Predictors of suicide in psychiatric hospital

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.

Meta-analysis of the strength of exploratory suicide prediction models; from clinicians to computers

BACKGROUND

Suicide prediction models have been formulated in a variety of ways and are heterogeneous in the strength of their predictions. Machine learning has been a proposed as a way of improving suicide predictions by incorporating more suicide risk factors.

AIMS

To determine whether machine learning and the number of suicide risk factors included in suicide prediction models are associated with the strength of the resulting predictions.

METHOD

Random-effect meta-analysis of exploratory suicide prediction models constructed by combining two or more suicide risk factors or using clinical judgement (Prospero Registration CRD42017059665). Studies were located by searching for papers indexed in PubMed before 15 August 2020 with the term suicid* in the title.

RESULTS

In total, 86 papers reported 102 suicide prediction models and included 20 210 411 people and 106 902 suicides. The pooled odds ratio was 7.7 (95% CI 6.7-8.8) with high between-study heterogeneity (I2 = 99.5). Machine learning was associated with a non-significantly higher odds ratio of 11.6 (95% CI 6.0-22.3) and clinical judgement with a non-significantly lower odds ratio of 4.7 (95% CI 2.1-10.9). Models including a larger number of suicide risk factors had a higher odds ratio when machine-learning studies were included (P = 0.02). Among non-machine-learning studies, suicide prediction models including fewer risk factors performed just as well as those including more risk factors.

CONCLUSIONS

Machine learning might have the potential to improve the performance of suicide prediction models by increasing the number of included suicide risk factors but its superiority over other methods is unproven.

The Importance of Suicide Risk Formulation in Schizophrenia

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

Risk factors for suicide in bipolar disorder: a cohort study of 12 850 patients

OBJECTIVE

Bipolar disorder carries a high risk of suicide. Identification of risk factors is important. The aim of this study was to study risk factors for suicide in a large cohort of men and women with bipolar disorder.

METHOD

A prospective cohort study using clinical data from the Swedish National Quality Register for Bipolar Affective Disorder (BipoläR). The outcome variable was suicide captured in the Cause of Death Register between 2004 and 2014. Hazard ratios (HR) were calculated using Cox proportional hazards models.

RESULTS

Of 12 850 persons (4844 men and 8006 women) with bipolar disorder, 90 (55 men and 35 women) died by suicide during the follow-up period (between 1 and 10 years). Male sex (HR 2.56), living alone (HR 2.45), previous suicide attempts (HR 4.10), comorbid psychiatric disorder (HR 2.64), recent affective episodes (HR 2.39), criminal conviction (HR 4.43), psychiatric inpatient care (HR 2.79), and involuntary commitment (HR 3.50) were significant risk factors for suicide. Several of the statistically significant risk factors for suicide in bipolar disorder differed between men and women.

CONCLUSIONS

Risk factors for suicide in bipolar disorder include factors associated with suicide in general, but also diagnosis-specific factors.

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.

Psychosis as a risk factor for suicidal thoughts and behaviors: a meta-analysis of longitudinal studies

BACKGROUND

Research has long noted higher prevalence rates of suicidal thoughts and behaviors among individuals with psychotic symptoms. Major theories have proposed several explanations to account for this association. Given the differences in the literature regarding the operationalization of psychosis and sample characteristics, a quantitative review is needed to determine to what extent and how psychosis confers risk for suicidality.

METHODS

We searched PsycInfo, PubMed, and GoogleScholar for studies published before 1 January 2016. To be included in the analysis, studies must have used at least one psychosis-related factor to longitudinally predict suicide ideation, attempt, or death. The initial search yielded 2541 studies. Fifty studies were retained for analysis, yielding 128 statistical tests.

RESULTS

Suicide death was the most commonly studied outcome (43.0%), followed by attempt (39.1%) and ideation (18.0%). The median follow-up length was 7.5 years. Overall, psychosis significantly conferred risk across three outcomes, with weighted mean ORs of 1.70 (1.39-2.08) for ideation, 1.36 (1.25-1.48) for attempt, and 1.40 (1.14-1.72) for death. Detailed analyses indicated that positive symptoms consistently conferred risk across outcomes; negative symptoms were not significantly associated with ideation, and were protective against death. Some small moderator effects were detected for sample characteristics.

CONCLUSIONS

Psychosis is a significant risk factor for suicide ideation, attempt, and death. The finding that positive symptoms increased suicide risk and negative symptoms seemed to decrease risk sheds light on the potential mechanisms for the association between psychosis and suicidality. We note several limitations of the literature and offer suggestions for future directions.

Psychiatry in Slovenia

Although considerable changes have taken place in Slovenia since it became independent in 1991, the psychiatric services face further challenges for their future. Among these, the two main priorities are a further development of the already proposed Patients Advocacy Act and Protection of Rights of Mental Patients Law, and a development of presently almost non-existent community psychiatric services (World Health Organization, Regional Office for Europe, 1999). The developing services should become needs-oriented as Slovenia is a country with extremely high suicide rate and has high rates of alcohol misuse and alcohol-related disorders, with both problems interacting significantly throughout the country.

Possible factors influencing the duration of hospital stay in patients with psychiatric disorders attempting suicide by jumping

BACKGROUND

Patients with psychiatric disorders have a high rate of suicide. The present study investigated factors influencing hospital stays for Japanese patients with psychiatric disorders attempting suicide by jumping.

METHODS

We diagnosed all suicide attempts (n = 113) by jumping based on the International Classification of Diseases 10th Revision (ICD-10) and investigated the mean hospital stays of patients with each diagnosis based on the ICD-10 code. We then analyzed differences in the demographic and clinical characteristics between the diagnostic groups to identify factors influencing the duration of hospital stay.

RESULTS

Patients diagnosed with schizophrenia (F2 code) were the most frequent (32.7%) of all diagnoses; therefore, we divided the diagnostic groups into schizophrenia group (n = 37) and other psychiatric diagnoses group (n = 76). The patients with schizophrenia showed a significantly longer hospital stay (125.7 ± 63.9 days) compared with the patients with other psychiatric diagnoses (83.6 ± 63.2) (β ± SE = 42.1 ± 12.7, p = 0.0013), whereas there was no difference in the jump height between the two groups (the average was the 3rd to 4th floor; p > 0.05). The number of injured parts, particularly lower-limb fractures, was significantly higher (p = 0.017) in patients with schizophrenia than in patients with other psychiatric diagnoses. The duration of psychiatric treatment in patients with schizophrenia were significantly longer (z = 3.4, p = 0.001) than in patients with other psychiatric diagnoses.

CONCLUSION

Our findings indicate that the number of injuries and the body parts injured in patients with schizophrenia are associated with a longer duration of hospital stay following a suicide attempt by jumping. The current use of antipsychotics and a longer duration of taking antipsychotics might contribute to the risk of bone fracture via hyperprolactinemia. Further cognitive impairment in patients with schizophrenia might prevent rehabilitation for the management of lower-limb fractures. From these results, we suggest that clinicians should monitor the level of prolactin and cognitive function in patients with schizophrenia in future studies on managing of lower-limb fractures.

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.

Inpatient Suicide in a Psychiatric Hospital: A Nested Case-control Study

OBJECTIVE

Risk factors for inpatient suicide are different from those in the general population. We examined sociodemographic and clinical variables of patients who committed suicide as an inpatient in a psychiatric hospital in India.

METHODS

Matched retrospective nested case-control design was adopted. Ten patients who died by suicide as inpatients between 2000 and 2013 were included, along with fifty controls, matched with respect to age, sex, diagnosis, and period of admission.

RESULTS

Suicide completers were mostly unskilled in occupation (P = 0.03), had a history of past suicide attempts (P < 0.001), shorter duration of hospital stay (P = 0.001), poorer improvement on psychopathology (P = 0.02), and were having more suicidal ideation (P = 0.02). Significantly more completers were receiving antidepressants (P = 0.04).

CONCLUSION

This study adds to the existing sparse literature on inpatient suicides from Asia. Strength of the study was close matching between case and controls and blindedness. Limitations were retrospective design, and variations in prescription behavior and treatment decisions.

Self-harm in schizophrenia is associated with dorsolateral prefrontal and posterior cingulate activity

Self-harm, such as self-cutting, self-poisoning or jumping from height, regardless of intentions, is common among people with schizophrenia. We wished to investigate brain activations relating to self-harm, in order to test whether these activations could differentiate between schizophrenia patients with self-harm and those without. We used event-related functional MRI with a go/no-go response inhibition paradigm. Fourteen schizophrenia patients with a history of self-harm were compared with 14 schizophrenia patients without a history of self-harm and 17 healthy control participants. In addition, we used standard clinical measures and neuropsychological tests to assess risk factors associated with self-harm. The right dorsolateral prefrontal cortex (DLPFC) and the left posterior cingulate cortex differentiated all three groups; brain activation in these regions being greatest in the control group, and the self-harm patient group being greater than in the non-self-harm patient group. In the self-harm patient group, right DLPFC activity was positively correlated with severity of suicidal thinking. In addition, both patient groups showed less activation in the right orbitofrontal cortex, left ventral anterior cingulate cortex and right thalamus. This is the first study to report right DLPFC activation in association with self-harm and suicidal thinking in patients with schizophrenia. This area could be a target for future neuromodulation studies to treat suicidal thinking and self-harm behaviors in patients with schizophrenia.

The development of insight and its relationship with suicidality over one year follow-up in patients with first episode psychosis

OBJECTIVE

Insight into psychosis has been linked to suicidality, although inconsistently. The co-variation between insight and suicidality over time is under-investigated. The aim of the present study was to investigate predictors of suicidality in patients with first episode of psychosis (FEP) over one year, focusing on the relationship between insight and suicidality.

METHODS

Patients with FEP (n=146) were interviewed as soon as possible after treatment starts and at one year follow-up.

RESULTS

At baseline 37% of patients were suicidal, significantly reduced to 20% at follow-up. The effect of insight on suicidality was in different directions at different time-points, with insight at baseline increasing and insight at follow-up decreasing the risk of suicidality at follow-up. Patients with stable levels of insight across baseline and follow-up did not differ in risk for suicidality at follow-up. However, patients who lost insight from baseline to follow-up were more often suicidal at follow-up, whilst patients who gained insight were more seldom suicidal at follow-up. Other predictors of suicidality at follow-up were more depressive episodes before study entry, longer duration of untreated psychosis, more suicide attempts six months prior to follow-up, and depression at follow-up.

CONCLUSION

The results indicate that the effect of insight on suicidality in FEP-patients depends on time of assessment and of changes in insight. Gaining insight during treatment was associated with reduced risk for suicidality, whilst losing insight had the opposite effect, underlining the need to monitor insight over time and tailor interventions according to illness phase.

Meta-analysis of suicide rates among psychiatric in-patients

OBJECTIVE

To examine factors associated with the number of psychiatric admissions per in-patient suicide and the suicide rate per 100,000 in-patient years in psychiatric hospitals.

METHOD

Random-effects meta-analysis was used to calculate pooled estimates, and meta-regression was used to examine between-sample heterogeneity.

RESULTS

Forty-four studies published between 1945 and 2013 reported a total of 7552 in-patient suicides. The pooled estimate of the number of admissions per suicide calculated using 39 studies reporting 150 independent samples was 676 (95% CI: 604-755). Recent studies tended to report higher numbers of admissions per suicide than earlier studies. The pooled estimate of suicide rates per 100,000 in-patient years calculated using 27 studies reporting 95 independent samples was 147 (95% CI: 138-156). Rates of suicide per 100,000 in-patient years tended to be higher in more recent samples, in samples from regions with a higher whole of population suicide rate, in samples from settings with a shorter average length of hospital stay and in studies using coronial records to define suicide.

CONCLUSION

Rates of in-patient suicide in psychiatric hospitals vary remarkably and are disturbingly high. Further research might clarify the extent to which patient factors and the characteristics of in-patient facilities contribute to the unacceptable mortality in psychiatric hospitals.

Relationship between lifetime suicide attempts and schizotypal traits in patients with schizophrenia

Patients with schizophrenia are at increased risk for suicide. Various risk factors for suicide have been reported in schizophrenia; however, few studies have examined the association between personality traits and suicidal behavior. We administered the Schizotypal Personality Questionnaire (SPQ) to 87 Japanese patients with schizophrenia (49 males; mean age 38.1±10.6 years) with and without a history of suicide attempts (SA and nSA groups, respectively), and 322 controls (158 males; mean age 40.8±13.9 years). As expected, an analysis of covariance (ANCOVA) controlling for age and sex showed that all SPQ indices (total SPQ score and all three factors, i.e., cognitive-perceptual, interpersonal, and disorganized) were significantly higher in patients with schizophrenia (SA+nSA groups), than controls (p<0.001 for all comparisons). Furthermore, there were significant differences in the total score and the interpersonal and disorganized factors between the SA and nSA groups (nSA<SA, p<0.01 for all comparisons). Receiver operating characteristic analysis showed that a total SPQ score of 33.5 was the optimal cut-off value to discriminate the SA group from the nSA group (χ²[1] = 10.6, p = 0.002, odds ratio: 4.7, 95% confidence interval: 1.8–12.1, sensitivity: 0.70, specificity: 0.67). These results suggest that high schizotypy is associated with lifetime suicide attempts, and that the total SPQ score might be useful to assess the risk of suicide attempt in patients with schizophrenia.

Characteristics of attempted suicide by patients with schizophrenia compared with those with mood disorders: a case-controlled study in northern Japan

Recent reports suggest a lifetime suicide risk for schizophrenia patients of approximately 5%. This figure is significantly higher than the general population suicide risk consequently, detection of those at risk is clinically important. This study was undertaken to define the characteristics of suicide attempts by schizophrenia patients compared with attempts by patients with mood disorders. All patients were diagnosed using the ICD-10 criteria. The study population comprised 65 patients with F2 disorders (schizophrenia, schizotypal and delusional disorders), i.e., “the F2 group”, and 94 patients with F3 disorders (mood disorders), i.e., “the F3 group”, who presented in the clinical setting of consultation-liaison psychiatry. The F2 group had a significantly younger mean age and significantly higher ratios of ‘past/present psychiatric treatment’ and ‘more than 3 months interruption of psychiatric treatment’. In contrast, the ratios of ‘physical disorder comorbidity’, ‘alcohol intake at suicide attempt’ and ‘suicide note left behind’ were significantly higher in the F3 group. The F2 group attempted suicide by significantly more serious methods. Furthermore, ‘hallucination-delusion’ was the most prevalent motive in the F2 group and was the only factor that showed a significant association with the seriousness of the method of suicide attempt (OR = 3.36, 95% CI: 1.05–11.33).

Preventing suicide among inpatients

OBJECTIVE

Inpatient suicide comprises a proportionately small but clinically important fraction of suicide. This study is intended as a qualitative analysis of the comprehensive English literature, highlighting what is known and what can be done to prevent inpatient suicide.

METHOD

A systematic search was conducted on the Cochrane Library, PubMed, Embase, Web of Knowledge, and a personal database for articles on cohort series, preferably controlled, of inpatient suicide (not deliberate self-harm or attempted suicide, unless they also dealt specifically with suicide data).

RESULTS

A qualitative discussion is presented, based on the findings of the literature searched.

CONCLUSIONS

The bulk of inpatient suicides actually occur not on the ward but off premises, when the patient was on leave or had absconded. Peaks occur shortly after admission and discharge. It is possible to reduce suicide risk on the ward by having a safe environment, optimizing patient visibility, supervising patients appropriately, careful assessment, awareness of and respect for suicide risk, good teamwork and communication, and adequate clinical treatment.

The relationship between depressive syndrome and suicidal risk in patients with acute schizophrenia

Aim

To determine the relationship between scores on five factors of the Positive and Negative Syndrome Scale (PANSS) and Calgary Depression scale for Schizophrenia (CDSS) and scores on the InterSePT Scale for Suicidal Thinking (ISST) in patients with acute schizophrenia.

Methods

Data were collected on sociodemographic and clinical characteristics of 180 drug-treated in-patients with acute schizophrenia. Their symptoms were assessed with PANSS, CDSS, and ISST and correlations between the scores were calculated. Statistically significant correlations were included in the logistic regression analysis to identify predictors of suicidal risk.

Results

CDSS (P < 0.001) score and negative (P < 0.001), disorganized (P = 0.041), emotional (P < 0.001), and total score on PANSS (P < 0.001) showed a significant positive correlation with ISST. Stepwise logistic regression analysis revealed that CDSS scores (odds ratio [OR] 5.18; confidence interval [CI] 1.58-16.95), and disorganized (0.90; 0.81-0.99) and emotional (1.15; 1.01-1.30) factors of PANSS were predictors of suicidal risk.

Conclusion

Our results suggested a considerable association between depressive syndrome as assessed by the PANSS emotional factor and CDSS score and suicidal risk in patients with acute schizophrenia.

Suicide mortality and risk factors in the 12 months after discharge from psychiatric inpatient care in Korea: 1989-2006

This study aimed to determine the suicide mortality within 1 year after discharge from psychiatric inpatient care and identify the risk factors for suicide completion during this period. A total of 8403 patients were admitted to general hospitals in Seoul, Korea, for psychiatric disorders from January 1989 to December 2006. The suicide mortality risk of these patients within 1 year of discharge was compared with that of gender- and age-matched subjects from the general population of Korea. The standardized mortality ratios (SMR) for suicide in the year following discharge were 49.7 for males and 45.5 for females. Patients aged 15-24 years had the highest risk for suicide. Among the different diagnostic groups, patients with personality disorders, schizophrenia, or affective disorders had the highest risk for suicide completion. Suicidal ideation at admission and inpatient stay more than 1 month were also associated with increased risk of suicide. In Korean psychiatric patients, the SMR is much higher in young female patients, a high percentage of patients commit suicide by jumping, and there is a stronger association of long duration of hospitalization and suicide. These factors should be considered in the development and implementation of suicide prevention strategies for Korean psychiatric patients.

Suicide attempt and suicidal ideation and their associations with demographic and clinical correlates and quality of life in Chinese schizophrenia patients

OBJECTIVES

This study aimed to examine the prevalence and correlates of lifetime suicide attempts and current suicidal ideation in community-dwelling schizophrenia patients in China.

METHOD

A sample of 540 schizophrenia patients was randomly selected in Beijing, China. All subjects were interviewed using standardized assessment instruments and their basic socio-demographic and clinical data including history of suicide attempts were collected.

RESULTS

The prevalence of lifetime suicide attempts and the point prevalence of suicidal ideation were 12.0%, and 21.1%, respectively. In multiple logistic regression analyses, the presence of lifetime suicide attempt was independently associated with rural residence, having major medical conditions and better social functioning, while higher likelihood of current suicidal ideation was associated with past suicide attempt, the severity of overall psychopathology and depressive symptoms and lower psychological quality of life (QOL).

CONCLUSION

Among Chinese outpatients with schizophrenia, increased current symptoms and poorer QOL were correlated with current suicidal ideation, while demographic factors and indicators of greater social support were mostly correlated with lifetime suicide attempts. This study may help to identify important subgroups of patients with schizophrenia at particularly high risk of suicidal behavior.

Suicide in recently admitted psychiatric in-patients: a case-control study

BACKGROUND

Around a quarter of in-patient suicides occur within the first week of admission to psychiatric in-patient care. Little is known on the factors associated with suicide during this critical time. We aimed to identify risk factors for suicide among in-patients within the first week of admission.

METHODS

A national population-based case-control study of 107 current psychiatric in-patients in England who died by suicide within a week of admission, matched on admission date with 107 living controls.

RESULTS

Forty-two (40%) suicide cases died within the first 3 day of admission. A fifth of all suicides were on authorised leave at the time of death, but 34% were off the ward without staff agreement compared to only 1% of controls. Independent risk factors for suicide included previous self-harm, recent adverse life events, and a short (<12 months) duration of illness.

LIMITATIONS

This is a retrospective study, using clinical data mainly collected from case records. Clinicians were not blind to case/control status.

CONCLUSIONS

The first few days of admission should be recognised as the period of highest risk. Careful risk evaluation is needed at this time, particularly in those with recent illness onset or previous suicide attempts. Knowledge of life events experienced before admission should be incorporated into risk assessments. Improvements to the ward environment to lessen the distress of an admission may be an important preventative measure. Protocols may require adapting to improve the safety of those on agreed leave, and prevent absconding through increased vigilance and closer observation of ward exits.

Clinical and neuropsychological aspects of non-fatal self-harm in schizophrenia

PURPOSE

To investigate demographic, clinical and neuropsychological aspects of self-harm in schizophrenia and identify which are independently predictive of and therefore the most relevant to clinical intervention.

SUBJECTS AND METHODS

Eighty-seven patients with schizophrenia were interviewed regarding substance misuse, depression, hopelessness, negative/positive symptoms and illness insight. Neuropsychological assessment included premorbid IQ, continuous performance test, cognitive-motor and trait impulsivity. A prospective three-month review of medical records was also undertaken.

RESULTS

Fifty-nine patients (68%) reported past self-harm (including attempted suicide). Those with past self-harm, compared to those without, were significantly more likely to report depression, hopelessness, impulsivity, a family history of self-harm, polysubstance abuse and had higher premorbid IQ. Logistic regression revealed that depression, higher premorbid IQ and polysubstance abuse were independently linked to self-harm. Five participants attempted self-harm during the 3-month prospective follow-up period. These all had a history of past self-harm and were significantly more likely to have been depressed at the initial interview than those who did not go on to self-harm.

DISCUSSION AND CONCLUSIONS

Independent predictors of self-harm in schizophrenia are premorbid IQ and polysubstance abuse. In addition, depression was both independently associated with past self-harm and predictive of self-harm in the follow-up period.

Suicides during 7 years among a catchment area cohort of patients with psychoses

OBJECTIVE

To investigate a series of consecutive suicides at a psychosis clinic by using a psychological autopsy technique.

METHOD

The clinic serves an adult population of 225,000 individuals, of whom 0.5% have regular contact with the clinic. During a 7½-year period, 23 men and nine women committed suicide, which corresponds to an odds ratio of 14.

RESULTS

Most patients were schizophrenic, and 24 were outpatients. Suicide methods were violent in all but two cases. Nineteen had a history of at least one suicide attempt, and 24 were known to have had suicidal ideation. More than half had no social contacts over the last year except with psychiatric staff. The median time between the last contact with the psychiatric services and the suicide was 4 days. No warning signs were noted. At the time of death, 3 of the 24 who were prescribed antipsychotics, and none of the 10 who were prescribed antidepressants had plasma levels of the corresponding drug.

CONCLUSION

Findings of special interest are the lack of forewarnings and the poor drug compliance. Patients appear to have played "business as usual" with the care-givers, and did it well. Is it a sign of health and despair, or illness?

Prospective study of risk factors for increased suicide ideation and behavior following recent discharge

OBJECTIVE

The purpose of this study is to prospectively examine the association between predictors from the three thematic areas - suicidality, personal risk factors and patient care factors - and the occurrence of postdischarge suicide ideation and behavior in recently discharged patients.

METHODS

The design is a prospective cohort study of all patients admitted to an inner city inpatient psychiatric service with a lifetime history of suicidal behavior and current suicidal ideation. Predictors of suicide ideation at 1, 3 and 6 months following discharge and suicide behavior over the 6 months of follow-up were examined.

RESULTS

The incidence of death by suicide during the study period was 3.3% [95% confidence interval (CI)=0.9%-8.3%], and 39.4% (95% CI=30.0%-49.5%) of the surviving participants reported self-injury or suicide attempts within 6 months of hospital discharge. Risk factors such as recent suicide attempts, levels of depression, hopelessness and impulsivity were predictive of increased suicide ideation or behavior after discharge from the inpatient service.

CONCLUSIONS

The high risk of suicide ideation, suicide attempts and suicide demonstrated in these recently discharged patients supports the need to develop selective prevention strategies.

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.

Comparison of characteristics of suicide attempters with schizophrenia spectrum disorders and those with mood disorders in Japan

Suicidality in patients with schizophrenia is high. To clarify the characteristics of suicidal behavior in patients with schizophrenia, we investigated suicide attempters with schizophrenia spectrum disorders in comparison with patients with mood disorders. One hundred patients with schizophrenia spectrum disorders and 155 patients with mood disorders admitted to an emergency department after a suicide attempt were interviewed in detail on items concerning 1) demographic characteristics, 2) previous suicidal behavior, and 3) index suicidal behavior. Differences between the two groups were subsequently analyzed. Patients with schizophrenia spectrum disorders showed a lower incidence of previous deliberate self-harm, and a higher incidence of a subsequent suicide attempt more than 1 year after the previous suicide attempt as well as a higher lethality of index suicide attempt compared to patients with mood disorders. Furthermore, the most common motive for making a suicide attempt in patients with schizophrenia spectrum disorders was having a mental problem. This study revealed the factors associated with suicide attempts among Japanese patients with schizophrenia spectrum disorders, and the nature of these factors makes it difficult to predict future attempts. This makes clear the importance of continuous long-term follow-up with careful attention to the mental symptoms and psychological burden for such patients.

Suicidality in first episode psychosis is associated with insight and negative beliefs about psychosis

INTRODUCTION

Suicidal behaviour is prevalent in psychotic disorders. Insight has been found to be associated with increased risk for suicidal behaviour, but not consistently. A possible explanation for this is that insight has different consequences for patients depending on their beliefs about psychosis. The present study investigated whether a relationship between insight, negative beliefs about psychosis and suicidality was mediated by depressive symptoms, and if negative beliefs about psychosis moderated the relationship between insight and suicidality in patients with a first episode of psychosis (FEP).

METHOD

One hundred ninety-four FEP-patients were assessed with a clinical interview for diagnosis, symptoms, functioning, substance use, suicidality, insight, and beliefs about psychosis.

RESULTS

Nearly 46% of the patients were currently suicidal. Depressive symptoms, having a schizophrenia spectrum disorder, insight, and beliefs about negative outcomes for psychosis were independently associated with current suicidality; contradicting a mediating effect of depressive symptoms. Negative beliefs about psychosis did not moderate the effect of insight on current suicidality.

CONCLUSION

The results indicate that more depressive symptoms, higher insight, and negative beliefs about psychosis increase the risk for suicidality in FEP-patients. The findings imply that monitoring insight should be part of assessing the suicide risk in patients with FEP, and that treating depression and counteracting negative beliefs about psychosis may possibly reduce the risk for suicidality.

Suicide inside: a systematic review of inpatient suicides

The literature on inpatient suicides was systematically reviewed. English, German, and Dutch articles were identified by means of the electronic databases PsycInfo, Cochrane, Medline, EMBASE psychiatry, CINAHL, and British Nursing Index. In total, 98 articles covering almost 15,000 suicides were reviewed and analyzed. Rates and demographic features connected to suicides varied substantially between articles, suggesting distinct subgroups of patients committing suicide (e.g., depressed vs. schizophrenic patients) with their own suicide determinants and patterns. Early in the admission is clearly a high-risk period for suicide, but risk declines more slowly for patients with schizophrenia. Suicide rates were found to be associated with admission numbers, and as expected, previous suicidal behavior was found to be a robust predictor of future suicide. The methods used for suicide are linked to availability of means. Timing and location of suicides seem to be associated with absence of support, supervision, and the presence of family conflict. Although there is a strong notion that suicides cluster in time, clear statistical evidence for this is lacking. For prevention of suicides, staff need to engage with patients' family problems, and reduce absconding without locking the door. Future research should take into account the heterogeneous subgroups of patients who commit suicide, with case-control studies addressing these separately.

Inpatient suicide: preventing a common sentinel event

OBJECTIVE

Suicide in the hospital is one of the most common types of sentinel events, and hospitals can (and should) take steps to decrease the likelihood of experiencing this type of crisis.

METHOD

MEDLINE, Cochrane Library, National Electronic Library for Mental Health, and PSYCHINFO searches were conducted. In addition, manual and phone queries were used to identify relevant empirical and clinical publications. Reference sections of published articles were also searched.

RESULTS

The current article discusses the rates of suicide in hospitals, related risk factors, methods of suicidal behavior, and factors which contribute to this tragic event. Environmental, patient care, staff training, and hospital policy recommendations for decreasing the number of inpatient suicides are presented.

CONCLUSION

Inpatient suicide is a traumatic event. Although it is a relatively rare occurrence that is often difficult to predict and prevent, continuing to refine our efforts to assist the population at risk is imperative.

Inpatient suicide in a general hospital

OBJECTIVES

This study aimed to compare the characteristics of psychiatric and nonpsychiatric suicidal inpatients in one general hospital and examine the predictors of completed suicide in the patients with suicidal acts during hospitalization.

METHODS

One hundred ten study subjects were identified by the adverse event reports of suicidal acts during hospitalization from 1995 to 2004. Demographic data and clinical information were collected by chart reviews.

RESULTS

Psychiatric inpatients with suicidal acts were mainly younger females with psychiatric diagnoses and previous suicide attempts. Nonpsychiatric suicidal inpatients had less suicide communication, performed suicidal acts more rapidly after admission and used more violent suicidal methods than the psychiatric inpatients did. Suicidal acts performed outside the hospital, use of violent suicidal methods and male gender increased the risk of suicide mortality in our suicidal inpatients.

CONCLUSION

This study suggests that suicide prevention efforts need to be tailored in psychiatric and nonpsychiatric wards according to differing patient risk characteristics in these patient cohorts.

Subjective experience and suicidal ideation in schizophrenia

Suicidal ideation and behavior are a frequent complication of schizophrenia. Although a number of risk factors have been identified, specific features of suicidality in schizophrenia remain poorly understood. In this study, 19 patients with schizophrenia were interviewed in depth on their suicidal ideation and intentions, followed by a qualitative phenomenological analysis of the material. Solitude with inability to participate in human interactions and feelings of inferiority were found to be the main sources of suicidal ideation. These experiences seem to resemble ordinary depressive reactions, yet we found them to be reflective of a more basic self-alienation and incapacity for immersion in the shared world. Ignoring this experiential level of patients' disturbances may lead to trivialization (and misjudgment) of the experiences at the root of suicidality in schizophrenia.

Inpatient suicide in a Chinese psychiatric hospital

Little is known about the risk factors for suicide among psychiatric inpatients in China. In this study we identified the risk factors of suicide among psychiatric inpatients at Guangzhou Psychiatric Hospital. All psychiatric inpatients who died by suicide during the 1956-2005 period were included in this study. Using a case-control design, 64 inpatients with schizophrenia who died by suicide were compared with a matched 64 controls. The results indicate that the rate of suicide was 133.1/100,000 admissions (95%CI 103.4-162.9). There were no significant differences in the method, location, or time of suicide between male and female inpatients. The number of hospitalizations was significantly larger in the suicide group than that in the control group. In logistic regression analyses, guilty thought, depressive mood, and suicidal ideation and suicide attempt 1 month before hospital admission were identified as independent predictors of suicide among inpatients with schizophrenia. The findings of risk factors for schizophrenic inpatient suicide should be taken into account when developing interventions to prevent suicide among these patients.

Suicide attempts of schizophrenia patients: a case-controlled study in tertiary care

BACKGROUND

Schizophrenia is one of the disorders in which suicide attempts and death by suicide are pronounced. However, there is paucity of data regarding suicide attempts by schizophrenia patients. The aim of the present study was to characterize a large sample of schizophrenia patients in tertiary care who had attempted suicide.

METHOD

Over a 15-year period all computerized records of admissions of adult schizophrenia patients were examined. Patients who had attempted suicide were defined as the index group and the comparison group was comprised of the next admission of a patient suffering from schizophrenia who did not attempt suicide prior to hospitalization.

RESULTS

There were 10,006 admissions of patients suffering from schizophrenia during the study period. Of these, 1094 (10.9%) records comprise the index group (patients who had attempted suicide), 380 women and 714 men, mean age for the group 39.6+/-12.9 years. The comparison group of patients matched for diagnosis (N=1094), consisted of 302 women and 792 men, mean age for this group was 42.9+/-13.7 years. Four variables significantly differentiated between groups. Patients who had attempted suicide were younger (39.6 vs. 42.9 years; p=0.00), higher percentage of females (34.7% vs. 27.6%; p=0.00), with increased rates of co-morbid physical illness (27.5% vs. 20.4%; p=0.00) notably cardiovascular and diabetes and with a higher rate of alcohol and drug abuse (32.1% vs. 12.4%; p=0.00).

CONCLUSIONS

The present study emphasizes several significant factors associated with attempted suicide amongst schizophrenia patients notably physical co-morbidity and abuse of alcohol and drugs. These need be integrated into existing risk assessment schemes thus aiding in decreasing adverse outcomes in this vulnerable group of patients.

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.

Review of predictors of suicide within 1 year of discharge from a psychiatric hospital

Previous research has shown that suicide risk is highest in the year after people have been discharged from a psychiatric hospital. As such, identifying predictors of suicide within this time frame is important. Results from a systematic database search showed that all significant suicide predictors--those found in more than one study--could be grouped into factors related to suicidality, patient care factors, and demographic and psychopathological factors. Increased knowledge of suicide predictors for this particularly high-risk time, identified in this review, can help inform prevention and intervention efforts that may significantly reduce suicide rates.

Suicide in schizophrenia: findings from a national clinical survey

BACKGROUND

A reduction in suicide among individuals with mental illness is an international public-health priority. Approximately 10% of patients with schizophrenia will die by suicide.

OBJECTIVE

The goal of this study was to describe social and clinical characteristics of people with schizophrenia who completed suicide, including aspects of the clinical care they received.

METHOD

A national clinical survey was conducted based on a 4-year (1996-2000) sample of people in England and Wales who had died by suicide and had been in contact with mental health services in the previous 12 months.

RESULTS

Of 20,927 individuals who committed suicide, 5,099 (24%) were known to have been in contact with mental health services in the year prior to death. Completed questionnaires were returned on 4,859 cases of suicide. Of these, 960 (20%) were diagnosed with schizophrenia. These suicides were characterized by more violent modes of death, with over a quarter (27%) jumping from a height or in front of a moving vehicle compared to 10% of the remaining sample. They were more likely than the other individuals in the sample to be young, male, unmarried, and from an ethnic minority with high rates of unemployment. Rates of previous violence and drug abuse were high and they were proportionally more likely to be inpatients at the time of death and to have been noncompliant with medication. Patients with schizophrenia and comorbid substance abuse showed particularly complex social and clinical morbidity.

CONCLUSIONS

Measures that may prevent suicide among patients with schizophrenia include improved ward safety, closer supervision in both inpatient and community settings, particularly for those with poor medication compliance, and effective treatment of substance abuse.

Suicide in mental health in-patients and within 3 months of discharge. National clinical survey

BACKGROUND

Suicide prevention is a health service priority. Suicide risk may be greatest during psychiatric in-patient admission and following discharge.

AIMS

To describe the social and clinical characteristics of a comprehensive sample of in-patient and post-discharge cases of suicide.

METHOD

A national clinical survey based on a 4-year (1996-2000) sample of cases of suicide in England and Wales who had been in recent contact with mental health services (n=4859).

RESULTS

There were 754 (16%) current in-patients and a further 1100 (23%) had been discharged from psychiatric in-patient care less than 3 months before death. Nearly a quarter of the in-patient deaths occurred within the first 7 days of admission; 236 (31%) occurred on the ward, the majority by hanging. Post-discharge suicide was most frequent in the first 2 weeks after leaving hospital; the highest number occurred on the first day.

CONCLUSIONS

Suicide might be prevented among in-patients by improving ward design and removing fixtures that can be used in hanging. Prevention of suicide after discharge requires early community follow-up and closer supervision of high-risk patients.

Where schizophrenic patients commit suicide: a review of suicide among inpatients and former inpatients

OBJECTIVE

To review the literature on suicide of inpatients with schizophrenia, to identify suicide risk factors as well as typical patterns of behavior and to suggest a rationale and strategies for future interventions.

METHOD

A computerized MedLine, Excerpta Medica and PsycLit search supplemented by an examination of cross-references and reviews.

RESULTS

Up to half the suicides among patients with schizophrenia occur during inpatient admission. Inpatient suicides were found among those of a young age group who were predominantly single, childless and socially isolated. The vast majority experienced an illness characterized by long duration and prolonged psychiatric hospitalizations or multiple admissions and discharges. Up to 50% of the suicides occurred in the first few weeks and months following discharge from the hospital. The paranoid subtype of schizophrenia, where positive symptoms prevail and negative symptoms are few, is associated with a suicide risk that is three times greater than that associated with nonparanoid subtypes and eight times greater than the risk associated with the deficit subtype.

CONCLUSIONS

Treatment of suicide is a major problem among inpatients with schizophrenia. Evidence suggests that suicide is generally carried-out by patients who have been recently discharged or by those who manage to get away from the hospital. Strategies aimed at preventing this phenomenon have been introduced to the medical personnel, but suicide in these patients does not seem to have been reduced. We emphasize the need to establish guidelines for the prevention of suicide in hospitalized patients with schizophrenia.

Early insight predicts depression and attempted suicide after 4 years in first-episode schizophrenia and schizophreniform disorder

OBJECTIVE

To map the development of insight in the 4 years after presentation with first-episode schizophrenia and schizophreniform disorder and to determine the effects of evolving insight on depression and the likelihood of attempted suicide.

METHOD

We assessed 101 individuals at presentation, 6 months and 4 years. We measured insight, including recognition of mental illness, recognition of need for treatment and ability to relabel psychotic symptoms. We measured depression and recorded all suicide attempts.

RESULTS

Insight improved with time. Recognition of mental illness at 6 months predicted depression and attempted suicide at 4 years.

CONCLUSION

Six months after presentation, the greater the acknowledgement by people that they had a mental illness, the more depressed they were at 4 years and the greater the likelihood that they would attempt suicide by 4 years. This may have implications for disclosure of diagnosis.

A case-control study of 92 cases of in-patient suicides

BACKGROUND

A significant number of patients committed suicide while receiving in-patient treatment in psychiatric hospitals. Most previous studies on psychiatric in-patient suicides were conducted in the West. This study aimed to describe the characteristics and identify risk factors of suicides occurring during psychiatric in-patient care in Hong Kong.

METHOD

The case record data of suicide cases (Coroner's verdicts of suicides and undetermined deaths) from all public psychiatric hospitals in the entire region within a 3 years' period (N=93) were compared with matched controls.

RESULTS

In-patient suicide rate was 269/100,000 admissions. Majority had schizophrenia. Suicide usually occurred after the first month of admission, during leave, and by jump from heights. There were little case-control differences in treatment received. Multiple conditional logistic regression found 5 risk factors: previous history of deliberate self-harm (OR=4.60, 95% CI=1.57-13.5); admitted because of suicidal behaviour (OR=3.92, 95% CI=1.3-11.9); depressive symptoms at time of suicide (OR=8.53, 95% CI=1.4-52); away without leave at anytime during index admission (OR=17, 95% CI=1.76-163); and extrapyramidal side effects/akathisia at time of suicide (OR=10.8, 95% CI=1.75-66.7).

LIMITATIONS

Retrospective case record review depended on non-standardized and variable quality of case notes entry. Matching for hospitals in this study would make the comparison between hospitals impossible. Although this is the second largest case-control study of psychiatric in-patient suicide, the estimated power suggested subtle risk factors would be missed.

CONCLUSION

Majority of in-patient suicides occurred at a time of perceived low risk. A high sensitivity to the risk of suicide and vigorous treatment of depressive symptoms were indicated. The care processes during the index admission could bear strong influences on the risk of in-patient suicides.

Schizophrenia and suicide: systematic review of risk factors

BACKGROUND

Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important.

AIMS

To identify risk factors for suicide in schizophrenia.

METHOD

The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts.

RESULTS

Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71).

CONCLUSIONS

Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.

Suicide attempts in schizophrenia and affective disorders with relation to some specific demographical and clinical characteristics

Demographical and clinical characteristics have been reported to modulate the risk for suicide. This study analysed demographical and clinical characteristics with respect to lifetime suicide attempts in 500 individuals affected with schizophrenic or affective disorders. Suicide attempts were associated with poor premorbid social adjustment, low age at onset, low scores on the "Global Assessment Scale" and childlessness in females.

Suicide and awareness of illness in schizophrenia: an overview

Suicide is the first cause of premature death in patients with schizophrenia. Numerous studies have identified risk factors for suicide among these patients. This study reviews available literature focusing on awareness of illness in patients with schizophrenia. Insight, or awareness of illness, has been considered a risk factor for suicide in schizophrenic patients. In assessing insight, many issues have to be taken into account, because a high degree of insight is not desirable in some conditions.

Lifetime psychiatric symptoms in persons with schizophrenia who died by suicide compared to other means of death

The focus of this report is to compare the psychiatric symptomatology of individuals with schizophrenia who have died by suicide to those who have died by other means of death. This study includes individuals with a diagnosis of schizophrenia whose families donated their brain tissue to the Maryland Brain Collection between September 1989 and August 1998. The psychological autopsy method was used to assess the deceased individual's demographic and clinical characteristics, psychiatric symptoms and history of suicidal thoughts and attempts. Ninety-seven individuals with schizophrenia were identified for this study. Fifteen had committed suicide, while the remaining 82 died from other causes. Thoughts of suicide and previous suicide attempts were more frequent among the group that died from suicide (93% compared to 26%) (p < 0.0001). Suicide victims had a higher rate of depressive symptoms and were twice as likely to have a depressed mood. The incidence of thoughts of dying was 60% compared to 20% in those who did not commit suicide (p = 0.002). Loss of interest was reported to occur in 20% in the suicide group compared to 4% in the group of individuals that died from other causes (p = 0.05). Victims of suicide also had higher rates of positive symptoms throughout their lifetime including thought control, flight of ideas, and loose associations. Suicide is one of the leading cause of premature death in individuals with schizophrenia and identification of risk factors is of great importance. Individuals who die by suicide experience higher rates of depressive symptoms, suicidal thoughts and positive symptoms during their life.

Slovenia: difficulties and strengths of psychiatric research in a small country

With a population of nearly 2 000 000 and an area of about 20 000 km2, Slovenia is a heterogeneous European country that extends from the Mediterranean Sea to the Alps. Slovenian political history dates back to the 6th century, when the first free principality of the ancient Slovenians was established – Caranthania – famous for its democratic institutions, legal system, popular elections of dukes and progressive legal rights for women. From the 13th century until 1918, Slovenians were ruled by the Habsburgs. After 1918, Slovenia became a part of Yugoslavia and again enjoyed a considerable degree of autonomy. But as the political and economic crisis of Yugoslavia worsened, at the plebiscite in December 1990 87% of the voting population voted in favour of sovereignty. Thus, Slovenia declared its independence on 25 June 1991, and became a member of the United Nations in May 1992. Until the Second World War the psychiatric tradition in Slovenia was German. Afterwards, the Anglo-Saxon tradition has gradually entered Slovene psychiatry.

Evidence-based prevention strategies of suicide behavior in the world: implications for Slovenia

In this review we consider how Slovenia could consider tackling its high rate of suicide (overall 29 per 100,000, 46 in males, 13 in females). First, we consider the evidence for risk factors that may contribute to Slovenia's high rate of suicide. Second, we describe the interventions to try to reduce the impact of these factors and the evidence for such interventions. We categorize interventions in terms of their operation at either the population level or that of high-risk groups. However, it should be borne in mind that settings often assumed to provide access to population groups, such as general practice and schools, do not reach some people who are likely to be at high risk; for example those who have dropped out of school or who have been excluded from a GP's list. We focus particularly on those for high-risk groups, as a number of East-European countries with high suicide rates such as Slovenia, Hungary, and the Baltic republics are currently considering a shift toward more community-based mental health services. The provision of community mental health services in Slovenia would provide an opportunity to study their impact on the suicide rate. However, we conclude that their development should be accompanied by other initiatives operating at population levels. This multilevel approach acknowledges the complexity of the etiology of suicide, the impossibility of reaching all those at risk through services and the lack of strong evidence for any one intervention.

Suicidal behaviour of psychiatric in-patients

OBJECTIVE

The study aimed to examine suicidal behaviour before and during in-patient care in a psychiatric state hospital.

METHOD

Based upon a psychiatric basic documentation system prevalence and risk factors of in-patient suicides, suicide attempts and suicidal thoughts were investigated over an 11-year period from 1989 until 1999.

RESULTS

A total of 30 in-patient suicides were found among 21 062 patients. According to the multivariate logistic regression analysis the risk of hospital suicide increases for patients with schizophrenia, higher cumulative length of stay, previous suicide attempt, part-time employment and training/retraining. Predictors of suicide attempt during hospitalization are suicide attempt on admission, personality disorder, suicidal thoughts on admission, schizophrenia and affective disorder.

CONCLUSION

As Schizophrenics represent the high-risk group of in-patient suicide, suicide prevention should be a major goal in their treatment. More frequent suicide risk assessment is recommended particularly before granting a leave or an outing.

Psychological vulnerability to completed suicide: a review of empirical studies

Retrospective research shows that close to 90 percent of suicides have a diagnosable psychiatric disorder; however, only a small proportion of individuals with psychopathology take their own lives. This article reviews the empirical literature on psychological vulnerability to completed suicide. A search of the MEDLINE and PsycINFO databases yielded 46 cohort or case-control studies that used standardized or structured assessments of psychological dimensions. Five constructs have been consistently associated with completed suicide: impulsivity/aggression, depression, anxiety, hopelessness, and self-consciousness/social disengagement. Current knowledge of psychological vulnerability to completed suicide could inform social and neurobiological research, and thereby deepen understanding of suicide while potentially bridging these areas of study.