderline personality disorder, higher levels of emotion-oriented coping were found to be a significant predictor of self-harm. Findings were partially consistent with hypotheses; emotion-oriented but not avoidance-oriented coping significantly predicted self-harm. This finding may help to identify and provide psychiatric inpatients who are at risk of self-harm with appropriate therapeutic interventions.

The effects of suicidal ideation and constructs of theory of planned behavior on suicidal intention in women: a structural equation modeling approach

BACKGROUND

The Theory of Planned Behavior (TPB) is proposed to predict behavioral intention. We conducted this study aimed to investigate the effects of Suicidal Ideation (SI) and constructs of TPB on suicidal intention.

METHODS

This cross-sectional study was conducted with 923 married women selected by multi-stage sampling method from Gilan-e Gharb County, the west part of Iran, in 2018. Data gathering tools were a questionnaire on demographic characteristics, the Beck Scale for Suicidal Ideation, and a four-part questionnaire based on constructs of TPB, including Attitude, Subjective Norms, Perceived Behavioral Control (PBC), and Intention. Data were analyzed by SPSS 19 and AMOS using Structural Equation Modeling (SEM).

RESULTS

Out of 923 participants, 345 women (37.4%) had some degree of suicidal ideation. The mean score of suicidal ideation in all of participants was 5.98 ± 7.79, while in the 345 individuals with suicidal ideation was 15.53 ± 3.65. Suicidal ideation had the strongest positive total effect on suicide intent, while PBC and attitude had the negative effect on suicide intent.

CONCLUSIONS

Since suicidal ideation had the strongest direct effect on suicidal intent, it is suggested that this variable be used for risk assessment in all suicide prevention programs and counseling measures be implemented to reduce suicidal thoughts. Also, undesirable attitudes toward suicide and perceived behavioral control on suicide intention can be considered and emphasized in planning future interventions.

Psychotic Symptoms Predict Suicidal Behavior Postdischarge in High Risk Psychiatric Inpatients

BACKGROUND

Psychotic disorders, as well as psychotic symptoms, are associated with a greater lifetime risk of suicidal behavior (SB). It is not known, however, whether psychotic symptoms are independent predictors for short-term SB.

METHODS

Data were collected from 201 psychiatric inpatients at Mount Sinai Beth Israel Hospital. Self-reported psychotic symptoms were assessed using the Brief Symptom Inventory (BSI). Postdischarge SB defined as an aborted, interrupted, or actual suicide attempt was assessed using the Columbia-Suicide Severity Rating Scale (C-SSRS), during the 4 to 8 weeks following discharge from an inpatient psychiatric unit (n=127, 63% retention). Logistic regressions were performed to assess the relationships between psychotic symptoms and SB, controlling for primary psychiatric disorders.

RESULTS

Self-reported psychotic symptoms were associated with subsequent postdischarge SB. There was no significant difference between the SB versus no SB groups on the basis of primary psychiatric disorder. Self-reported psychotic symptoms remained an independent and significant predictor of postdischarge SB when the analysis controlled for primary psychiatric disorder.

CONCLUSIONS

These results suggest that psychotic symptoms are a dimensional predictor of near-term postdischarge SB and are a necessary component of suicide risk assessment during inpatient hospitalization, independent of psychiatric diagnosis.

Does Compulsory Admission Prevent Inpatient Suicide Among Patients with Schizophrenia? A Nationwide Cohort Study in Taiwan

OBJECTIVE

The aim of this study was to analyze the risk of inpatient suicide in patients with schizophrenia during 2007-2013 and to determine putative risk factors.

METHODS

We conducted a national population-based cohort study of 2,038 psychiatric inpatients in their first compulsory admission, matched with 8,152 controls who were voluntary inpatients. Only patients with schizophrenia were included in the study. We used data derived from the Taiwanese National Health Insurance Database 2005, comprising 1 million beneficiaries randomly selected from the entire population of Taiwan.

RESULTS

During the follow-up period, 23 and 75 inpatient suicides were observed in the compulsory and control groups, respectively. Kaplan-Meier curves showed that the cumulative incidence rate of inpatient suicide was not significantly different between compulsory and voluntary admissions (log-rank test, p = .206).

CONCLUSIONS

Our results suggest that compulsory admission has no protective effects on risk reduction of inpatient suicide for patients with schizophrenia who are compulsorily admitted compared with voluntarily admitted controls. Clinicians should be more alert for the prevention of inpatient suicide among patients with schizophrenia and consider the close monitoring of inpatient suicide risk in the first week of admission.

Predictive Validity of Proposed Diagnostic Criteria for the Suicide Crisis Syndrome: An Acute Presuicidal State

BACKGROUND

Determining imminent risk of suicide continues to challenge psychiatrists. To this end, we test the clinical utility of a proposed set of diagnostic criteria for the suicide crisis syndrome (SCS) for prediction of imminent suicidal thoughts and behaviors prospectively.

METHOD

One hundred and seventy individuals hospitalized for suicidal thoughts and behaviors (STB) were evaluated within 72 hr of admission with measures assessing symptoms of the proposed SCS, history of STB, current ideation, and depression severity. Four-eight weeks following discharge, STB were reassessed. Associations between SCS and postdischarge attempts were examined using chi-square and logistic regression analyses. The receiver operator characteristic analysis was used to test the optimal number of symptoms required to meet proposed SCS criteria.

RESULTS

The syndrome was maximally informative about short-term risk of postdischarge suicide behavior when all criteria were met. The syndrome conferred a sevenfold increase in risk of postdischarge suicide attempt, and significantly improved prediction by standard risk factors, which was null to limited.

CONCLUSIONS

The SCS diagnostic criteria are supported and appear to describe a clinically meaningful syndrome in a high-risk population. Assessment of SCS may meaningfully improve clinical assessment of imminent suicide risk. Further study is needed to better understand the syndrome and its applicability in low-risk populations.

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.

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.

Suicide risk assessment among psychiatric inpatients: a systematic review and meta-analysis of high-risk categories

BACKGROUND

The clinical care of psychiatric patients is often guided by perceptions of suicide risk. The aim of this study was to examine the methods and results of studies reporting high-risk models for inpatient suicide.

METHODS

We conducted a registered meta-analysis according to PRISMA guidelines. We searched for relevant peer-reviewed cohort and controlled studies indexed in Medline, EMBASE and PsychINFO.

RESULTS

The pooled odds ratio (OR) among 18 studies reporting high-risk models for inpatient suicide was 7.1 [95% confidence interval (CI) 4.2-12.2]. Between-study heterogeneity in ORs was very high (range 0-94.8, first quartile 3.4, median 8.8, third quartile 26.1, prediction interval 0.80-63.1, I2 = 88.1%). The meta-analytically derived sensitivity was 53.1% (95% CI 38.2-67.5%, I2 = 95.9%) and specificity was 84.2% (95% CI 71.6-91.9%, I2 = 99.9%) with an associated meta-analytic area under the curve of 0.83. The positive predictive value of risk categorization among six cohort studies was 0.43% (95% CI 0.014-1.3%, I2 = 95.9%). A history of suicidal behavior and depressive symptoms or affective disorder was included in the majority of high-risk models.

CONCLUSIONS

Despite the strength of the pooled association between high-risk categorization and suicide, the very high degree of observed heterogeneity indicates uncertainty about our ability to meaningfully distinguish inpatients according to suicide risk. The limited sensitivity and low positive predictive value of risk categorization suggest that suicide risk models are not a suitable basis for clinical decisions in inpatient settings.

Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence

Background

Instruments have been developed to facilitate suicide risk assessment. We aimed to evaluate the evidence for these instruments including assessment of risk of bias and diagnostic accuracy for suicide and suicide attempt.

Methods

PubMed (NLM), PsycInfo, Embase, Cinahl and the Cochrane Library databases were searched until December 2014. We assessed risk of bias with QUADAS-2. The average sensitivity and specificity of each instrument was estimated and the certainty of the evidence was assessed with GRADE. We considered instruments with a sensitivity > 80% and a specificity > 50% to have sufficient diagnostic accuracy.

Results

Thirty-five relevant studies were identified but 14 were considered to have high risk of bias, leaving 21 studies evaluating altogether 15 risk assessment instruments. We could carry out meta-analyses for five instruments. For the outcome suicide attempt SAD PERSONS Scale had a sensitivity of 15% (95% CI 8–24) and specificity of 97% (96–98), and the Manchester Self-Harm Rule (MSHR) a sensitivity of 97% (97–97) and a specificity of 20% (20–21). ReACT, which is a modification of MSHR, had a similar low specificity, as did the Sodersjukhuset Self Harm Rule. For the outcome suicide, the Beck Hopelessness Scale had a sensitivity of 89% (78–95) and specificity of 42% (40–43).

Conclusions

Most suicide risk assessment instruments were supported by too few studies to allow for evaluation of accuracy. Among those that could be evaluated, none fulfilled requirements for sufficient diagnostic accuracy.

Connecting with suicidal patients in psychiatric wards: Therapist challenges

In this qualitative interview study, the authors investigated how therapists experience and view treatment and care for suicidal patients in psychiatric wards. The focus is on aspects that may contribute toward shaping and possibly constraining therapists' connections with suicidal individuals. They conducted semistructured interviews of 4 psychiatrists and 4 psychologists and analyzed the data by means of thematic analysis. The findings suggest that high emphasis on diagnostics and standardized suicide risk assessments, limited direct care of suicidal patients, and fragmented mental health services may challenge therapists' connections with suicidal patients.

Risk Estimates and Risk Factors Related to Psychiatric Inpatient Suicide-An Overview

People with mental illness have an increased risk of suicide. The aim of this paper is to provide an overview of suicide risk estimates among psychiatric inpatients based on the body of evidence found in scientific peer-reviewed literature; primarily focusing on the relative risks, rates, time trends, and socio-demographic and clinical risk factors of suicide in psychiatric inpatients. Psychiatric inpatients have a very high risk of suicide relative to the background population, but it remains challenging for clinicians to identify those patients that are most likely to die from suicide during admission. Most studies are based on low power, thus compromising quality and generalisability. The few studies with sufficient statistical power mainly identified non-modifiable risk predictors such as male gender, diagnosis, or recent deliberate self-harm. Also, the predictive value of these predictors is low. It would be of great benefit if future studies would be based on large samples while focusing on modifiable predictors over the course of an admission, such as hopelessness, depressive symptoms, and family/social situations. This would improve our chances of developing better risk assessment tools.

Mental Health Nurses' Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor

The purpose of the study is to investigate mental health nurses' experiences of recognizing and responding to suicidal behavior/self-harm and dealing with the emotional challenges in the care of potentially suicidal inpatients. Interview data of eight mental health nurses were analyzed by systematic text condensation. The participants reported alertness to patients' suicidal cues, relieving psychological pain and inspiring hope. Various emotions are evoked by suicidal behavior. Mental health nurses seem to regulate their emotions and emotional expressions, and balance involvement and distance to provide good care of patients and themselves. Mental health nurses have an important role and should receive sufficient formal support.

SPECIFIC MOOD SYMPTOMS CONFER RISK FOR SUBSEQUENT SUICIDAL IDEATION IN BIPOLAR DISORDER WITH AND WITHOUT SUICIDE ATTEMPT HISTORY: MULTI-WAVE DATA FROM STEP-BD

BACKGROUND

Little is known about specific mood symptoms that may confer risk for suicidal ideation (SI) among patients with bipolar disorder (BD). We evaluated prospectively whether particular symptoms of depression and mania precede the onset or worsening of SI, among adults with or without a history of a suicide attempt.

METHODS

We examined prospective data from a large (N = 2,741) cohort of patients participating in the Systematic Treatment Enhancement Program for BD (STEP-BD). We evaluated history of suicide attempts at baseline, and symptoms of depression and mania at baseline and follow-up visits. Hierarchical linear modeling tested whether specific mood symptoms predicted subsequent levels of SI, and whether the strength of the associations differed based on suicide attempt history, after accounting for the influence of other mood symptoms and current SI.

RESULTS

Beyond overall current depression and mania symptom severity, baseline SI, and illness characteristics, several mood symptoms, including guilt, reduced self-esteem, psychomotor retardation and agitation, increases in appetite, and distractibility predicted more severe levels of subsequent SI. Problems with concentration, distraction, sleep loss and decreased need for sleep predicted subsequent SI more strongly among individuals with a suicide attempt history.

CONCLUSIONS

Several specific mood symptoms may confer risk for the onset or worsening of SI among treatment-seeking patients with BD. Individuals with a previous suicide attempt may be at greater risk in part due to greater reactivity to certain mood symptoms in the form of SI. However, overall, effect sizes were small, suggesting the need to identify additional proximal predictors of SI.

Perception of Suicide Risk in Mental Health Professionals

This study employed an independent-groups design (4 conditions) to investigate possible biases in the suicide risk perception of mental health professionals. Four hundred participants comprising doctors, nurses and social workers viewed a vignette describing a fictitious patient with a long-term mental illness. The case was presented as being drawn from a sample of twenty similar clinical case reports, of which 10 were associated with an outcome of suicide. The participant tasks were (i) to decide whether the presented vignette was one of those cases or not, and (ii) to provide an assessment of confidence in that decision. The 4 conditions were used to investigate whether the presence of an associated face, and the nature of the emotional state expressed by that face, affected the response profile. In fact, there were no significant differences between conditions, but there was a significant bias across all conditions towards associating the vignette with suicide, despite the base rate being pre-determined at 50%. The bias was more pronounced in doctors and in male respondents. Moreover, many participants indicated substantial confidence in their decisions. The results are discussed in terms of availability bias and over-confidence bias.

Daily monitoring of temporal trajectories of suicidal ideation predict self-injury: A novel application of patient progress monitoring

OBJECTIVE

The interpersonal theory of suicide argues that suicidal ideation predicts self-injury. We hypothesized that distinct patterns of suicidal ideation could be identified and these ratings could allow early identification of self-injury.

METHOD

The sample consisted of 562 psychiatric inpatients who reported suicidal ideation.

RESULTS

Latent growth class analysis identified five classes of change in suicidal ideation. Patients who displayed prolonged suicidal ideation could be identified with improved sensitivity (89.66%) and negative predictive power (94%), compared to a model based on routine ratings of suicidality at admission (sensitivity = 50%; negative predictive power = 74%). These patients had a fourfold increased risk of self-injury.

CONCLUSIONS

Daily measurement of suicidal ideation may identify inpatients at risk and inform clinical decision-making.

Determinants of completed railway suicides by psychiatric in-patients: case-control study

BACKGROUND

Suicide prediction during psychiatric in-patient treatment remains an unresolved challenge.

AIMS

To identify determinants of railway suicides in individuals receiving in-patient psychiatric treatment.

METHOD

The study population was drawn from patients admitted to six psychiatric hospitals in Germany during a 10-year period (1997-2006). Data from 101 railway suicide cases were compared with a control group of 101 discharged patients matched for age, gender and diagnosis.

RESULTS

Predictors of suicide were change of therapist (OR = 22.86, P = 0.004), suicidal ideation (OR = 7.92, P<0.001), negative or unchanged therapeutic course (OR = 7.73, P<0.001), need of polypharmaceutical treatment (OR = 2.81, P = 0.04) and unemployment (OR = 2.72, P = 0.04). Neither restlessness nor impulsivity predicted in-patient suicide.

CONCLUSIONS

Suicidal ideation, unfavourable clinical course and the use of multiple psychotropic substances (reflecting the severity of illness) were strong determinants of railway suicides. The most salient finding was the vital impact of a change of therapist. These findings deserve integration into the clinical management of patients with serious mental disease.

Inpatient suicide prevention: promoting a culture and system of safety over 30 years of practice

In April 2012, the Joint Commission (JC) report noted that psychiatric hospitals were the most frequent setting for a sentinel event. In 2010-12, suicide was among the top 5 causes of a sentinel event and was a more frequent cause of sentinel events than medication errors. Suicide was ranked as the 10th leading cause of death among persons 10 years of age and older, accounting for 36,891 deaths in 2009. Previous research on suicide has focused on patient evaluation, disease management, symptom assessment, and the use of risk prevention tools, but few publications have reported on system-wide integrated approaches to successful suicide prevention. In this article on inpatient suicide prevention, I present the successful strategies based on epidemiological findings that have been used in one institution to reduce inpatient suicide risk. This report covers strategies that have been used for over 32 years in the treatment of more than 60,000 patients. The successful prevention efforts described in this article involved staff training and deployment, thorough patient assessment, environmental protections, complete handouts, and patient care protocols.

Improving the short-term prediction of suicidal behavior

Aspirational Goal 3 of the National Action Alliance for Suicide Prevention's Research Prioritization Task Force is to predict who is at risk for attempting suicide in the near future. Despite decades of research devoted to the study of risk and protective factors for suicide and suicidal behavior, surprisingly little is known about the short-term prediction of these behaviors. In this paper, we propose several questions that, if answered, could improve the identification of short-term, or imminent, risk for suicidal behavior. First, what factors predict the transition from suicidal thoughts to attempts? Second, what factors are particularly strong predictors of making this transition over the next hours, days, or weeks? Third, what are the most important objective markers of short-term risk for suicidal behavior? And fourth, what method of combining information about risk and protective factors yields the best prediction? We propose that the next generation of research on the assessment and prediction of suicidal behavior should shift, from cross-sectional studies of bivariate risk and protective factors, to prospective studies aimed at identifying multivariate, short-term prediction indices, examining methods of synthesizing this information, and testing the ability to predict and prevent suicidal events.

Can Theory Predict the Process of Suicide on Entry To Prison?

Background: Each year approximately 110,000 people are imprisoned in England and Wales and new prisoners remain one of the highest risk groups for suicide across the world. The reduction of suicide in prisoners remains difficult as assessments and interventions tend to rely on static risk factors with few theoretical or integrated models yet evaluated. Aims: To identify the dynamic factors that contribute to suicide ideation in this population based on Williams and Pollock’s (2001) Cry of Pain (CoP) model. Method: New arrivals (N = 198) into prison were asked to complete measures derived from the CoP model plus clinical and prison-specific factors. It was hypothesized that the factors of the CoP model would be predictive of suicide ideation. Results: Support was provided for the defeat and entrapment aspects of the CoP model with previous self-harm, repeated times in prison, and suicide-permissive cognitions also key in predicting suicide ideation for prisoners on entry to prison. Conclusion: An integrated and dynamic model was developed that has utility in predicting suicide in early-stage prisoners. Implications for both theory and practice are discussed along with recommendations for future research.

Psychiatric in-patient care and suicide in England, 1997 to 2008: a longitudinal study

BACKGROUND

Psychiatric in-patients are at high risk of suicide. Recent reductions in bed numbers in many countries may have affected this risk but few studies have specifically investigated temporal trends. We aimed to explore trends in psychiatric in-patient suicide over time.

METHOD

A prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997-2008). Suicide rates were determined using National Confidential Inquiry and Hospital Episode Statistics (HES) data.

RESULTS

Over the study period there were 1942 psychiatric in-patient suicides. Between the first 2 years of the study (1997, 1998) and the last 2 years (2007, 2008) the rate of in-patient suicide fell by nearly one-third from 2.45 to 1.68 per 100,000 bed days. This fall in rate was observed for males and females, across ethnicities and diagnoses. It was most marked for patients aged 15-44 years. Rates also fell for the most common suicide methods, particularly suicide by hanging on the ward (a 59% reduction). Although the number of post-discharge suicides fell, the rate of post-discharge suicide may have increased by 19%. The number of suicide deaths in those under the care of crisis resolution/home treatment teams has increased in recent years to approximately 160 annually.

CONCLUSIONS

The rate of suicide among psychiatric in-patients in England has fallen considerably. Possible explanations include falling general population rates, changes in the at-risk population or improved in-patient safety. However, a transfer of risk to the period after discharge or other clinical settings such as crisis resolution teams cannot be ruled out.

Taking Stock and Taking Steps: The Case for an Adolescent Version of the Short-Assessment of Risk and Treatability

The field of violence risk assessment has matured considerably, possibly advancing beyond its own adolescence. At this point in the field's evolution, it is more important than ever for the development of any new device to be accompanied by a strong rationale and the capacity to provide a unique contribution. With this issue in mind, we first take stock of the field of adolescent risk assessment in order to describe the rapid progress that this field has made, as well as the gaps that led us to adapt the Short-Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicholls, & Desmarais, 2009) for use with adolescents. We view the Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV; Nicholls, Viljoen, Cruise, Desmarais, & Webster, 2010; Viljoen, Cruise, Nicholls, Desmarais, & Webster, in progress) as complementing other risk measures in four primary ways: 1) rather than focusing solely on violence risk, it examines broader adverse outcomes to which some adolescents are vulnerable (including self-harm, suicide, victimization, substance abuse, unauthorized leave, self-neglect, general offending); 2) it places a balanced emphasis on adolescents' strengths; 3) it focuses on dynamic factors that are relevant to short-term assessment, risk management, and treatment planning; and 4) it is designed for both mental health and justice populations. We describe the developmentally-informed approach we took in the adaptation of the START for adolescents, and outline future steps for the continuing validation and refinement of the START:AV.

Predictors of suicide-related behaviors during treatment following a first episode of psychosis: the contribution of baseline, past, and recent factors

BACKGROUND

Suicide-related behaviors (suicide attempts and suicides) are common in the early phase of psychotic disorders. Studies have examined risk factors among baseline and historical (i.e., past) variables, yet little is known about recent characteristics that increase suicide risk during treatment for first-episode psychosis (FEP). This study had two aims: first, to determine the relative importance of baseline, past, and recent variables to the prediction of suicide-related behaviors in patients with FEP; second, to identify recent characteristics that exert most influence on suicide risk levels and which could become foci of preventive interventions.

METHODS

This was a case-control study of 180 patients from a cohort entering a specialist FEP service between 1/12/2002 and 30/11/2005. Data for 72 cases and 108 matched controls were obtained via medical record audit. Multivariate logistic regression models assessed the contribution of baseline, past, and recent domains. Suicide attempt or suicide during treatment was the outcome variable.

RESULTS

The strongest risk factors for suicide-related behaviors were: baseline depressive symptoms, baseline suicidal ideation/intent, past negative events, past non-suicidal self-injurious behavior, recent negative events, recent depressive symptoms, and recent non-suicidal self-injurious behavior. However, when these were entered into a hierarchical logistic regression model, only recent non-suicidal self-injurious behavior (AOR=72.96, p<0.001), and recent negative events (AOR=1.90, p=0.003) remained significant predictors. The final model accurately classified 75.5% of cases and 89.2% of controls, and explained 72.0% of variance in the suicide attempt status.

CONCLUSIONS

Since recent negative events and recent non-suicidal self-injurious behavior were the strongest predictors of suicide-related behaviors during treatment for FEP, psychiatric services could consider incorporating psychosocial interventions addressing affect regulation, interpersonal effectiveness, stress management and problem solving, alongside case management and pharmacotherapy, to help to reduce the rates of suicide attempts and suicides in first-episode patients.

Are there associations between caregiver information and suicidal behavior in psychiatric inpatients?

OBJECTIVE

The study aimed at exploring associations between inpatient suicides/attempted suicides in a psychiatric hospital and involvement of family caregivers in treatment.

METHODS

Based on the German psychiatric basic documentation systems (DGPPN-BADO), we analyzed a total sample of 49,257 cases of inpatient care (1998-2007) from a large psychiatric tertiary care university hospital and as a subsample all cases of schizophrenia, depression, acute stress/adjustment disorders and personality disorders (n = 22,880). Involvement of family caregivers was evaluated according to the following variables: admission to hospital due to recommendation of caregiver, conversation between therapist and caregiver, psychoeducation of caregiver as well as psychopharmacological and/or psychotherapeutic non-compliance of patient. Descriptive and bivariate analyses were performed.

RESULTS

Of the 22,880 cases in the subsample, 31 inpatient suicides and 198 attempted inpatient suicides were recorded. We could not find any significant associations of caregiver involvement variables with inpatient suicide. In contrast, for the total sample (n = 49,257), attempted suicide was associated with more conversation between therapists and caregivers (χ(2) = 3.863, df = 1, p = 0.049) and with psychopharmacological (χ(2) = 4.822, df = 1, p = 0.028) and psychotherapeutic (χ(2) = 13.041, df = 1, p = 0.000) non-compliance of the patients.

CONCLUSION

Further research is needed regarding the influence of caregivers on suicidal behavior of mentally ill inpatients.

Sentinel events and predictors of suicide among inpatients at psychiatric hospitals

BACKGROUND

The objective of this study was to assess sentinel event analysis and relative factors in different mental healthcare settings. In addition, the occurrence of sentinel events in different hospital settings was compared and potential risk factors contributing to sentinel events identified.

METHODS

A total of 75 consecutive adult subjects were enrolled from 2 psychiatric units, 1 within a general hospital and 1 at a psychiatric hospital in southern Taiwan. A retrospective chart review of the psychiatric inpatients was conducted for patients that met the criteria for a sentinel event between July 2004 and May 2011. A comparison of the hospital settings was made and differences between suicidal and non-suicidal sentinel events studied.

RESULTS

Psychiatric patients that received general hospital psychiatric services (1) appeared to experience a sentinel event soon after admission, (2) the time between the sentinel event occurrence and patient death was shorter, (3) there was a higher probability of potential medical illness than among inpatients treated at a specialized psychiatric hospital, (4) the sentinel event subjects that committed suicide were younger, had a shorter hospital stay, shorter time to occurrence of the sentinel event followed by an unexpected death than the non-suicidal group, and (5) a younger age, higher education level, previous suicide attempt and family psychiatric history were important predictors of suicide among psychiatric inpatients.

CONCLUSIONS

The results of this study suggest that psychiatric inpatients treated at a general hospital require careful examination for potential physical illness and greater efforts to prevent suicide. A younger age, higher education level, history of a previous suicide attempt and family psychiatric history are additional risk factors for suicide among these patients.

Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients

OBJECTIVE

To estimate the strength of the associations between the suicide of psychiatric in-patients and demographic, historical, symptomatic, diagnostic and treatment factors.

METHOD

A systematic review and meta-analysis of controlled studies of the suicide of psychiatric in-patients including suicides while on approved or unapproved leave.

RESULTS

Factors that were significantly associated with in-patient suicide included a history of deliberate self-harm, hopelessness, feelings of guilt or inadequacy, depressed mood, suicidal ideas and a family history of suicide. Patients suffering from both schizophrenia and depressed mood appeared to be at particular risk. The association between suicidal ideas and in-patient suicide was weak and did not reach statistical significance after a quantitative correction for publication bias. A high-risk categorization as defined by a combination of retrospectively determined individual risk factors was strongly statistically associated with in-patient suicide (OR=10.9), with a sensitivity of 64% and a specificity of 85%.

CONCLUSION

Despite the apparently strong association between high-risk categorization and subsequent suicide, the low base rate of in-patient suicide means that predictive value of a high-risk categorization is below 2%. The development of safer hospital environments and improved systems of care are more likely to reduce the suicide of psychiatric in-patients than risk assessment.

Suicides in psychiatric in-patients: what are we doing wrong?

Given the uncontested role of psychiatric illnesses in both fatal and non-fatal suicidal behaviours, efforts are continuously made in improving mental health care provision. In cases of severe mental disorder, when intensified treatment protocols and continuous supervision are required due to individual's impaired emotional, cognitive and social functioning (including danger to self and others), psychiatric hospitalisation is warranted. However, to date there is no convincing evidence that in-patient care prevents suicide. In fact, quite paradoxically, both admissions to a psychiatric ward and recent discharge from it have been found to increase risk for suicidal behaviours. What elements in the chain of well-intentioned approaches to treating psychiatric illness and suicidality fail to protect this vulnerable population is still unclear. The same holds true for the identifications of factors that may increase the risk for suicide. This editorial discusses current knowledge on this subject, proposing strategies that might improve prevention.

Revisiting the association of aggression and suicidal behavior in schizophrenic inpatients

Our study investigated the association of aggression and suicidal behavior in schizophrenic inpatients. Eight thousand nine hundred one admissions for schizophrenia (1998-2007) to a psychiatric university hospital were included. Schizophrenic suicides (n = 7)/suicide attempters (n = 40) were compared to suicides (n = 30)/suicide attempters (n = 186) with other diagnoses and to schizophrenic non-attempters regarding aggression. Logistic regression analysis was performed to explore risk factors for attempted suicide. Schizophrenic suicides/suicide attempters did not differ from other suicides/suicide attempters or from schizophrenic non-attempters with regard to aggression. Risk of inpatient suicide attempt was increased for patients with attempted suicide at admission, high school graduation, and disorganized subtype. Aggression could not be found to be a predictor of attempted suicide. Aggression seems to have a minor role for suicidal behavior in schizophrenia.

Patients' own statements of their future risk for violent and self-harm behaviour: a prospective inpatient and post-discharge follow-up study in an acute psychiatric unit

Recently patients' responsibility for and ownership of their own treatment have been emphasised. A literature search on patients'' structured self-reported assessment of future risk of violent, suicidal or self mutilating behaviour failed to disclose any published empirical research. The present prospective naturalistic study comprised all involuntary and voluntary acutely admitted patients (n=489) to a psychiatric hospital during one year. Patients' self-reported risks of violence and self-harm at admission and at discharge were compared with episodes recorded during hospital stay and 3 months post-discharge. Patients' predictions were significant concerning violent, suicidal and self-injurious behaviour, with AUC values of 0.73 (95%CI=0.61-0.85), 0.92 (95%CI=0.88-0.96) and 0.82 (95%CI=0.67-0.98) for hospital stay, and 0.67 (95%CI=0.58-0.76), 0.63 (95%CI=0.55-0.72) and 0.66 (95%CI=0.57-0.76) after 3 months, respectively. Moderate or higher risk predictions remained significant in multivariate analysis, and risk of violence even after gender stratification. Self-harm predictions were significant for women. Moderate or higher risk scores remained significant predictors of violence one year post-discharge. Controlling for readmissions the results remained the same. Low sensitivity limits the clinical value, but relatively high positive predictive values might be clinically important. Still future research is recommended to explore if self prediction is a valid adjuvant method to established risk assessment procedures.

Time patterns of inpatient suicides

Abstract Objective. Time patterns of suicides have been investigated in many population-based studies, but there are no studies exploring time patterns of suicides during psychiatric inpatient stay up to now. Methods. All inpatient suicides (1998-2007) of a psychiatric university hospital were identified by the German psychiatric basic documentation system (DGPPNBADO). Descriptive and univariate analyses were performed to analyse time patterns of inpatient suicides. Results. No significant differences could be found for the occurrence of the 37 inpatient suicides due to season (χ(2)=1.595, P=0.696), month (χ(2)=4.838, P=0.958) or weekday (χ(2)=5.189, P=0.550) of suicide. Furthermore, we could not find an unequal distribution of suicides due to month of birth (χ(2)=12.622, P=0.337). 78.4% of inpatient suicides occurred within 50 days after admission. Fourteen inpatients committed suicide around public holidays, two around their birthday. Conclusions. Apart from a notably enhanced risk of suicide in the period after admission, we could not find any time patterns to be of high relevance to inpatient suicides. There may be more relevant risk factors than cyclic or temporal variations.

A checklist to identify inpatient suicide hazards in veterans affairs hospitals

BACKGROUND

Approximately 1,500 suicides take place in inpatient hospital units in the United States each year. This study, the first of its kind, examines the implementation and effectiveness of using a standardized checklist for mental health units to improve patient safety in a large health care system.

METHODS

In 2006 a Department of Veterans Affairs (VA) committee was charged with developing a checklist to explicitly identify environmental hazards on acute mental health units treating suicidal patients. The committee developed both general guidelines to be applied to all areas of the psychiatric unit and detailed guidelines for specific rooms, such as bathrooms, bedrooms, and seclusion rooms.

RESULTS

Some 113 VA facilities used the Mental Health Environment of Care Checklist to evaluate their mental health units, identifying and rating 7,642 hazards. At the end of the first year of the project, because of the checklist, 5,834 (76.3%) of these hazards had been abated by facilities; approximately 2% were identified as critical hazards, and another 27% were rated as serious. The most common hazard was anchor points for hanging, followed by material that could be used as a weapon against staff or other patients and problems keeping patients in the secured unit environment. Anchor points had the greatest risk-level classification, followed by suffocation risk and poison risk. High-risk locations included bedrooms and bathrooms.

DISCUSSION

Anchor points represented almost 44% of the total number of identified hazards, and materials that could be used as weapons comprised nearly 14% of the total. It is critical to review the mental health environment of care with an eye for these potential weapons. The checklist and resulting mitigations of hazards represent steps toward the overall goal of preventing inpatient suicides.

How the psychiatrists of a mental health department managed their patients before an attempted suicide

AIMS

The aim of this survey was to describe patients in care at a large mental health department in northern Italy who attempted suicide, and the clinical management adopted by their psychiatrists before the event.

METHODS

Data collection was based on a questionnaire administered to the reference psychiatrists.

RESULTS

Over a period of 12 months, 166 catchment area residents attempted suicide. Sixty-six (40%) had contacted the mental health department in the previous two years and completed data were obtained on 63. Twenty-nine (46%) suffered from mood, 26 (41%) from personality and 11 (18%) from schizophrenic disorders. Thirty-four attempts occurred within one year of psychiatric ward discharge, mostly in the first quarter. The reference psychiatrists reported that, at the last evaluation, 38 of 63 patients (60%) presented no change in clinical conditions, and 41 of 63 (68%) were considered at no immediate risk of suicide. Most of the attempted suicides in question (45, 72%) were judged to be unpreventable. In the two logistic regression analyses carried out, no independent variables were able to statistically significantly explain the variance in judged suicidal risk or the preventability of the index attempted suicide.

CONCLUSIONS

According to the psychiatrists' descriptions of their last contact with the patients, most attempted suicides have not been preceded by a change in clinical conditions. Moreover, psychiatrists, irrespective of their age and gender, and of patient diagnosis, frequently judged the attempts to have been unpreventable.

In-patient suicide--a 13-year assessment

OBJECTIVE

To describe the suicide rates of psychiatric in-patients in the canton of Zurich for the period 1992-2004, and to determine putative risk factors.

METHOD

The data were derived from the psychiatric case register of the canton Zurich. The analyses were based on person-years calculations and standardised mortality ratios. Additional information was assessed via case records.

RESULTS

During the 13-year period the standardised mortality ratio was 48.9. The risk of suicide was particularly high in patients with personality and affective disorders. Most suicides occurred during regular leave periods, despite the fact that clinical assessment had indicated there was no suicide risk for the patient.

CONCLUSION

The suicide risk of in-patients is distinctly higher than in the general population. A better assessment of suicide risk before regular leave periods could lead to a decrease of suicides in in-patient settings, as well as a more rigorous treatment of borderline cases, and of affective and psychotic symptoms.

Self-focused attention reduces self-injurious behavior in alcohol-intoxicated men

Both chronic alcohol use and acute intoxication are risk factors for self-aggression (i.e., intentional self-injury) across the spectrum of lethality. Studies designed to identify a cause-and-effect relation between alcohol intoxication and self-aggression, or the factors that facilitate or mitigate this effect, are rare due to the inherent difficulty of studying self-injurious behavior experimentally. In this study, we experimentally demonstrate that alcohol intoxication leads to heightened self-injurious behavior, and that enhanced self-focused attention (self-awareness) attenuates this effect. Specifically, 40 men consumed either alcohol (mean Blood Alcohol Concentration [BAC] = .10) or a veridical control drink, and then completed a laboratory task designed to assess self-injurious behavior. Self-focused attention was experimentally enhanced in half the participants in each drink condition. Results support the notion that prevention and intervention programs designed to reduce intentional self-injurious behaviors should include components that address alcohol misuse and self-awareness.

Inpatient suicide and suicide attempts in Veterans Affairs hospitals

BACKGROUND

Suicide is the eleventh leading cause of death in the United States. Approximately 1,500 suicides occur in inpatient hospital units in the United States each year. In an attempt to determine the methods and environmental factors involved in inpatient suicide and suicide attempts in Department of Veterans Affairs (VA) hospitals, all root cause analysis (RCA) reports of inpatient suicides and suicide attempts submitted to the VA National Center for Patient Safety (NCPS) before June 2006 were reviewed.

METHODS

VA medical centers are required to conduct RCAs on all inpatient suicides and report all suicides and serious suicide attempts to the NCPS. All reports of inpatient suicide and suicide attempts submitted between December 1999 and June 2006 were reviewed, including methods and environmental factors involved in the events.

RESULTS

A total of 185 inpatient suicide and suicide attempts were reported; 42 were completed suicides and 143 were suicide attempts. Approximately 52% of the total number of events occurred while the patient was on an inpatient psychiatry unit. Three methods of self harm--intentional drug overdose, cutting with a sharp object, and hanging--accounted for 71% of the total number of events. Doors and wardrobe cabinets accounted for 41% of the anchor points when hanging was the method of self-harm. For suicide attempts involving cutting behaviors, razor blades accounted for 37% of the total number of events; 57% of jumping-related events occurred from balconies and walkways.

CONCLUSIONS

Careful review of RCA reports of inpatient suicide has resulted in focused interventions to improve patient care and patient safety in VA medical centers, including a comprehensive environment-of-care checklist for reviewing inpatient psychiatry units.

Predicting inpatient suicides and suicide attempts by using clinical routine data?

OBJECTIVE

The study aimed at exploring prevalence and risk factors of inpatient suicides and attempted suicides in a psychiatric hospital.

METHOD

Based on the German psychiatric basic documentation system, 20,543 patients with 40,451 episodes of inpatient care (1995-2004) in a psychiatric state hospital were included. Besides univariate analyses, multivariate logistic regression analyses and classification and regression tree analyses were performed.

RESULTS

Forty-one inpatient suicides were recorded. Risk of inpatient suicide is increased for patients with resistance to psychopharmacological treatment, previous suicide attempt, severe side effects and supportive psychotherapy before admission. Two hundred fourteen inpatient suicide attempts occurred during the 10-year period. Risk factors of inpatient suicide attempt are assault, personality disorder, previous suicide attempt, psychopharmacological treatment resistance, suicidal thoughts at admission, schizophrenia, depression, female sex and length of stay.

CONCLUSION

The identified risk factors underline the need for a cautious investigation of previous suicide attempts as well as for giving special attention to patients who have problems with psychopharmacotherapy during hospitalization.

A chronological perspective on suicide--the last days of life

A combined psychological autopsy and narrative approach was used to study the completed suicides of 67 Israeli soldiers. Three issues were addressed. First, the authors examined the typology of the life narratives of suicide completed during active army duty. Second, focusing on the last 3 weeks of the soldiers' lives, they sought to examine their triggers for suicide, emotional state of mind, army duty functioning, and communication of suicidal intent. Finally, they examined military responses to communication of intent, help provision, and help acceptance. Four types of narratives were identified: regressive, stable, tragic (progression and sudden collapse), and romantic (ups and downs). During the last days of life, suicide completers exhibited a split between an emotional state of mind (evidencing an emotional deterioration) and a behavioral military functioning, which was mostly stable. The analysis also revealed a resistance to receive help and a resistance to provide help, both of which impeded intervention. The gap between functioning and emotional distress in suicidal individuals and the incongruence between crisis and help are highlighted. The need to educate military personnel to look beyond duty functioning and the need to develop clear guideline about referrals to professional helps are discussed.

Life trajectories and burden of adversity: mapping the developmental profiles of suicide mortality

BACKGROUND

Little is known about differential suicide profiles across the life trajectory. This study introduces the life-course method in suicide research with the aim of refining the longitudinal and cumulative assessment of psychosocial factors by quantifying accumulation of burden over time in order to delineate distinctive pathways of completed suicide.

METHOD

The psychological autopsy method was used to obtain third-party information on consecutive suicides. Life-history calendar analysis served to arrive at an adversity score per 5-year segment that was then cluster-analysed and correlated to define victim profiles.

RESULTS

Two distinct life trajectories emerged: (1) individuals who experienced childhood traumas, developmental adversity and little protection were more likely to present concurrent psychiatric and Axis II disorders; and (2) individuals who experienced less adversity but seemed more reactive to later major difficulties.

CONCLUSIONS

The life calendar approach presented here in suicide research adds to the identification of life events, distal and recent, previously associated with suicide. It also quantifies the burden of adversity over the life course, defining two distinct profiles that could benefit from distinct targeted preventive intervention.