Prevention of suicide: aspirations and evidence

Proximal characteristics of suicide attempts: a study in a public hospital in Spain

INTRODUCTION

Different parameters of suicide attempts treated since the implementation of the Attention to Suicide Risk Program (ARSUIC) in 2012 at the Hospital Ramón y Cajal in Madrid Region are described in this paper.

METHOD

The sample was composed of 107 patients and the information was collected through a questionnaire created ad hoc with the following variables: type of suicidal ideation; drug use immediately prior to the attempt; method (in case of drug overdosing: drug/s used); location; accessibility to rescue; planning; intentionality; criticism; and brakes.

RESULTS

Descriptive statistics were obtained and a comparison by gender was made through the χ2 and contingency coefficients tests. The data from the retrospective longitudinal study showed that the most common profile was of patients with unstructured ideas of death and no previous drug use who took an unplanned drug overdose in the family home, with the intention of self-harm or avoidance of discomfort, especially with benzodiazepines. Patients tend to ask for help afterwards and criticise the attempt, but potential restraints are often not recorded in the clinical report. Regarding the dissimilarities based on gender, statistically significant differences were found in prior alcohol consumption, in favour of men and in the overdose method, specifically with benzodiazepines, in favour of women.

CONCLUSIONS

Knowing the types of attempts at self-harm is essential for improving prevention, understanding and patient management.

Dying by Suicide in Nursing Homes: A Preventable End of Life Outcome for Older Residents

Suicide research and suicide prevention have given comparatively little attention to the older adult residents of nursing homes. This population is characterized by advanced age, significant infirmity, limited autonomy and social connections, and other factors associated with high suicide risk such as self-neglect. However, little is known of the actual incidence and prevalence of suicide in older adults in such residential care settings, partly because of how such deaths are reported. Suicide risk screenings are nominal, facility staff lack training to identify signs of suicidality, and suicide prevention programs are not common in the nursing home industry. These deficits can be remedied by increasing awareness among family members, facility caregivers, contracted providers, community aging services, accrediting and regulatory agencies, and residents.

Associations between social fragmentation, socioeconomic deprivation and suicide risk across 1887 municipalities in Japan, 2009-2017: a spatial analysis using the Bayesian hierarchical model

OBJECTIVE

Previous studies have indicated that spatial variation in suicide mortality is associated with area-specific socioeconomic characteristics, such as socioeconomic deprivation and social fragmentation. However, most of these studies have been conducted in the West and findings from Asian countries are limited. This study aims to investigate associations between socioeconomic characteristics and suicide mortality rates across 1887 municipalities in Japan between 2009 and 2017. We also assessed these associations by gender and age group.

METHODS

Suicide data were obtained from the suicide statistics of the Ministry of Health, Labour and Welfare in Japan and included information on the number of suicides by gender, age and municipality location. Social fragmentation, socioeconomic deprivation and urbanicity were used as socioeconomic characteristics in this study and were created from survey data obtained from the 2010 census. Bayesian hierarchical models were used to examine associations between socioeconomic characteristics and suicide risk.

RESULTS

Suicide rates were significantly higher in municipalities with higher levels of deprivation, with a rate ratio of 1.13 (95% credible interval: 1.10 to 1.17) in the highest quartile compared with the lowest. Higher levels of urbanicity had significantly lower suicide rates, with a rate ratio of 0.79 (95% credible interval: 0.77 to 0.82) in the highest quartile compared with the lowest. However, associations between exposures and suicide varied considerably by gender and age. Among both men and women aged 0-39 years, fragmentation was significantly associated with suicide, with rate ratios of 1.07 and 1.15 for men and women, respectively, in the highest quartile compared with the lowest.

CONCLUSION

Suicide prevention in Japan should particularly focus on areas with high levels of deprivation or low levels of urbanicity. Furthermore, young Japanese people residing in the most fragmented municipalities were also at high risk of suicide, and appropriate measures need to be taken.

Problems with Suicidal Behavior Prevention in Adolescents: a Narrative Literature Review

BACKGROUND

Among the existing issues related to the health and quality of life of Russian adolescents, suicidal behavior is being actively discussed; however, the available comprehensive measures for prevention of suicide and attempts at suicide at this age do not provide an adequate solution. This is due to the fact that suicide is an integrative phenomenon, and the act of suicide itself is interpreted, in essence, as the "tip of the iceberg". What is especially clearly manifested in adolescence is the fact that the readiness to commit suicide is associated not so much with the level of severity of mental pathology and personality dysfunction, but with the general social context lack of well-being of total trouble. Therefore, suicide prevention cannot be based purely on the timely identification of persons at risk for mental pathology.

AIM

The purpose of this work is to analyze the available literature on current approaches that have demonstrated their efficacy in reducing suicidal behavior in adolescents.

METHODS

The authors performed a narrative review of the relevant literature published between 2012 and 2021. They analyzed the works presented in the PubMed, MEDLINE, and Web of Science electronic databases. Descriptive analysis was used to generalize the data obtained.

RESULTS

The article discusses preventive approaches to suicidal behavior in adolescents, which are most often studied, and which are also used in practical healthcare. It outlines the problems associated with the implementation and evaluation of the efficacy of these preventive programs.

CONCLUSIONS

The continuing high rate of suicide among adolescents calls for an urgent concerted effort to develop, disseminate, and implement more effective prevention strategies. School-based approaches are the most convenient in practical terms, but they require systematic and long-term use of anti-suicidal programs. Digital interventions can reduce the economic burden of their use, including assessing suicidal risk and identifying psychopathology associated with suicidality.

Sensitivity is the dimension of temperament most associated with the progression from ideation to suicide attempts

BACKGROUND

To analyze the association between temperament (emotional and affective) and scrutinize the progression from suicide ideation to attempt, by using data from a large internet-based sample.

METHODS

It is a cross-sectional study, based on the Brazilian Internet Study on Temperament and Psychopathology (BRAINSTEP). Temperament was assessed by the Affective and Emotional Composite Temperament Scale (AFECTS), and life-long suicidal behavior was determined by the adapted Suicidal Behaviors Questionnaire (SBQ-17). Odds ratios were obtained through multivariate logistic regression and a multiple linear regression were used in the analysis. According to the "ideation-to-action framework", we performed analyzes using two different reference groups: no suicidal ideation and suicidal ideation.

RESULTS

The affective temperaments that showed the greatest association with suicide attempts were depressive, cyclothymic, and volatile. The temperaments that reflected higher associations for progression from ideation to suicide attempt were cyclothymic, depressive, and euphoric. Sensitivity was manifested as the emotional temperament with the strongest positive association with the severity of suicidal behavior, followed by desire and control. Stability was estimated as the emotional trait with the strongest negative association with the severity of suicidal behavior.

LIMITATIONS

It is not a population based sample. BRAINSTEP is a self-selected sample whose participants are mostly women, who are highly educated and young.

CONCLUSIONS

Our results suggest that temperament assessment using AFECT model may be relevant to assess the risk for the progression from ideation to suicide attempts. These results strengthen the "ideation-to-action" framework that risk factors to suicide ideators can differ from suicide attempters.

Suicidality risk among adults with binge-eating disorder

OBJECTIVE

To estimate relative suicidality risk associated with binge-eating disorder (BED).

METHODS

Retrospective study of patients identified as having BED (N = 1042) and a matched general population cohort (N = 10,420) from the Optum electronic health record database between January 2009 and September 2015. Patients had ≥1 outpatient encounter with a provider who recognized BED during the 12-month baseline preceding entry date. Incidence and relative risk of suicidality were assessed.

RESULTS

Incidence per 1000 person-years (95% CI) of suicidal ideation and suicide attempts, respectively, was 31.1 (23.1, 41.0) and 12.7 (7.9, 19.4) in the BED cohort and 5.8 (4.7, 7.1) and 1.4 (0.9, 2.2) in the comparator cohort. Risk of suicidal ideation and suicide attempts was greater in the BED cohort (HR [95% CIs], 6.43 [4.42, 9.37]) than in the comparator cohort (HR [95% CI], 9.47 [4.99, 17.98]) during follow-up. After adjusting for psychiatric comorbidities, associations of suicidal ideation and suicide attempts with BED remained elevated in patients with BED having histories of suicidality.

CONCLUSIONS

Findings suggest that history of suicidality may result in an increased risk of suicidal ideation and suicide attempts in patients with BED relative to the general population. Psychiatric comorbidity burden may explain the elevated risk of these conditions in BED.

Smartphone Applications for Mindfulness Interventions with Suicidality in Asian Older Adults: A Literature Review

Elderly suicide is a rising concern. Despite the advent of mobile technology, there remained a gap in the evidence base as to whether smartphone applications could be used for mindfulness intervention for suicidality in Asian older adults. This paper aimed to review recent research relevant to smartphone applications that could be used in providing mindfulness interventions for suicidality to Asian older adults. The inclusion criteria for this review were papers published in peer-reviewed journals from 2008 to 2018 with the usage of specific search terms, namely, ‘smartphone application’, ‘mobile application’, and ‘mindfulness’, assessed against the inclusion criteria and screened by an experienced Asian clinician to be of clinical utility for mindfulness intervention for suicidality with Asian older adults. Initial search on databases yielded 236 results. A total of 35 full text papers that fit the inclusion criteria were assessed for eligibility and 10 papers were included in the current review. This review highlighted the paucity of rigorous empirically validated research into effective smartphone applications that can be used for mindfulness interventions for suicidality with Asian older adults.

A systematic analysis of online broadcasts of suicidality in China

INTRODUCTION

This study attempts to analyze the epidemiological characteristics of online broadcasts of suicidality in China.

METHODS

A total of 193 incidents were identified by systematically searching for relevant news reports on the internet. A content analysis on these news reports was conducted to obtain information on the characteristics of each individual incident.

RESULTS

Of these incidents, the ratio of males to females was 1:1.7 (age: 24.6 ± 6.1 years old). Approximately 45.4% and 70.8% of incidents were located in the region of Eastern China and Southern China, respectively, and 15.7% of incidents were unemployed. The most common suicide method was wrist cutting (57.5%), and the most common suicide location was at home (35.2%). Instant messaging apps (52.8%) were most frequently used for broadcasting suicidal thoughts and actions. Relationship breakup (61.1%) was reported as the leading cause of suicide. Furthermore, of the 193 incidents, 19 indicated that they suffered from a mental disorder, and 12 revealed that they had a history of suicide attempts. There were significant gender, age, regional, and occupational differences across the categories.

DISCUSSION

This study indicates that in China, suicide prevention programmes need to target internet users.

School-based gatekeeper training programmes in enhancing gatekeepers' cognitions and behaviours for adolescent suicide prevention: a systematic review

Suicide is a leading cause of death in adolescence. School provides an effective avenue both for reaching adolescents and for gatekeeper training. This enables gatekeepers to recognize and respond to at-risk students and is a meaningful focus for the provision of suicide prevention. This study provides the first systematic review on the effectiveness of school-based gatekeeper training in enhancing gatekeeper-related outcomes. A total of 815 studies were identified through four databases (Ovid Medline, Embase, PsycINFO and ERIC) using three groups of keywords: 'school based', 'Suicide prevention programme' and 'Gatekeeper'. Fourteen of these studies were found to be adequate for inclusion in this systematic review. The improvement in gatekeepers' knowledge; attitudes; self-efficacy; skills; and likelihood to intervene were found in most of the included studies. Evidence of achieving improvement in attitudes and gatekeeper behaviour was mixed. Most included studies were methodologically weak. Gatekeeper training appears to have the potential to change participants' knowledge and skills in suicide prevention, but more studies of better quality are needed to determine its effectiveness in changing gatekeepers' attitudes. There is also an urgent need to investigate how best improvements in knowledge and skills can be translated into behavioural change.

Against a high-risk strategy in the prevention of suicide

Standard approaches to the prevention of suicide have concentrated on the rigorous assessment and management of suicidal risk. Using deliberate self-harm as a specific example, we discuss the relative merits of this ‘high-risk’ strategy and compare it with a population-based preventive strategy. We conclude that a combined approach offers the best hope for reducing the rate of suicide, although it may not fit easily with medical models of care.

Antidepressant prescribing prior to suicide: role of doctors

The pharmacological treatment of depression and the time elapsed since last seen by a doctor were investigated among 507 adults who subsequently killed themselves. The proportion of people consulting a general practitioner or psychiatrist prior to suicide was lower than reported by the British government in the Health of the Nation document. General practitioners prescribed relatively low doses of antidepressants. Nineteen out of the 115 people receiving antidepressants used the drugs to kill themselves. Our findings emphasise the importance of prescribing adequate doses of antidepressants and underline the need for safer prescribing.

Coping with a coroner's inquest: a psychiatrist's guide

During the period 2000–2004 the average annual suicide rate in England and Wales was 10.2 deaths per 100 000 population over 10 years of age. About a quarter of those who take their own lives are in contact with mental health services in the year before their death. This means that an average in-patient, sector or community psychiatrist is likely to experience the death of at least one patient by suicide in most years. Suicides by patients cause considerable distress for the psychiatrist that is unlikely to resolve until after the coroner's hearing. This article discusses suicide prevention and provides guidance for psychiatrists on preparing for a coroner's inquest following a patient's death that may have been by suicide.

Evaluating risks

Mistakes are inevitable in any branch of medicine, but psychiatry is a particularly risky business (Holloway, 1997). When psychiatrists get it wrong there may serious consequences for their patients, the clinical team and the wider public. The Government introduced a series of initiatives in the 1990s: the Care Programme Approach (1990), the supervision register (Department of Health & Home Office, 1994) and supervised discharge (Secretary of State for Health, 1997). One of the main purposes of this legislation was to minimise the risk psychiatric patients pose to the community. Future service provision will be shaped by clinical governance and the National Service Framework for Mental Health (Secretary of State for Health, 1997), and evaluation and management of risk will become increasingly important.

Psychodynamics of self-directed destructive behaviour in adolescence

The Government white paper ‘Health of the Nation’ set a target for reduction of suicide rates by 15% by the year 2000. Although the document did not make specific reference to adolescence, it is no less important an issue in this age group than in adulthood since, along with accidental death and malignancy, suicide is one of the most common causes of death in late adolescence and early adulthood and there is an upward trend (Diekstra, 1993; McClure, 1994; Diekstra et al, 1995). How the reduction should be achieved is not clear, since suicide is a rare event which is the culmination of complex processes, and present knowledge does not give a firm foundation for evidence-based practice (Gunnell & Frankel, 1994).

A survey of admissions following self-poisoning

Aims and Method

Patients who self-poison are at increased risk of future self-poisoning and early death. Admission patterns and effective treatment strategies are unclear although psychosocial assessment may reduce readmissions. This study aimed to determine admission patterns and the proportion of patients receiving a psychiatric assessment in 4220 consecutive admissions.

Results

The average age was 34 years (s.d.=13, range 13–94); most were female (56 v. 44%, P<50.001). Twelve per cent of patients were aged 13–18 years, again the majority were female (70 v. 30%, P<50.001). Twenty per cent of patients had multiple admissions, accounting for 42% of the total admissions. There were slightly more admissions per day at the weekend (Friday, Saturday and Sunday; P<0.002). As many as 245 patients were either not referred or ‘self-discharged’ before they were assessed by the liaison psychiatry service.

Clinical Implications

These findings may help target medical resources, suggesting that consistent numbers of staff are required during all days of the week.

Establishing a clinical database for hospital attendances because of self-harm

Self-harm is a major risk factor for suicide (Gunnell & Frankel, 1994) with around a quarter of suicides preceded by non-fatal self-harm in the previous year (Owens & House, 1994). Strategies for suicide prevention should include accurate monitoring of health service contacts due to self-harm. Unfortunately, the published literature points to few practical steps for ensuring this accuracy. We offer an account of running a database, to assist others who might be setting out on this monitoring process.

Full metal jacket or the emperor's new clothes?

Launched with little more than a whimper during the Labour Party Conference the much vaunted National Service Framework for Mental Health (NSF–MH) outlines the Government's ‘ambitious agenda’ for mental health services (Department of Health, 1999a). The official driving force has been the desire to deliver a quality service throughout the whole NHS via clinical governance and underpinned by professional self-regulation. Developed following widespread consultation and with the advice of the External Reference Group (although some of this advice was clearly disregarded), the NSF–MH provides a series of seven core standards with examples of good practice. Although developed with general psychiatry and severe mental illness in mind, the NSF is not quite the ‘National Schizophrenia Framework’ that some envisaged, since it also acknowledges the needs of young people and the influence of developmental factors on adult mental health. The NSF–MH sets standards in five areas: mental health promotion, primary care and access to services, services for the severely mentally ill, caring about carers and preventing suicide. It is only the second to be published (the other being for coronary care) which is hopefully a reflection of the ‘priority’ once more being given to mental health. However, the near-simultaneous appointment of a cancer ‘tsar’ suggests that ‘priority’ is a readily used and easily diluted term.

Suicide by pesticide poisoning remains a priority for suicide prevention in China: Analysis of national mortality trends 2006-2013

BACKGROUND

Despite recent declines, suicide remains a priority for China. Ease of availability of high-lethality suicide methods, such as pesticides and firearms, contributes to the overall incidence and is an important target for suicide prevention. This study investigates whether changes in the distribution of methods of suicide have contributed to the recent reduction in suicide in China.

METHOD

Suicide rates (2006-2013) were calculated using the Chinese Disease Surveillance Points system, stratified by gender, age group, and urban-rural residence, to investigate trends in suicide over the study period. Multilevel negative binomial regression models were used to investigate associations between socio-demographic factors and method-specific suicide.

RESULTS

The most common method of suicide in China for both males and females was pesticide poisoning, followed by hanging. All methods declined over the study period, with the exception of suicide by jumping in males. Suicide rates for pesticide poisoning and for hanging increased exponentially with age in those aged over ≥45 years in both sexes. Pesticide poisoning declined from 55% to 49% of all suicides, while hanging increased from 27% to 31%.

LIMITATIONS

This was an ecological study of a time series of suicide rates, with risk factor adjustment being limited to population-level point estimates derived from a single census.

CONCLUSIONS

Suicide by pesticide poisoning and hanging remain the leading methods of suicide in China. Changes to the safe use of pesticides and targeted prevention initiatives to restrict access, along with socio-economic development and urbanisation, are likely contributors to declines in suicide by pesticide poisoning.

Postcards in Persia: A Twelve to Twenty-four Month Follow-up of a Randomized Controlled Trial for Hospital-Treated Deliberate Self-Poisoning

This study reports the outcomes, during follow-up, of a low-cost postcard intervention in a Randomized Control Trial of hospital-treated self-poisoning (n = 2300). The intervention was 9 postcards over 12 months (plus usual treatment) versus usual treatment. Three binary endpoints at 12-24 months (n = 2001) were: any suicidal ideation, suicide attempt, or self-cutting. There was a significant reduction in any suicidal ideation (RRR 0.20 CI 95% 0.13-0.27), (NNT 8, 6-13), and any suicide attempt (RRR 0.31, 0.06-0.50), (NNT 35, 19-195), in this non-western population. However, there was no effect on self-cutting (RRR -0.01, -1.05-0.51). Sustained, brief contact by mail may reduce some forms of suicidal behavior in self-poisoning patients during the post intervention phase.

Association between Suicide Ideation and Attempts and Being an Immigrant among Adolescents, and the Role of Socioeconomic Factors and School, Behavior, and Health-Related Difficulties

The risk of suicide behaviors in immigrant adolescents varies across countries and remains partly understood. We conducted a study in France to examine immigrant adolescents' likelihood of experiencing suicide ideation in the last 12 months (SI) and lifetime suicide attempts (SA) compared with their native counterparts, and the contribution of socioeconomic factors and school, behavior, and health-related difficulties. Questionnaires were completed by 1559 middle-school adolescents from north-eastern France including various risk factors, SI, SA, and their first occurrence over adolescent's life course (except SI). Data were analyzed using logistic regression models for SI and Cox regression models for SA (retaining only school, behavior, and health-related difficulties that started before SA). Immigrant adolescents had a two-time higher risk of SI and SA than their native counterparts. Using nested models, the excess SI risk was highly explained by socioeconomic factors (27%) and additional school, behavior, and health-related difficulties (24%) but remained significant. The excess SA risk was more highly explained by these issues (40% and 85%, respectively) and became non-significant. These findings demonstrate the risk patterns of SI and SA and the prominent confounding roles of socioeconomic factors and school, behavior, and health-related difficulties. They may be provided to policy makers, schools, carers, and various organizations interested in immigrant, adolescent, and suicide-behavior problems.

Assessment of Suicidal Intent

BACKGROUND

Suicide and suicidal attempt are an important cause of mortality and denotes severe morbidity among the population. Successful suicide attempt is associated with previous suicide attempts. Identifying factors in suicide attempters will help in formulating a comprehensive response to these issues.

OBJECTIVE

To identify the sub group who are more vulnerable and the factors associated with this group.

SETTING AND DESIGN

A cross sectional observational study of this sub group was carried out.

MATERIAL AND METHODS

study was conducted on patients who were referred to the Psychiatry department for attempted suicide. They were assessed to identify those with high suicidal intent and study the factors associated with high suicidal intent.

STATISTICS

Epiinfo by CDC was used to analyze the results.

RESULTS

High intent was associated with history of psychiatric illness, history of previous attempts and family history of suicidal attempts.

CONCLUSIONS

A sub group was identified which had a high intent and possibly higher chance of repeating an attempt.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Preventing repetition of attempted suicide-III. The Amager Project, 5-year follow-up of a randomized controlled trial

BACKGROUND

The Amager Project was initiated as a quasi-experimental study in 2005, based on an active outreach suicide preventive intervention inspired by the Norwegian Baerum Model. A 1-year follow-up study was conducted as a randomized controlled trial showing that this kind of active outreach to suicide attempters had a significant preventive effect on the prevalence of suicide attempts and significantly reduced the number of patients repeating a suicide attempt.

AIMS

In this 5-year RCT follow-up the aim was to investigate the sustainability of the suicide preventive effect shown in a 1-year follow-up study.

METHOD

One hundred and thirty-three suicide attempters were included at this 5-year follow-up RCT study at Copenhagen University Hospital, Amager, and randomized to a rapid outreach suicide preventive intervention (OPAC) or TAU.

RESULTS

Offering OPAC intervention to patients after a suicide attempt has a significant preventive effect on the total of suicide attempts and significantly reduces the number of patients repeating a suicide attempt. The suicide preventive effect lasts up to 265 weeks. After 3-4 years the effect on the number of patients repeating a suicide attempt is no longer sustainable, while the effect on the number of repetitive events remains significant.

CONCLUSION

This study emphasizes the importance of a rapid and active outreach intervention and points out that the effect on the number of patients repeating a suicide attempt wears off and is no longer sustainable after 3-4 years, suggesting the need for a follow-up intervention.

Suicide among Animals: A Review of Evidence

Naturalists have not identified suicide in nonhuman species in field situations, despite intensive study of thousands of animal species. In this review, evidence on suicidal behavior among animals is analyzed to discover analogies with human suicidal behavior. Literature was retrieved by exploring Medline/PubMed and PsychINFO databases (1967–2007) and through manual literature searches. Keyword terms were “suicide or suicidal behavior” and “animal or animal behavior.” Few empirical investigations have been carried out on this topic. Nevertheless, sparse evidence supports some resemblance between the self-endangering behavior observed in the animal kingdom, particularly in animals held in captivity or put under pressure by environmental challenges, and suicidal behavior among humans. Animal models have contributed to the study of both normal and pathological human behaviors: discovering some correlates of suicide among animals could be a valid contribution to the field.

Comparison of Suicide Attempters and Decedents in the U.S. Army: A Latent Class Analysis

A clearer understanding of risk factors for suicidal behavior among soldiers is of principal importance to military suicide prevention. It is unclear whether soldiers who attempt suicide and those who die by suicide have different patterns of risk factors. As such, preventive efforts aimed toward reducing suicide attempts and suicides, respectively, may require different strategies. We conducted a latent class analysis (LCA) to examine classes of risk factors among suicide attempters (n = 1,433) and decedents (n = 424). Both groups were represented by three classes: (1) External/Antisocial Risk Factors, (2) Mental Health Risk Factors, and (3) No Pattern. These findings support the conceptualization that military suicide attempters and decedents represent a single population.

Differences between Impulsive and Non-Impulsive Suicide Attempts among Individuals Treated in Emergency Rooms of South Korea

OBJECTIVE

A considerable proportion of suicide attempts are the result of sudden desires. Understanding such impulsive suicide attempts is necessary for effective interventions. We evaluated the impulsivity of suicide attempters treated in emergency rooms. The aim of the study was to identify the characteristics of impulsive suicide attempts by comparing these individuals to those who attempted to commit suicide in a non-impulsive manner.

METHODS

This study analyzed suicide attempters who visited the emergency departments of seven selected university hospitals. A total of 269 medical records in which impulsivity of suicide attempt were confirmed were subject to be analyzed. The impulsivity of the suicide attempt was examined using a summative score of items 6 and 15 on the Suicide Intent Scale.

RESULTS

A total of 48.0% of the participants were impelled by sudden inclinations to attempt suicide. Impulsive attempters were younger, unmarried and less physical illness than non-impulsive attempters, whereas no significant differences were found on psychiatric history and previous suicide history. Impulsive suicide attempters had suicide ideations that were not as severe (χ(2)=55.33, p<0.001) or intense (t=-8.38, p<0.001) as their counterparts'. Furthermore, medical results of impulsive suicide attempts were better than non-impulsive suicide attempts (t=-3.77, p<0.001).

CONCLUSION

The results suggested that a considerable proportion of suicide attempts were the result of sudden inclinations. Impulsive attempts were made in relatively earlier stages of suicide ideation; consequently, they have less intent than non-impulsive attempts.

Development and Validation of the Gatekeeper Behavior Scale

Abstract. Background: Community-based gatekeeper trainings are effective tools in increasing gatekeeper skills but few validated measures assess impact. Aims: This study aimed at determining the validity of an 11-item Gatekeeper Behavior Scale (GBS) to assess gatekeeper skills that predict behavior. Method: To validate the scale, 8,931 users were administered GBS surveys at pretraining, posttraining, and follow-up periods. The training was one of five from the suite of online At-Risk mental health learning simulations for university faculty/staff or students or high/middle school educators. Results: A confirmatory factor analysis revealed the three-factor model based on the subscales of preparedness, likelihood, and self-efficacy fit the data best. Factor loadings showed all items correlated highly with theoretical constructs (r ≥ .84, p < .001). The GBS had high internal consistency (α = 0.93). Criterion-related validity for likelihood to discuss concerns at posttraining was significantly related to approaching students believed to be in psychological distress (r = .219, p < .001). Likelihood to refer significantly correlated with the number of students referred (r = .235, p < .001). Convergent validity was established via a correlation between self-efficacy in motivating someone to seek help and general self-efficacy (r = .519, p < .001). Conclusion: The GBS appears to be a valid tool in measuring the impact of online gatekeeper training simulations and holds promise for assessing other delivery methods.

Analysis of Internet Suicide Pacts Reported by the Media in Mainland China

BACKGROUND

In mainland China, frequent Internet suicide pacts in recent years have raised strong concerns from several social sectors and the influence of social networks on suicide is constantly growing.

AIMS

To identify the epidemiological characteristics of media-reported Internet suicide pacts in mainland China.

METHOD

Our study comprised 62 Internet suicide pacts involving 159 victims in mainland China before June 1, 2015. Kendall's randomness test, a trend test, and a circular distribution test were applied to identify the rising or concentrated trends in the time of occurrence of Internet suicide pacts.

RESULTS

The overall male-to-female ratio was 2.3:1. Suicide victims were mainly people in their 20s to 30s (84.1%). In all, 87.1% suicide victims completed suicide in sealed hotels or rental housing, and charcoal-burning suicide accounted for 80.6% of cases.

CONCLUSION

People who complete suicide as part of an Internet suicide pact are more likely to be males, aged 20-30 years. Charcoal-burning suicide in sealed hotels or rental housing was the commonest way of dying.

Mental health service changes, organisational factors, and patient suicide in England in 1997-2012: a before-and-after study

BACKGROUND

Research into which aspects of service provision in mental health are most effective in preventing suicide is sparse. We examined the association between service changes, organisational factors, and suicide rates in a national sample.

METHODS

We did a before-and-after analysis of service delivery data and an ecological analysis of organisational characteristics, in relation to suicide rates, in providers of mental health care in England. We also investigated whether the effect of service changes varied according to markers of organisational functioning.

FINDINGS

Overall, 19 248 individuals who died by suicide within 12 months of contact with mental health services were included (1997-2012). Various service changes related to ward safety, improved community services, staff training, and implementation of policy and guidance were associated with a lower suicide rate after the introduction of these changes (incidence rate ratios ranged from 0·71 to 0·79, p<0·0001). Some wider organisational factors, such as non-medical staff turnover (Spearman's r=0·34, p=0·01) and incident reporting (0·46, 0·0004), were also related to suicide rates but others, such as staff sickness (-0·12, 0·37) and patient satisfaction (-0·06, 0·64), were not. Service changes had more effect in organisations that had low rates of staff turnover but high rates of overall event reporting.

INTERPRETATION

Aspects of mental health service provision might have an effect on suicide rates in clinical populations but the wider organisational context in which service changes are made are likely to be important too. System-wide change implemented across the patient care pathway could be a key strategy for improving patient safety in mental health care.

FUNDING

The Healthcare Quality Improvement Partnership commissions the Mental Health Clinical Outcome Review Programme, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, on behalf of NHS England, NHS Wales, the Scottish Government Health and Social Care Directorate, the Northern Ireland Department of Health, Social Services and Public Safety, and the States of Jersey and Guernsey.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.

OBJECTIVES

To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures.

MAIN RESULTS

We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported.

AUTHORS' CONCLUSIONS

CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.

Identifying Risk for Self-Harm: Rumination and Negative Affectivity in the Prospective Prediction of Nonsuicidal Self-Injury

Research suggests nonsuicidal self-injury (NSSI) may function as a maladaptive strategy to regulate negative emotions, and individuals high in trait negative affectivity (NA) may be particularly at risk. Rumination, a cognitive emotion regulation strategy, may amplify negative affect, increasing the likelihood of NSSI. The current study found that high NA and high rumination interacted to predict both likelihood of engagement in NSSI and frequency of NSSI. This study provides support for the joint contribution of cognitive and temperamental factors impacting the relationship between NA and NSSI and suggests that interventions targeted at maladaptive emotion regulation strategies may help inform individualized treatment.

Characteristics of female mentally disordered offenders culpable under the new legislation in Japan: A gender comparison study

BACKGROUND

Although a substantial increase in the number of female offenders has drawn interest towards understanding their unique characteristics, few studies have investigated the characteristics of female mentally disordered offenders in Japan and none since the legislation enacted in 2005 in Japan, which provided for special services for them.

AIMS

The aim of this study is to identify those characteristics of people detained under this legislation, which distinguish the women from the men and may indicate special needs among the women.

METHODS

A retrospective records-based study of all patients admitted to one secure unit in the 8 years since its opening in July 2005 until a census date of 31 October 2013.

RESULTS

Thirty-six (15%) of the patients were women. Marriage, mood disorders, past suicide attempts and homicide were more common among the women than the men. Six of the female offender-patients had committed filicides, of which four were infanticides.

CONCLUSION

There appears to be a particularly vulnerable sub-group of women with severe mood disorders, a history of serious suicide attempts and young children at risk of harming those children. Our sample was small and from a single unit so, given the potential importance of improving understanding of who is at risk in such circumstances, extending our study nationally seems indicated.

Clinical Features, Psychiatric Assessment, and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital

The objective of this study was to characterize admissions to an emergency hospital due to suicide attempts and verify outcomes in 2 years. Data were collected from medical records and were analyzed using descriptive statistics and logistic regression. The sample consisted of 412 patients (58.7% women; mean age = 32.6 years old, SD = 14.3). Self-poisoning was the most frequent method (84.0%), and they were diagnosed mainly as depressive (40.3%) and borderline personality disorders (19.1%). Previous suicide attempts and current psychiatric treatment were reported by, respectively, 32.0% and 28.4%. Fifteen patients (3.6%, 9 males) died during hospitalization. At discharge, 79.3% were referred to community-based psychiatric services. Being male (OR = 2.11; 95% CI = 1.25-3.55), using violent methods (i.e., hanging, firearms, and knives) (OR = 1.96; 95% CI = 1.02-3.75) and psychiatric treatment history (OR = 2.58; 95% CI = 1.53-4.36) were predictors for psychiatric hospitalization. Of 258 patients followed for 2 years, 10 (3.9%) died (3 suicide), and 24 (9.3%) undertook new suicide attempts. Patients with a history of psychiatric treatment had higher risks of new suicide attempts (OR = 2.46, 95% CI = 1.07-5.65). Suicide attempters admitted to emergency hospitals exhibit severe psychiatric disorders, and despite interventions, they continue to present high risks for suicide attempts and death.

Effect of Systematic Follow-Up by General Practitioners after Deliberate Self-Poisoning: A Randomised Controlled Trial

Objective

To assess whether systematic follow-up by general practitioners (GPs) of cases of deliberate self-poisoning (DSP) by their patients decreases psychiatric symptoms and suicidal behaviour compared with current practice.

Design

Randomised clinical trial with two parallel groups.

Setting

General practices in Oslo and the eastern part of Akershus County.

Participants

Patients aged 18–75 years admitted to hospital for DSP. We excluded patients diagnosed with psychoses, without a known GP, those not able to complete a questionnaire, and patients admitted to psychiatric in-patient care or other institutions where their GP could not follow them immediately after discharge.

Intervention

The GPs received a written guideline, contacted the patients and scheduled a consultation within one week after discharge, and then provided regular consultations for six months. We randomised the patients to either intervention (n = 78) or treatment as usual (n = 98).

Main Outcome Measures

Primary outcome measure was the Beck Scale for Suicide Ideation (SSI). Secondary outcomes were Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS), self-reported further self-harm and treatment for DSP in a general hospital or an emergency medical agency (EMA). We assessed patients on entry to the trial and at three and six months. We collected data from interviews, self-report questionnaires, and hospital and EMA medical records.

Results

There were no significant differences between the groups in SSI, BDI, or BHS mean scores or change from baseline to three or six months. During follow-up, self-reported DSP was 39.5% in the intervention group vs. 15.8% in controls (P = 0.009). Readmissions to general hospitals were similar (13% in both groups (P = 0.963), while DSP episodes treated at EMAs were 17% in the intervention group and 7% in the control group (P = 0.103).

Conclusion

Structured follow-up by GPs after an episode of DSP had no significant effect on suicide ideation, depression or hopelessness. There was no significant difference in repeated episodes of DSP in hospitals or EMAs. However, the total number of incidents of deliberate self-harm reported by the patients was significantly higher in the intervention group.

Trial registration

Trial registration ClinicalTrials.gov Identifier: NCT01342809

WITHDRAWN: Psychosocial and pharmacological treatments for deliberate self harm

This review has been withdrawn because the topic has been split into three separate reviews, one on psychosocial interventions for self‐harm in adults; another on interventions for self‐harm in children and adolescents; and a third on pharmacological interventions for self‐harm in adults.

The editorial group responsible for this previously published document have withdrawn it from publication.

Group problem-solving skills training for self-harm: randomised controlled trial

BACKGROUND

Rates of self-harm are high and have recently increased. This trend and the repetitive nature of self-harm pose a significant challenge to mental health services.

AIMS

To determine the efficacy of a structured group problem-solving skills training (PST) programme as an intervention approach for self-harm in addition to treatment as usual (TAU) as offered by mental health services.

METHOD

A total of 433 participants (aged 18-64 years) were randomly assigned to TAU plus PST or TAU alone. Assessments were carried out at baseline and at 6-week and 6-month follow-up and repeated hospital-treated self-harm was ascertained at 12-month follow-up.

RESULTS

The treatment groups did not differ in rates of repeated self-harm at 6-week, 6-month and 12-month follow-up. Both treatment groups showed significant improvements in psychological and social functioning at follow-up. Only one measure (needing and receiving practical help from those closest to them) showed a positive treatment effect at 6-week (P = 0.004) and 6-month (P = 0.01) follow-up. Repetition was not associated with waiting time in the PST group.

CONCLUSIONS

This brief intervention for self-harm is no more effective than treatment as usual. Further work is required to establish whether a modified, more intensive programme delivered sooner after the index episode would be effective.

Pharmacological interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm.

OBJECTIVES

To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients.

SEARCH METHODS

For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013.

SELECTION CRITERIA

We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.

AUTHORS' CONCLUSIONS

Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.

Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching

BACKGROUND

Although deliberate self-harm is a strong predictor of suicide, evidence for effective interventions is missing. The aim of this study was to examine whether psychosocial therapy after self-harm was linked to lower risks of repeated self-harm, suicide, and general mortality.

METHODS

In this matched cohort study all people who, after deliberate self-harm, received a psychosocial therapy intervention at suicide prevention clinics in Denmark during 1992-2010 were compared with people who did not receive the psychosocial therapy intervention after deliberate self-harm. We applied propensity score matching with a 1:3 ratio and 31 matching factors, and calculated odds ratios for 1, 5, 10, and 20 years of follow-up. The primary endpoints were repeated self-harm, death by suicide, and death by any cause.

FINDINGS

5678 recipients of psychosocial therapy (followed up for 42·828 person-years) were matched with 17,034 individuals with no psychosocial therapy in a 1:8 ratio. During 20 year follow-up, 937 (16·5%) recipients of psychosocial therapy repeated the act of self-harm, and 391 (6·9%) died, 93 (16%) by suicide. The psychosocial therapy intervention was linked to lower risks of self-harm than was no psychosocial therapy (odds ratio [OR] 0·73, 95% CI 0·65-0·82) and death by any cause (0·62, 0·47-0·82) within a year. Long-term effects were identified for repeated self-harm (0·84, 0·77-0·91; absolute risk reduction [ARR] 2·6%, 1·5-3·7; numbers needed to treat [NNT] 39, 95% CI 27-69), deaths by suicide (OR 0·75, 0·60-0·94; ARR 0·5%, 0·1-0·9; NNT 188, 108-725), and death by any cause (OR 0·69, 0·62-0·78; ARR 2·7%, 2·0-3·5; NNT 37, 29-52), implying that 145 self-harm episodes and 153 deaths, including 30 deaths by suicide, were prevented.

INTERPRETATION

Our findings show a lower risk of repeated deliberate self-harm and general mortality in recipients of psychosocial therapy after short-term and long-term follow-up, and a protective effect for suicide after long-term follow-up, which favour the use of psychosocial therapy interventions after deliberate self-harm.

FUNDING

Danish Health Insurance Foundation; the Research Council of Psychiatry, Region of Southern Denmark; the Research Council of Psychiatry, Capital Region of Denmark; and the Strategic Research Grant from Health Sciences, Capital Region of Denmark.

Suicide Prevention

Suicide is a public health problem affecting people across the lifespan. It is currently the 10th leading cause of death, with rates having remained relatively flat for the past century. This article summarizes the problem of suicide and suicidal behavior along with suicide prevention efforts in the United States. Part 1 provides an overview of the epidemiology of suicide, including groups most at risk of suicide and suicidal behavior. Part 2 provides a review of common risk factors, organized by developmental life stage. A brief discussion of the lesser well-researched area of protective factors follows. Part 3 provides an overview of suicide prevention today, including the major types of prevention strategies, their successes, including means restriction, quality improvement in behavioral services, and comprehensive programs; and limitations to date, such as a lack of evidence for impact on actual deaths or behavior, small sample sizes, and low base rates. Finally, part 4 discusses challenges and future directions with an eye toward the great many opportunities that exist for prevention.

Psychiatric and psycho-social characteristics of suicide completers: a comprehensive evaluation of psychiatric case records and postmortem findings

Objectives

To explore the demographic, psychosocial and clinical characteristics of individuals known to the mental health services, who died by probable suicide in the West of Ireland.

Methods

Postmortem reports between January 2006 and May 2012 detailed 153 individuals who died by probable suicide, 58 of whom attended the mental health services. Relevant socio-demographic and clinical data was extracted from individuals’ lifetime case notes.

Results

Recurrent depressive disorder (44%) was the most common diagnosis and hanging the most common method of death (58%). Of individuals who died by hanging, 79% previously attempted suicide by the same method. For individuals with a documented history of depression, only 32% had antidepressants detected in their toxicology reports. Similarly, only one individual (20%) with schizophrenia had antipsychotics detected in their toxicology report.

Conclusions

Individuals who died by probable suicide, most commonly died by hanging and drowning; with previous attempts of hanging particularly prevalent in the group who subsequently died by hanging. At the time of death, less than one-third of individuals according to toxicology reports were taking the medication that was last prescribed to them by the mental health services suggesting a high rate of treatment non-concordance in individuals who died by probable suicide.

APSI: a proposed integrative model for suicide prevention

BACKGROUND

Deaths by suicide have been increasing in recent years in Ireland, many of whom have co-morbid mental health difficulties and/or have attended primary care services 1 month before death. Aims To profile how 'Access to Psychological Services Ireland' (APSI) provides stepped-care therapies for mild-to-moderate adult mental health presentations and the potential effectiveness of this model based on comparison to a review of evidence-based strategies in suicide prevention. A secondary aim is to highlight how APSI has the potential to target those at risk of suicide and provide an integrative after-care service to complement secondary care mental health services. Findings In a context of inter-agency working, APSI provides an integrated continuum of suicide prevention interventions that map onto or intervene across the continuum of suicide behaviour. Hence, APSI appears to implement what the literature suggests will work in preventing suicide. However, outcome research is needed to establish APSI's impact in preventing suicide. Recommendations It is recommended that Irish-based research is conducted to establish APSI's impact in preventing suicide with a view to rolling out APSI as a national mental health clinical care programme.

Gender and family disparities in suicide attempt and role of socioeconomic, school, and health-related difficulties in early adolescence

Suicide attempt (SA) is common in early adolescence and the risk may differ between boys and girls in nonintact families partly because of socioeconomic, school, and health-related difficulties. This study explored the gender and family disparities and the role of these covariates. Questionnaires were completed by 1,559 middle-school adolescents from north-eastern France including sex, age, socioeconomic factors (family structure, nationality, parents' education, father's occupation, family income, and social support), grade repetition, depressive symptoms, sustained violence, sexual abuse, unhealthy behaviors (tobacco/alcohol/cannabis/hard drug use), SA, and their first occurrence over adolescent's life course. Data were analyzed using Cox regression models. SA affected 12.5% of girls and 7.2% of boys (P < 0.001). The girls living with parents divorced/separated, in reconstructed families, and with single parents had a 3-fold higher SA risk than those living in intact families. Over 63% of the risk was explained by socioeconomic, school, and health-related difficulties. No family disparities were observed among boys. Girls had a 1.74-time higher SA risk than boys, and 45% of the risk was explained by socioeconomic, school, and mental difficulties and violence. SA prevention should be performed in early adolescence and consider gender and family differences and the role of socioeconomic, school, and health-related difficulties.

Suicidal thoughts and acts in Irish adolescents

Objectives: To determine the frequency of reported suicidal thoughts and acts in (a) a school-based sample of Irish adolescents, (b) adolescents attending a community child and family mental health service.

Method: The study population consisted of: (a) 195 adolescents aged 13-15 years attending ten secondary schools throughout Ireland. The schools were selected to represent a wide social and cultural spread: and (b) 66 adolescents aged 13-15 years attending a community child mental health service. The measures used were the Child Behaviour Checklist completed by the parents of the adolescents and the Youth Self Report completed by the adolescents.

Results: Within the school sample, the parents of 3% of adolescents reported that their child had talked of harming him/herself, but none reported acts of self-harm. Fifteen percent of the adolescents themselves reported that they had thoughts of harming or killing themselves, and 8% reported that they had tried to harm or kill themselves.

Within the mental health clinic attenders sample, the parents of 33% of the adolescents reported that their child had talked of harming him/herself, and the parents of 27% reported that their child had tried to harm or kill themselves. Twenty-one percent of the adolescents themselves reported that they had thoughts of harming or killing themselves, and 21% percent reported that they had tried to do so. In both groups, adolescents with higher total problem, internalising and externalising scores on the questionnaires, indicating greater disturbance, were more likely to report thoughts and acts of self harm.

Conclusions: Thoughts of suicide and acts of self harm are common in Irish adolescents and are not limited to those attending mental health services. Parents are frequently unaware of these thoughts. Further studies involving interviews with adolescents at risk are indicated to determine the significance of these thoughts and how adolescents deal with them.

Trends in suicide in Northern Ireland 1922-1992

Objective: The trends in suicide in Northern Ireland over a 70 year period were examined with respect to sex, age and method used, and then compared with rates of unemployment and homicide.

Method: The records in the office of the registrar general in Belfast were examined to obtain data. Unemployment figures were obtained from the Department of Economic Development.

Results: Suicide is increasing in Northern Ireland and particularly in young men (aged 34 and under). There is a relation to unemployment although it is not felt to be directly causal. Men prefer more violent methods although vehicle exhaust gas is popular. A large number of women still choose drowning.

Conclusions: Despite all initiatives, the suicide rate is increasing in Northern Ireland, in common with many European countries. It represents a major health care issue. Measures of a social or political nature may have more effect than health care advances in reducing the rate of suicide.

Employment loss during economic crisis and suicidal thoughts in Belgium: a survey in general practice

BACKGROUND

The economic crisis of 2009 led to a wave of corporate reorganisations and bankruptcies, with many dismissals of employees. GPs were confronted with subsequent health consequences.

AIM

To assess the possible relationship between losing one's job and having suicidal thoughts.

DESIGN AND SETTING

A survey of patients aged 18-49 years recruited from GP practices in Belgium in Deurne (Flemish region) and La Louvière (Walloon region) from September to December 2010. Method Anonymous self-administered questionnaire.

RESULTS

Of all eligible patients (n = 1818), 831 were offered the questionnaire and 377 completed it (45.4%). More than one in five had been confronted with employment loss in the past year (the responder or someone close losing their job). Almost one in ten had lost their job themselves in the past year. More than one in four had experienced suicidal thoughts and 11.7% had seriously considered ending their life in the past year. In the logistic regression analysis, the following characteristics showed a statistically significant relationship with having suicidal thoughts: being single (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.7 to 13.8), not having satisfying social contacts (OR = 5.1, 95% CI = 1.6 to 16.2), having depressive complaints (OR = 18.4, 95% CI = 5.8 to 58.4), and having lost one's employment in the past year (OR = 8.8, 95% CI = 2.0 to 39.3).

CONCLUSION

This study points to a statistically significant relationship between losing one's employment in the past year and having suicidal thoughts. It emphasises the important role of the GP in the continuous and reinforced assessment of suicidal risk in times of recession.