Ethnicity, social factors, illness and suicide: a follow-up study of a random sample of the Swedish population

Suicidal behaviour in over-indebted individuals: a cross-sectional study in Sweden

OBJECTIVE

Associations between debt and suicidal behaviour have been identified, but the research is sparse. Thus, more research is needed to understand the association between economic vulnerability and suicide. The study aimed to generate further knowledge about over-indebted individuals who have attempted suicide at least once.

METHOD

Participants were a Swedish sample comprising 641 over-indebted individuals. The inclusion criteria were that the participants should be indebted and have been subjected to debt collection measures and/or seizure orders by the Swedish Enforcement Authority. Participants answered questionnaires regarding socio-demographic variables, debt size, history of suicide attempt, critical life events, and social contacts, and filled the Hospital Anxiety and Depression Scale (HADS). In the statistical analyses, Chi2 test for independence and t-test was used, and binary logistic regression to adjust for the confounding effects of the variables on each other.

RESULTS

The analysis revealed that nearly one in five (19.3%, N = 123) had attempted suicide at least once. A larger part of the respondents who had a history of suicide attempts reported that they were living alone (OR 2.30 (95% CI 1.34-3.89, p = .002). Many of those living alone were women (χ2 (1, n = 121) = 4.88, p = 0.03, ɸ = 0.22).

CONCLUSIONS

The results of the current study point to the fact that economic vulnerability is an important psychosocial aspect to take into serious consideration concerning mental health and suicide prevention. Longitudinal research is needed to explain, predict and prevent suicide due to over-indebtedness.

Using iterative random forest to find geospatial environmental and Sociodemographic predictors of suicide attempts

Introduction

Despite a recent global decrease in suicide rates, death by suicide has increased in the United States. It is therefore imperative to identify the risk factors associated with suicide attempts to combat this growing epidemic. In this study, we aim to identify potential risk factors of suicide attempt using geospatial features in an Artificial intelligence framework.

Methods

We use iterative Random Forest, an explainable artificial intelligence method, to predict suicide attempts using data from the Million Veteran Program. This cohort incorporated 405,540 patients with 391,409 controls and 14,131 attempts. Our predictive model incorporates multiple climatic features at ZIP-code-level geospatial resolution. We additionally consider demographic features from the American Community Survey as well as the number of firearms and alcohol vendors per 10,000 people to assess the contributions of proximal environment, access to means, and restraint decrease to suicide attempts. In total 1,784 features were included in the predictive model.

Results

Our results show that geographic areas with higher concentrations of married males living with spouses are predictive of lower rates of suicide attempts, whereas geographic areas where males are more likely to live alone and to rent housing are predictive of higher rates of suicide attempts. We also identified climatic features that were associated with suicide attempt risk by age group. Additionally, we observed that firearms and alcohol vendors were associated with increased risk for suicide attempts irrespective of the age group examined, but that their effects were small in comparison to the top features.

Discussion

Taken together, our findings highlight the importance of social determinants and environmental factors in understanding suicide risk among veterans.

Prevalence of Suicide in Immigrants/Refugees: A Systematic Review and Meta-Analysis

OBJECTIVE

In recent years, there has been an increase in immigrant populations worldwide. This study aims to present the global prevalence of suicide between immigrants and refugees as well as to report the prevalence of suicide ideation, suicide mortality, suicide attempts, and plan of suicide.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA's) rules were used as a guide in the current research path. PubMed and EMBASE were targeted for the study until December 2019. After collecting the data, the number of events and sample size extracted for each study and also pooled odds ratio and confidence interval (CI) were used to investigate the suicide ratio among immigrants and refugees compared to the native population.

RESULTS

Fifty-one studies were included in the meta-analysis to investigate suicide prevalence or suicide odds ratio. The prevalence of suicidal ideation was 16% (CI: 0.12-0.20, I² = 99.4%), for attempted suicide was 6% (CI: 0.05-0.08, I² = 98.0%), and for suicide plan prevalence was 4% (CI: 0.00-0.08, I² = 96.8%). The prevalence of suicidal ideation was 10% (CI: 0.04-0.17, I² = 0.0%) in men and 17% (CI: 0.10-0.24, I² = 96.8%) in women. The prevalence of attempted suicide was 1% (CI: 0.01-0.02, I² = 0.0%) in men and 7% (CI: 0.03-0.10, I² = 94.4%) in women. The odds ratio of suicide mortality among immigrants was 0.91 (CI: 0.90-0.93, p < 0.001; I² = 97.6%) and for attempted suicide was 1.15 (CI: 1.10-1.20, p < 0.001; I² = 92.0%). Begg's test (p = 0.933) (Egger test; p = 0.936) rejected publication bias.

CONCLUSION

Given the high prevalence of suicide, especially suicide ideation and suicide attempts in immigrants, increased attention needs to be paid to the mental health of this population.

Substance use, affective symptoms, and suicidal ideation among Russian, Somali, and Kurdish migrants in Finland

Comorbidity of substance use with affective symptoms and suicidality has been well documented in the general population. However, population-based migrant studies about this association are scarce. We examined the association of affective symptoms and suicidal ideation with binge drinking, daily smoking, and lifetime cannabis use among Russian, Somali, and Kurdish migrants in comparison with the Finnish general population. Cross-sectional data from the Finnish Migrant Health and Wellbeing Study (Maamu, n = 1307) and comparison group data of the general Finnish population (n = 860) from the Health 2011 Survey were used. Substance use included self-reported current binge drinking, daily smoking, and lifetime cannabis use. Affective symptoms and suicidal ideation were measured using the Hopkins Symptom Checklist-25 (HSCL-25). We performed multivariate logistic regression analyses, including age, gender, and additional socio-demographic and migration-related factors. Suicidal ideation (OR 2.4 95% CI 1.3-4.3) was associated with binge drinking among Kurds and lifetime cannabis use among Russians (OR 5.6, 95% CI 1.9-17.0) and Kurds (OR 5.5, 95% CI 1.9-15.6). Affective symptoms were associated with daily smoking (OR 1.6, 95% CI 1.02-2.6) and lifetime cannabis use (OR 6.1, 95% CI 2.6-14.5) among Kurdish migrants. Our results draw attention to the co-occurrence of suicidal ideation, affective symptoms, and substance use, especially among Kurdish migrants. These results highlight the variation of comorbidity of substance use and affective symptoms between the different populations. This implies that screening for substance use in mental healthcare cannot be neglected based on presumed habits of substance use.

Socio-Demographic and Clinical Characteristics of Psychiatric Patients Who Have Committed Suicide: Analysis of Bulgarian Regional Suicidal Registry for 10 Years

Introduction: Suicide is a major public health problem but factors determining suicide risk are still unclear. Studies in this field in Bulgaria are limited, especially on a regional level. Methods: By a cross-sectional design, we accessed the medical records of all psychiatric patients committed suicide over a 10-year period (2009-2018) in one major administrative region of Bulgaria. A statistical analysis was performed of the association between age of suicide as an indirect yet measurable expression of the underlying suicidal diathesis and a number of socio-demographic and clinical characteristics. Results: Seventy-seven of 281 suicides (28%) had psychiatric records. Most common diagnoses were mood disorders (44%), followed by schizophrenia (27%), anxiety disorders (10%), substance use disorders (9%) and organic conditions (8%). Male gender, single/divorced marital status, early illness onset, co-occurring substance misuse and lower educational attainment (for patients aged below 70) were significantly associated with earlier age of suicide whereas past suicide attempts and psychiatric hospitalizations, comorbid somatic conditions and unemployment showed insignificant association. Substantial proportion of patients (60%) had contacted psychiatric service in the year preceding suicide, with nearly half of these encounters being within 30 days of the accident. Conclusion: Severe mental disorders are major suicide risk factor with additional contribution of certain socio-demographic and illness-related characteristics. Monitoring for suicidality must be constant in chronic psychiatric patients. Registration of suicide cases in Bulgaria needs improvement in terms of information concerning mental health. More studies with larger samples and longitudinal design are needed to further elucidate distal and proximal suicide risk factors.

Posttraumatic stress disorder and psychiatric co-morbidity: symptoms in a random sample of female Bosnian refugees

Objectives

This study investigated psychological symptoms in Bosnian women 3–4 years after their arrival in Sweden.

Methods

A simple random sample of 163 Bosnian women aged 19–59 was drawn from the Swedish populations register in 1996. The control group consisted of 392 Swedish-born women. Data were collected in face-to-face interviews. The Hopkins Symptom Checklist 25 (HSCL-25) and the Posttraumatic Symptom Scale (PTSS-10) were used to measure psychological symptoms of depression, anxiety, psychological distress, and posttraumatic stress disorder (PTSD). Unconditional logistic regression was used to estimate odds ratios (OR) for psychological symptoms after adjustment for age, country of birth, education, marital status, economic difficulties, social network, and feeling secure.

Results

The prevalence of symptoms of PTSD was 28.3% among the Bosnian women. Bosnian women had significantly higher risks of symptoms of depression, anxiety, and psychological distress than Swedish-born women. For depression the odds ratio was 9.50 among Bosnian women.

Conclusions

Psychiatric community interventions need to target Bosnian refugee women. Awareness among health-care workers who encounter these women in a clinical setting should be improved.

Social Status and Suicidal Activity Among Psychiatric Patients: Moderating Effects of Gender, Race and Psychiatric Diagnosis

The relationship between suicide and social class has proved to be complex. Durkheim predicted suicide rates would increase with social status, while others thought the opposite. Results have been mixed. In some studies, suicidality has increased with increasing social status, and in other studies, the two variables have had an inverse relationship. These studies have been primarily conducted on general non-psychiatric populations The present study, in contrast, examines this relationship on a 20-year prospective longitudinal sample of 400 psychiatric patients (differentiated by psychiatric diagnosis) after index hospitalization. Of these, 160 patients show some sign of suicide risk (87 cases of suicidal ideation, 41 of suicide attempts, and 32 suicide completions). A complicated pattern emerges across psychiatric diagnosis, gender, and race. The great majority of patients show no statistically significant relationship between social status and suicide risk. At the maximally different extremes, however, a dramatic difference does emerge. White women diagnosed with nonpsychotic depression show a positive relationship between social status and suicide risk (p < .01) while black men diagnosed with schizophrenia show a negative relationship between these 2 variables (p < .02). The relationship between social status and suicidality among psychiatric patients varies across race, gender, and psychiatric diagnosis. More research needs to be done on this complex and important topic, especially with regard to samples of psychiatric patients. The role of anomie should be studied.

What do register-based studies tell us about migrant mental health? A scoping review

BACKGROUND

Previous studies investigating the mental health of migrants have shown mixed results. The increased availability of register data has led to a growing number of register-based studies in this research area. This is the first scoping review on the use of registry and record-linkage data to examine the mental health of migrant populations. The aim of this scoping review is to investigate the topics covered and to assess the results yielded from these studies.

METHODS

We used a scoping review methodology to search MedLine, PubMed, PsychINFO, Web of Science, and SCOPUS for all register-based studies on the mental health of migrants. Two reviewers screened all papers, independently, using iteratively applied inclusion and exclusion criteria. Using gradually broadening inclusion and exclusion criteria for maximum "scope," newly published criteria developed to appraise the methodological quality of record-linkage studies were applied to eligible papers and data were extracted in a charting exercise.

RESULTS

A total of 1309 papers were screened and appraised, 51 of which met the eligibility and quality criteria and were included in the review. This review identified four major domains of register-based research within the topic of migrant mental health: rates and risks of psychiatric disorders, rates and risks of suicide mortality, the use of psychotropic drugs, and health service utilisation and mental health-related hospitalisation rates. We found that whilst migrants can be at an increased risk of developing psychotic disorders and suicide mortality, they are less likely to use psychotropic medication and mental health-related services.

CONCLUSIONS

This review systematically charts the register-based studies on migrants' mental health for the first time. It shows the main topics and gaps in knowledge in this research domain, discusses the disadvantages of register-based studies, and suggests new directions for forthcoming studies.

The complex impact of risk and protective factors on suicide mortality: a study of the Ukrainian general population

This study assesses the complex impact of risk and protective factors on suicide mortality in the Ukrainian general population. Data on suicide rates and socioeconomic and medical factors were obtained from the Ukrainian State Statistical Office, WHO, and the European Social Survey. Structural equation modeling was used for data analysis. Religion and education were negatively associated with suicide. The relationship between drug addiction/alcoholism and suicide was positive. The association between urbanization and suicide mortality was negative. The relationship between gross regional product (GRP) and female suicide was slightly negative. Religiosity was the protective factor most strongly linked with suicide mortality followed by urbanization. The harmful role of drug addiction and alcoholism was confirmed. The role of education and GRP is controversial. No striking gender differences were found.

Basic psychological needs, suicidal ideation, and risk for suicidal behavior in young adults

Associations between the satisfaction of basic psychological needs of autonomy, competence, and relatedness with current suicidal ideation and risk for suicidal behavior were examined. Two logistic regressions were conducted with a cross-sectional database of 440 university students to examine the association of need satisfaction with suicidal ideation and risk for suicidal behavior, while controlling for demographics and depressive symptoms. Suicidal ideation was reported by 15% of participants and 18% were found to be at risk for suicidal behavior. A one standard deviation increase in need satisfaction reduced the odds of suicidal ideation by 53%, OR (95% CI) = 0.47 (0.33-0.67), and the odds of being at risk for suicidal behavior by 50%, OR (95% CI) = 0.50 (0.37-0.69). Young adults whose basic psychological needs are met may be less likely to consider suicide and engage in suicidal behavior. Prospective research is needed to confirm these associations.

Sociodemographic, psychiatric and somatic risk factors for suicide: a Swedish national cohort study

BACKGROUND

More effective prevention of suicide requires a comprehensive understanding of sociodemographic, psychiatric and somatic risk factors. Previous studies have been limited by incomplete ascertainment of these factors. We conducted the first study of this issue using sociodemographic and out-patient and in-patient health data for a national population.

METHOD

We used data from a national cohort study of 7,140,589 Swedish adults followed for 8 years for suicide mortality (2001-2008). Sociodemographic factors were identified from national census data, and psychiatric and somatic disorders were identified from all out-patient and in-patient diagnoses nationwide.

RESULTS

There were 8721 (0.12%) deaths from suicide during 2001-2008. All psychiatric disorders were strong risk factors for suicide among both women and men. Depression was the strongest risk factor, with a greater than 15-fold risk among women or men and even higher risks (up to 32-fold) within the first 3 months of diagnosis. Chronic obstructive pulmonary disease (COPD), cancer, spine disorders, asthma and stroke were significant risk factors among both women and men (1.4-2.1-fold risks) whereas diabetes and ischemic heart disease were modest risk factors only among men (1.2-1.4-fold risks). Sociodemographic risk factors included male sex, unmarried status or non-employment; and low education or income among men.

CONCLUSIONS

All psychiatric disorders, COPD, cancer, spine disorders, asthma, stroke, diabetes, ischemic heart disease and specific sociodemographic factors were independent risk factors for suicide during 8 years of follow-up. Effective prevention of suicide requires a multifaceted approach in both psychiatric and primary care settings, targeting mental disorders (especially depression), specific somatic disorders and indicators of social support.

[About epidemiology of suicidal behavior: an investigation in the health-service district of Brixen]

OBJECTIVE

Aim of this investigation is to find out how many parasuicids as well as suicides are commited and which epidemiological characteristics (sex, age, substance addictions, relationships, job, life-events and suicide attempts in past) show people who commit suicide, and people who commiting parasuicide. After that we try to find variables predicting a suicide or variables what show a vulnerability to commit suicide.

METHODS

Clinicans assess patients who commit parasuicide by the WHO-Parasuicide-Monitoring-Questionnaire and suicide victims by interview with the bereaved. Afterwards, data are assimilated and aggregated.

RESULTS

In this period a mean of 37 (SD = 7.78) parasuicides and 6.32 (SD = 3.79) suicides happened yearly. The sample shows different characteristics in age, sex, life-events in the run-up to the action, job situation and parasuicide(s) in past. No differences were found between relationship and substance abuse/addiction and regarding both types of suicidal behavior.

CONCLUSION

The incidence concerning suicide is slightly lower; the incidence with regard to parasuicide is lower than in other samples. Demographic variables show that people commiting suicide differ from those who commit parasuicide.

Effects of educating local government officers and healthcare and welfare professionals in suicide prevention

Suicide is a major public health issue. In Japan, local governments are responsible for suicide prevention, and local government officers are therefore expected to act as gatekeepers for suicide prevention. In this study, through a questionnaire survey, the authors examined the current knowledge and attitudes concerning suicide prevention among local government officers and healthcare and welfare professionals, and the effects of providing suicide prevention education on their knowledge of and attitudes toward suicide and its prevention. One hundred eighty-three local government officers and 432 healthcare/welfare professionals completed the survey before and after a single education session. Before the session, the local government officers and healthcare/welfare professionals showed mainly positive attitudes toward suicide prevention efforts, with little difference between the two groups. After the training, knowledge and attitudes were further improved for most questionnaire items. Respondents with one or more experiences of suicide prevention training showed significantly more knowledge and positive attitudes before the training than those with no such experience. Moreover, knowledge of depression and having a sympathetic attitude were found to be especially associated with the overall attitude that “suicide can be prevented”. Training in suicide prevention was shown to be effective in promoting appropriate knowledge and attitudes among local government officers and healthcare/welfare professionals who are gatekeepers for preventing suicide. Our findings confirm the importance of suicide prevention education, and will contribute to creating a standard educational program on suicide prevention in Japan.

Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic meta-analysis

BACKGROUND

The increased risk of suicide in the period after discharge from a psychiatric hospital is a well-recognized and serious problem.

OBJECTIVE

The aim of this study was to establish the risk factors for suicide in the year after discharge from psychiatric hospitals and their usefulness in categorizing patients as high or low risk for suicide in the year following discharge.

METHOD

A systematic meta-analysis of controlled studies of suicide within a year of discharge from psychiatric hospitals.

RESULTS

There was a moderately strong association between both a history of self-harm (OR = 3.15) and depressive symptoms (OR = 2.70) and post-discharge suicide. Factors weakly associated with post-discharge suicide were reports of suicidal ideas (OR = 2.47), an unplanned discharge (OR = 2.44), recent social difficulty (OR = 2.23), a diagnosis of major depression (OR = 1.91) and male sex (OR = 1.58). Patients who had less contact with services after discharge were significantly less likely to commit suicide (OR = 0.69). High risk patients were more likely to commit suicide than other discharged patients, but the strength of this association was not much greater than the association with some individual risk factors (OR = 3.94, sensitivity = 0.40, specificity = 0.87).

CONCLUSIONS

No factor, or combination of factors, was strongly associated with suicide in the year after discharge. About 3% of patients categorized as being at high risk can be expected to commit suicide in the year after discharge. However, about 60% of the patients who commit suicide are likely to be categorized as low risk. Risk categorization is of no value in attempts to decrease the numbers of patients who will commit suicide after discharge.

Influence of social and material individual and area deprivation on suicide mortality among 2.7 million Canadians: a prospective study

BACKGROUND

Few studies have investigated how area-level deprivation influences the relationship between individual disadvantage and suicide mortality. The aim of this study was to examine individual measures of material and social disadvantage in relation to suicide mortality in Canada and to determine whether these relationships were modified by area deprivation.

METHODS

Using the 1991-2001 Canadian Census Mortality Follow-up Study cohort (N = 2,685,400), measures of individual social (civil status, family structure, living alone) and material (education, income, employment) disadvantage were entered into Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for male and female suicide mortality. Two indices of area deprivation were computed - one capturing social, and the other material, dimensions - and models were run separately for high versus low deprivation.

RESULTS

After accounting for individual and area characteristics, individual social and material disadvantage were associated with higher suicide mortality, especially for individuals not employed, not married, with low education and low income. Associations between social and material area deprivation and suicide mortality largely disappeared upon adjustment for individual-level disadvantage. In stratified analyses, suicide risk was greater for low income females in socially deprived areas and males living alone in materially deprived areas, and there was no evidence of other modifying effects of area deprivation.

CONCLUSIONS

Individual disadvantage was associated with suicide mortality, particularly for males. With some exceptions, there was little evidence that area deprivation modified the influence of individual disadvantage on suicide risk. Prevention strategies should primarily focus on individuals who are unemployed or out of the labour force, and have low education or income. Individuals with low income or who are living alone in deprived areas should also be targeted.

Characteristics of suicide attempters with family history of suicide attempt: a retrospective chart review

BACKGROUND

Family history of suicide attempt is one of the risks of suicide. We aimed at exploring the characteristics of Japanese suicide attempters with and without a family history of suicide attempt.

METHODS

Suicide attempters admitted to an urban emergency department from 2003 to 2008 were interviewed by two attending psychiatrists on items concerning family history of suicide attempt and other sociodemographic and clinical information. Subjects were divided into two groups based on the presence or absence of a family history of suicide attempt, and differences between the two groups were subsequently analyzed.

RESULTS

Out of the 469 suicide attempters, 70 (14.9%) had a family history of suicide attempt. A significantly higher rate of suicide motive connected with family relations (odds ratio 2.21, confidence interval 1.18-4.17, p < .05) as well as a significantly higher rate of deliberate self-harm (odds ratio 2.51, confidence interval 1.38-4.57, p < .05) were observed in patients with a family history of suicide compared to those without such history. No significant differences were observed in other items investigated.

CONCLUSION

The present study has revealed the characteristics of suicide attempters with a family history of suicide attempt. Further understanding of the situation of such individuals is expected to lead to better treatment provision and outcomes, and family function might be a suitable focus in their treatment.

Differential association of socioeconomic status in ethnic and age-defined suicides

Suicide rates vary among racel- and age-defined groups, yet little is known about how suicide risk factors differentially impact individual groups. This study assessed differential associations of socioeconomic status among age- and race-defined groups of suicide victims. A database containing demographic information on declared suicides in Fulton County, GA, from 1 January 1988 through 31 December 2003 was combined with annual per capita income by zip code in Atlanta, GA. Analyses were performed to evaluate differential associations of socioeconomic status among age- and race-defined groups of suicide victims. Compared with the respective ethnic populations of Fulton County, white suicide victims lived in areas with lower per capita income ($51,232 vs. $35,893); African American suicide victims did not ($17,384 vs. $18,179). Elderly suicide victims (>or= 65 years) were more likely to live in the lowest per capita income areas compared with other age groups (OR 1.80, 95% C.I. 1.14, 2.84). Cox proportional hazards models showed increasing income increased the instantaneous risk of suicide among adolescents (HR 2.76; 95% C.I. 2.15, 3.53), particularly African American adolescents (HR 4.22; 95% C.I. 2.19, 8.11), and decreased risk among the elderly (HR 0.58; 95% C.I. 0.50, 0.68). Socioeconomic status had differential associations among age- and race-defined groups of suicide victims.

High social class and suicide in persons at risk for schizophrenia

OBJECTIVE

The relationship between suicide and social class has been equivocal. While some authors have reported that higher social class is related to higher rates of suicide, most other studies report that lower social class is associated with higher rates of suicide. Our study attempted to resolve these inconsistencies by using a High Risk for schizophrenia method.

METHOD

Children of women with severe schizophrenia were assessed in 1962. In 2005, when subjects were a mean age of 58 years, we identified those who had committed suicide.

RESULTS

A higher rate of suicide was associated with risk for schizophrenia in the High-Risk sample. Higher social class origin was associated with suicide in persons at risk for mental illness.

CONCLUSION

Higher social class origin was associated with suicide in subjects at genetic risk for schizophrenia (but not those without risk).

Prevalence of depressive symptoms and related risk factors for depressive symptoms among elderly persons living in a rural Japanese community: a cross-sectional study

To clarify the prevalence of depression in a rural community in Japan and to evaluate the social and familial risk factors for depression, with the goal of suicide prevention, a questionnaire survey was conducted on a total of 2,763 elderly persons. The determined prevalence of depressive symptoms (Zung's self-rated depression scale score of 50 points or more) was 10.4%. Logistic regression analysis showed associations between depressive symptoms and age, absence of a friendly companion, irritation with one's family, frequent loneliness, the opinion that stress has a large impact on one's life, suicide ideation, and poor subjective physical and mental health.

Suicide risk in relation to level of urbanicity—a population-based linkage study

BACKGROUND

The extent to which the high suicide rate in urban areas is influenced by exposures to risk factors for suicide other than urbanicity remains unknown. This population-based study aims to investigate suicide risk in relation to the level of urbanicity in the context of other factors, and to study the risk variation in a sex, age, and calendar year perspective.

METHODS

The study is a nested case-control study comprising 21 169 suicides and 423 128 population controls matched for age and sex. Personal data on place of residence, socioeconomic status and psychiatric history were retrieved from various Danish longitudinal registers. Data were analysed with conditional logistic regression.

RESULTS

This study confirms that people living in more urbanized areas are at a higher risk of suicide than their counterparts in less urbanized areas. However, this excess risk is largely eliminated when adjusted for personal marital, income, and ethnic differences; it is even reversed when further adjusted for psychiatric status. Moreover, the impact of urbanicity on suicide risk differs significantly by sex and across age. Urban living reduces suicide risk significantly among men, especially young men, but increases the risk among women, especially women aged 24-35 or >65 years. In addition, during 1981-1997, the suicide risk associated with urbanicity remained rather constant among women, whereas it dropped significantly among men, a trend that seemingly gained strength during the last part of this period.

CONCLUSIONS

Suicide risk associated with urbanicity varies significantly by sex and age groups and recent years have seen a decline in the urban-rural disparities among men. The increased risk in urban areas can largely be explained by the effects of marital status, ethnics, income, and psychiatric status.

Impact of country of birth on hospital admission for women of childbearing age in Sweden: a five year follow up study

STUDY OBJECTIVE

This study examines whether morbidity, defined as the first psychiatric hospital admission and the first somatic hospital admission, differs among subgroups of foreign born and second generation (that is, native born with at least one parent born abroad) women compared with Swedish born women (that is, with both parents native born) after adjusting for sociodemographic factors.

DESIGN SETTING

In this follow up study the population consisted of 1 452 944 women, of whom 369 771 have an immigrant background (including second generation immigrants), aged 20-45 years. The population of 31 December 1993 was followed up to 31 December 1998. Differences in risk (hazard ratio) between different groups of immigrant women were estimated, adjusting for age, marital status, number of children, and disposable income.

MAIN RESULTS

All four groups of foreign born women had higher age adjusted risks (HRs varied from 1.44 to 1.67) for a first psychiatric hospital admission than Swedish born women. The risk decreased only marginally when the sociodemographic factors were taken into consideration. Additionally, second generation women also had a higher age adjusted risk (HR = 1.42; CI = 1.37 to 1.48) than Swedish born women. The risk decreased only slightly in the main effect model. However, on analysing country of birth and first somatic hospital admissions, only non-European refugee women showed an increased age adjusted risk (HR = 1.26; CI = 1.24 to 1.29), which remained after adjusting for sociodemographic factors.

CONCLUSIONS

Foreign born and second generation women of childbearing age had a higher risk than Swedish born women for a first psychiatric hospital admission. However, only non-European refugees were at higher risk of somatic hospital admissions.

Suicide prevention: a study of patients' views

BACKGROUND

Suicide prevention strategies are usually formulated without seeking the views of people with psychiatric illnesses.

AIMS

To establish what helped patients with severe psychiatric illness when they felt suicidal.

METHOD

A semi-structured interview was constructed following transcribed interviews with 12 patients. This was administered to 59 out-patients with serious and enduring mental illness, focusing on factors they found helpful or unhelpful when at their most despairing.

RESULTS

Three-quarters of patients were in contact with psychiatric services when feeling at their lowest, and this contact was generally deemed to be helpful. Social networks were considered just as helpful as psychiatric services by the half of patients who discussed their feelings with friends or relatives. Religious beliefs and affiliations were helpful. Negative influences included the media and the stigma of psychiatric illness.

CONCLUSIONS

Efforts at suicide prevention might usefully focus on enhancing patients' social networks, increasing the likelihood of early contact with psychiatric services and decreasing the stigma attached to psychiatric illness. Larger studies of patients exposed to different service models would be informative.

Mortality in affective disorders

BACKGROUND

To investigate the mortality rates in affective disorders due to unnatural and natural causes with respect to illness subtype and social-demographic features.

METHODS

Mortality data were determined from a prospective study of 354 outpatients with affective disorders during a follow-up period of 5 years. Death from natural and unnatural causes was compared to sex- and age-specific expectations in the general population. Standardized mortality rates (SMR) in diagnostic subgroups and the influence of social-demographic features were investigated.

RESULTS

The observed 30 deaths represented nearly three times (SMR, 2.9) the number expected on the basis of age- and sex-standardized reference population rates. Death from natural causes occurred with the same rate as expected (SMR, 1.0), death from unnatural causes was 28.8 times higher than expected. Women with affective disorders had a considerable high risk to die from unnatural causes (SMR, 47.1). A significant excess of unnatural death was found in all subtypes of affective disorders, particularly in recurrent major depressive episodes (SMR, 46.7).

LIMITATIONS

The sample was restricted in size. Therefore subgroup differences and multiple relationships of risk factors could not be analyzed with high statistical power.

CONCLUSIONS

The results corroborate earlier findings of excess mortality in major affective disorders and strengthen the view that suffering from recurrent major depression confers per se an important biological risk for suicide. Natural causes of death in affective disorders are comparable to expectations from reference populations. Social-demographic characteristics may contribute to an additional risk of premature death by suicide, particularly in women.

Gender, marital status and ethnicity. A Swedish retrospective study of criminality, morbidity and mortality among victims of non-fatal firearm injuries

OBJECTIVE

To study gender and ethnic aspects in a population consisting of patients treated for non-fatal firearm injuries at public hospitals in Stockholm, Sweden, during a period of 21 years.

DESIGN

Retrospective study. Ethnicity was defined as being a foreign-born individual or a native Swede. The morbidity and criminality data were analysed with unconditional logistic regression and the mortality data were analysed by a proportional hazard model.

RESULTS

Females and foreign-born persons were more often victims of attempted murder than males or native Swedes. Attempted suicide was more common among native Swedes. Male patients, single persons and Finnish immigrants treated for a firearm injury all showed an increased risk of being registered for criminality or committing a violent crime. There was no difference between native Swedes and foreign-born persons concerning the number of hospitalisations during the follow-up period. Living alone and being of male gender were associated with an increased risk of hospitalisation. Firearm victims, independently of ethnicity, had an increased mortality rate compared to a Swedish population; the standardised mortality ratio (SMR) for males was almost 3 and for females almost 8 compared to the SMR of 1 for the whole Swedish population.

CONCLUSION

Firearm victims constitute a population at risk from social, psychological as well as from medical points of view. The present study shows an association between gender, ethnicity, criminality, and morbidity among firearm victims underlining the importance of ethnic- and gender-specific violence prevention strategies.