Suicide among adults aged 30-49: a psychological autopsy study in Hong Kong

Views of services users and staff on a combined money advice and psychological therapy service within IAPT

BACKGROUND

Research has indicated that having financial difficulties may increase mental health problems and prevent recovery when receiving psychological treatment. A combined approach within the Improving Access to Psychological Therapies (IAPT) service could help clients by tackling their financial difficulties alongside supporting their mental health.

AIMS

We aimed to explore the experiences and views of a potential combined intervention by speaking to IAPT service users who have/had experiences of money worries, as well as IAPT therapists and Citizen's Advice (CA) money advisers.

METHOD

We conducted online semi-structured interviews with 16 IAPT service users, 14 IAPT therapists/practitioners, and 6 CA money advisors. Interviews were transcribed verbatim and analysed thematically.

RESULTS

Themes discussed including the impact of money worries and mental health, the benefits of a combined intervention, how and when it should be introduced to clients and delivered, and how information should be shared between the services. It was felt by most participants that such an intervention would improve mental health and provide a more holistic service with a better referral pathway.

CONCLUSIONS

Our findings provide a blueprint for a combined money advice and psychological therapy service within IAPT, which both service users and staff identified would be beneficial.

Suicide prevention in Hong Kong: pushing boundaries while building bridges

Hong Kong is a natural laboratory for studying suicides-small geographic footprint, bustling economic activity, rapidly changing socio-demographic transitions, and cultural crossroads. Its qualities also intensify the challenges posed when seeking to prevent them. In this viewpoint, we showed the research and practices of suicide prevention efforts made by the Hong Kong Jockey Club Centre for Suicide Research and Prevention (CSRP), which provide the theoretical underpinning of suicide prevention and empirical evidence. CSRP adopted a multi-level public health approach (universal, selective and indicated), and has collaboratively designed, implemented, and evaluated numerous programs that have demonstrated effectiveness in suicide prevention and mental well-being promotion. The center serves as a hub and a catalyst for creating, identifying, deploying, and evaluating suicide prevention initiatives, which have the potential to reduce regional suicides rates when taken to scale and sustained.

Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study

BACKGROUND

Reducing suicide risk in middle-aged males (40-54 years) is a national priority. People have often presented to their GP within 3 months before suicide thus highlighting an opportunity for early intervention.

AIM

To describe the sociodemographic characteristics and identify antecedents in middle-aged males who recently consulted a GP before dying by suicide.

DESIGN AND SETTING

This study was a descriptive examination of suicide in a national consecutive sample of middle-aged males in 2017 in England, Scotland, and Wales.

METHOD

General population mortality data were obtained from the Office for National Statistics and National Records of Scotland. Information was collected about antecedents considered relevant to suicide from data sources. Logistic regression examined associations with final recent GP consultation. Males with lived experience were consulted during the study.

RESULTS

In 2017, a quarter (n = 1516) of all suicide deaths were in middle-aged males. Data were attained on 242 males: 43% had their last GP consultation within 3 months of suicide; and a third of these males were unemployed and nearly half were living alone. Males who saw a GP recently before suicide were more likely to have had recent self-harm and work-related problems than males who had not. Having a current major physical illness, recent self-harm, presenting with a mental health problem, and recent work-related issues were associated with having a last GP consultation close to suicide.

CONCLUSION

Clinical factors were identified that GPs should be alert to when assessing middle-aged males. Personalised holistic management may have a role in preventing suicide in these individuals.

The impact of the minimum wage on suicide rates in Hong Kong

Increases in minimum wages have been associated with reductions in suicide rates in the United States, but little evidence is available for Asia where social and contextual factors, as well as drivers of suicide, may be different. We investigated the impact of the introduction of the minimum wage in Hong Kong in May 2011 on suicide rates using an interrupted time series design for the period January 2006 to December 2016. We investigated both immediate and gradual changes in monthly suicide rates after the introduction of the minimum wage taking into account secular trends. We conducted stratified analyses by age and gender. In total 9396 suicides were recorded in Hong Kong during the 11-year study period. Introduction of the minimum wage was associated with an immediate decrease of 13.0% in the monthly suicide rate (95% confidence interval (CI) 5.4%-19.9%, P = 0.001). There was an immediate decrease of 15.8% in older working aged (25-64 years) men (95% CI: 4.2%-25.9%, P = 0.009). Point estimates of immediate effect for other subgroups were also in a negative direction, but were not statistically significant. There was no evidence of a gradual effect on suicide rates at the population level or by subgroup other than a small increase in younger working aged men. We estimate that 633 suicides were prevented by the minimum wage legislation for the period from May 2011 to December 2016, the majority in older working aged men. Our results provide new evidence that, similar to findings in Western settings, minimum wages may help to reduce suicide in Asia, particularly for working age men. Our study highlights the importance of examining the health impacts of government economic policy and suggests minimum wages may provide policy makers with an upstream population-based strategy to reduce suicide rates.

Suicide capability within the ideation-to-action framework: A systematic scoping review

Suicide capability is theorised to facilitate the movement from suicidal ideation to suicide attempt. Three types of contributors are posited to comprise suicide capability: acquired, dispositional, and practical. Despite suicide capability being critical in the movement from ideation-to-attempt, there has been no systematic synthesis of empirical evidence relating to suicide capability that would enable further development and refinement of the concept. This study sought to address this synthesis gap. A scoping review was conducted on suicide capability studies published January 2005 to January 2022. Eleven electronic databases and grey literature sources were searched returning 5,212 potential studies. After exclusion criteria application, 90 studies were included for final analysis. Results synthesis followed a textual narrative approach allocating studies based on contributors of suicide capability. Most studies focused on investigating only one factor within contributors. Painful and provocative events appear to contribute to acquired capability more so than fearlessness about death. Whilst emerging evidence for dispositional and practical contributors is promising, the small number of studies prevents further conclusions from being drawn. An unexpected additional cognitive contributor was identified. The focus of a single factor from most studies and the limited number of studies on contributors other than acquired capability limits the theoretical development and practical application of suicide capability knowledge. Given that suicide is a complex and multifaceted behaviour, future research that incorporates a combination of contributors is more likely to advance our understandings of suicide capability.

Midlife suicide: A systematic review and meta-analysis of socioeconomic, psychiatric and physical health risk factors

Suicide is an increasing contributing cause of mortality in middle-aged adults; however, knowledge to guide prevention is limited. This first systematic review and meta-analysis of studies on midlife suicide has provided an overview of published research on this issue and synthesized the evidence on socioeconomic and physical and mental health factors associated with this mortality. Using PRISMA guidelines MEDLINE, Embase, PsycINFO, Scopus and Web of Science were searched for English-language publications that involved persons aged 35 to 65, used individual-level data, and reported prevalence of exposure(s) or relative risks. The search identified 62 studies on midlife suicides and associated factors (28 for SES, 22 for psychiatric disorder and 23 for physical illness). All studies were from high income countries, and most (80.6%) used data from population registries. Meta-analyses showed that the pooled prevalence of exposure in suicide decedents was 57.8% for psychiatric disorder, 56.3% for low income, 43.2% for unemployment, and 27.3% for physical illness. The associated pooled risk ratio was 11.68 (95% confidence intervals: 5.82-23.47) for psychiatric illness of any type, 12.59 (8.29-19.12) for mood disorders, 3.91 (2.72-5.59) for unemployment, 3.18 (2.72-3.72) for being separated or divorced, 2.64 (2.26-3.10) for cancer, 2.50 (0.96-6.38) for central nervous system illness, and 2.26 (1.16-4.41) for low income. In conclusion, midlife suicide is strongly associated with socioeconomic difficulties and physical and psychiatric illnesses that are common in this age population. Future investigations should consider the interactions between risk factors, the intersectionality of sex and ethnicity, and include data from low- and middle-income countries.

Suicide Presentations to an Emergency Department Pre and During the COVID Lockdown, March-May 2020, in Spain

The impact of the COVID-19 pandemic and lockdown may affect suicide risk and behavior. We compared suicide-related presentations during the national quarantine with pre-COVID data. This observational incidence study compared all suicide-related presentations at the University Hospital Reina Sofia emergency department (ED) in Cordoba, Spain, for the lockdown period from 15 March to 15 May 2020, with the same period in 2019. Descriptive and inferential analyses of case characteristics between 2019 and 2020 periods were conducted, and a multivariable logistic regression model developed. Results: Despite a decrease in overall ED cases during the lockdown, the number of suicide-related presentations stayed the same and represented a significantly larger proportion of cases in comparison to the pre-COVID period (0.42 vs. 0.87%, in 2019 and 2020, respectively; p < .001). The number presenting alone more than doubled during the COVID lockdown, increasing to 42.9% compared with 19.4% in 2019 (p = .002). An increase in presentations with a family history of suicide was also found. Conclusions: Suicide cases represented an increased proportion of ED cases during the lockdown. Presenting to ED alone, having a family history of suicide, habitual drug consumption, and hospital admission to ICU differentiated cases between pre and during COVID periods. These findings should be considered in light of the second wave and further implementation of lockdown measures.

A natural experiment reveals impacts of built environment on suicide rate: Developing an environmental theory of suicide

BACKGROUND

Suicide is a global challenge. Although it is clear that socioeconomic and demographic factors influence suicide rates, we know little about the impacts of the built environment on suicide rates.

METHODS

We investigated the relationship between characteristics of the built environment and suicide death rates over a 13-year period in 151 rent-only public housing communities in Hong Kong. The regulations of the public housing authority in Hong Kong constituted a natural experiment with minimal self-selection bias. We conducted hierarchical regression analyses and found that characteristics of the built environment were significantly associated with suicide rates after controlling for SES and demographic factors at the community level.

RESULTS

Three significant environmental factors were identified distance to the nearest urban center, distance to the nearest Mass Transit Railway station, and gross flat area per person.

CONCLUSION

These findings demonstrate a significant association between features of the built environment and suicide rates. They also suggest possible interventions that might reduce suicide through design, or redesign, of the built environment. Lastly, we propose an environmental theory of suicide based on the Interpersonal Theory of Suicide.

The impact of transitions from employment to retirement on suicidal behaviour among older aged Australians

PURPOSE

Transition from employment to retirement may be detrimental to mental health, and associated with suicidal behaviour. This study investigated the association between employment and retirement status and suicidal behaviour among older aged Australians.

METHODS

This study was based on the '45 and Up Study', a large prospective cohort study of participants from New South Wales (Australia) aged 45 years and older (N = 267,153), followed up over the period 2006-2018. The risk of attempted suicide and suicide was compared between categories of employment and retirement status in a series of recurrent event survival analysis models adjusting for identified time variant and invariant confounders.

RESULTS

Compared to those who were employed, the risk of attempted suicide was higher among those who were not in the labour force and not retired (predominantly those who were sick or disabled, or carers) (HR = 1.97-95% CI 1.49-2.62), those who retired involuntarily (HR = 1.35-95% CI 1.03-1.77), and to a lesser extent those unemployed (HR = 1.31-95% CI 0.89-1.92). Risk of attempted suicide among those who retired voluntarily was similar to those who remained employed (HR = 1.09-95% CI 0.82-1.45). A similar pattern was evident for suicide, with a higher risk of suicide among those who were not in the labour force or retired, and those who retired involuntarily, compared to those who remained employed; however, these differences were not statistically significant.

CONCLUSION

Transition from employment to retirement may be an important precipitating factor for suicidal behaviour, affected by current and previous mental health status. Services and programs facilitating continued or re-employment in older age, and adjustment to the transition from employment to retirement may prevent suicidal behaviour.

Psychiatric Comorbidity and Economic Hardship as Risk Factors for Intentional Self-Harm in Gambling Disorder-A Nationwide Register Study

Background: There is an increased risk of suicidality in gambling disorder (GD) and economic hardship is common in the population. Economic hardship itself is a risk factor for suicidality. This study aims to explore the risk of intentional self-harm in GD utilizing social welfare payment (SWP) as a proxy for economic hardship and exploring how economic hardship, gender, criminality, socioeconomic-, and psychiatric risk factors might contribute to intentional self-harm in GD. Methods: This is a nationwide register-based study of 848 individuals diagnosed with GD in the Swedish healthcare system during the years of 2011-2014 with an average follow up of 4.9 years. Pearson's Chi-square analyses were carried out for comparisons regarding psychiatric comorbidity and intentional self-harm with regards to gender and SWPs. Univariable and multivariable Cox regression were utilized to analyse risk factors for intentional self-harm. Results: A large part of the study population received SWPs (45.5% with an insignificant overrepresentation of women) and psychiatric disorders were more common in these individuals (p < 0.001). Conviction for crime in general (p < 0.001) as well as intentional self-harm (p = 0.025) were also more common amongst recipients of SWPs. Criminal conviction in general was abundant (26.5%). In the stepwise multivariable regression, substance-related diagnoses as well as anxiety, depressive, and personality disorders remained risk factors for intentional self-harm and no significant results were found with regards to gender, criminal history, or SWPs. Conclusions: Social welfare payment was common among GD patients and intentional self-harm was more common amongst recipients than GD patients as a whole. Social welfare payments were however not a significant risk factor for intentional self-harm. However, attention to suicidality and self-injurious behavior should be paid from social services controlling SWPs due to the large prevalence of intentional self-harm in this group. In accordance with previous studies, comorbid psychiatric disorders such as anxiety, depression, substance use, and personality disorders increased the risk of intentional self-harm.

A clinical study of suicide in patients admitted in psychiatry unit in Assiut University

Background

This study was performed for clinical study of suicide including risk factors in psychiatric patients admitted in psychiatric unit of Assiut University Hospital (AUH).

Results

We found that frequency of suicidal attempts is more in MDD (major depressive disorder), bipolar disorders followed by schizophrenia. And frequency of suicidal attempts in patients with multiple previous attempts before this one was higher in patients with mood disorders (53.8%) than psychotic and substance-induced disorders (32.3%, 13.8% respectively), with statistically significant difference in patients with MDD as well as there was significant treatment outcome on suicidal behavior.

Conclusion

The frequency of suicidal attempts is more in MDD (major depressive disorder), bipolar disorders followed by schizophrenia. There was significant severity of suicidal behavior in patients with psychotic disorders in comparison to patients with substance-induced disorder or mood disorders.

Putting the Blame on Others in Suicide Notes From Shanghai and Wuhan, China

Abstract. Background: Suicide note leavers sometimes blame others for their death. The blame could reveal extrinsic suicide risk factors and thus countermeasures may be ascertained. Aims: This study included suicide note leavers in Shanghai and Wuhan ( n = 555) to examine (a) who was inclined to put the blame (b) on whom and (c) for what reason(s). Method: Logistic regressions were used to compare the note leavers who blamed others with those who did not. Cramer's V tests were used to examine the correlations between the note leavers' demographics and the targets of the blame. Results: Note leavers who used poisoning and cutting were more likely to blame others compared with those who used jumping, drowning, and hanging. Non-native note leavers tended to more frequently blame social problems and their workplaces compared with the natives. The common reasons for the blame on nonfamily members, children, and lovers/spouses were being mistakenly blamed for something, being disobedient, and having conflicts/hatred, respectively. Limitations: Some blame could have been made under the influence of psychiatric disorder/substances, and thus potentially deviated from the facts. Conclusion: Emotional/marriage consultations and family-therapy services should be made available to females experiencing love/family crises. Mental health services in the workplace could help reduce suicide risks.

The Monetary Value of Human Lives Lost to Suicide in the African Continent: Beating the African War Drums

Background: Suicide is an important public health problem in the African continent whose economic burden remains largely unknown. This study estimated the monetary value of human lives lost due to suicide in the African continent in 2017. Methods: The human capital approach was applied to monetarily value the years of life lost due to premature mortality from suicide deaths (SD) among 54 African countries. A 3% discount rate was used to convert future losses into their present values. The sensitivity of monetary value of human lives lost to changes in discount rate and average life expectancy was tested. Results: The 75,505 human lives lost from suicide had a grand total monetary value of International Dollars (Int$) 6,989,963,325; and an average present value of Int$ 92,576 per SD. About 31.1% of the total monetary value of SD was borne by high-income and upper-middle-income countries (Group 1); 54.4% by lower-middle-income countries (Group 2); and 14.5% by low-income countries (Group 3). The average monetary value per human life lost from SD was Int$ 234,244 for Group 1, Int$ 109,545 for Group 2 and Int$ 32,223 for Group 3. Conclusions: Evidence shows that suicide imposes a substantive economic burden on African economies. The evidence reinforces the case for increased investments to ensure universal coverage of promotive, preventive, curative and rehabilitative mental health services.

Risk Factors of Suicide Death Based on Psychological Autopsy Method; a Case-Control Study

INTRODUCTION

Investigation in each community can contribute to understanding the key factors involved in suicide death and its prevention. The present study aimed to investigate suicide death risk factors based on psychological autopsy method.

METHODS

The present case-control study was conducted from April to September 2017, in Tehran, Iran, to compare two groups of people; those who died by suicide and controls (over the age of 18 years). Data were collected by one interviewer via Structured Clinical Interviews (SCID-I), questionnaires used in the SUPREMISS study, and the Dickman impulsivity scale.

RESULTS

Each group consisted of 40 individuals. There was no significant difference between the case and control groups in terms of all demographic variables except for the level of education (p = 0.06) and occupational status (p = 0.009). The frequency of previous history of suicide attempt (p = 0.001), family history of suicide (p = 0.003), DSM IV Axis I disorders (p = 0.006), and substance and alcohol consumption (p = 0.01) were significantly higher in the case group. The most commonly diagnosed disorders included MDD (45%) and substance use disorders (30%), respectively. The most common methods used in suicide included hanging (32.5%), and Aluminum phosphide poisoning (32.5%) known as rice tablet. The strongest predictor of suicide death was the deceased person's Previous history of suicide attempt (OR= 9.3; p = 0.04), smoking (OR= 6.4; p = 0.006), unemployment (OR= 5; p = 0.02), and DSM IV axis I disorders (OR= 3.8; p = 0.04).

CONCLUSION

Previous suicide attempt, smoking, unemployment, and suffering from at least one mental disorder were the significant predictors of suicide death. Among mental disorders, major depressive disorder and substance use disorder were the most prevalent mental health problems.

Over-indebtedness and its association with sleep and sleep medication use

BACKGROUND

Over-indebtedness is currently rising in high-income countries. Millions of citizens are confronted with the persistent situation when household income and assets are insufficient to cover payment obligations and living expenses. Previous research shows that over-indebtedness increases the risk of various adverse health effects. However, its association with sleep problems has not yet been examined. The objective of this study was to investigate the association between over-indebtedness and sleep problems and sleep medication use.

METHODS

A cross-sectional study on over-indebtedness (OID survey) was conducted in 70 debt advisory centres in Germany in 2017 that included 699 over-indebted respondents. The survey data were combined with the nationally representative German Health Interview and Examination Survey for Adults (DEGS1; n = 7987). We limited analyses to participants with complete data on all sleep variables (OID: n = 538, DEGS1: n = 7447). Descriptive analyses and logistic regression analyses were used to examine the association between over-indebtedness and difficulty initiating and maintaining sleep, and sleep medication use.

RESULTS

A higher prevalence of sleep problems and sleep medication use was observed among over-indebted individuals compared to the general population. After adjustment for socio-economic and health factors (age, sex, education, marital status, employment status, subjective health status and mental illness), over-indebtedness significantly increased the risk of difficulties with sleep onset (adjusted odds ratio (aOR) 1.79, 95%-confidence interval (CI) 1.45-2.21), sleep maintenance (aOR 1.45, 95%-CI 1.17-1.80) and sleep medication use (aOR 3.94, 95%-CI 2.96-5.24).

CONCLUSIONS

Evidence suggests a strong association between over-indebtedness and poor sleep and sleep medication use independent of conventional socioeconomic measures. Considering over-indebtedness in both research and health care practice will help to advance the understanding of sleep disparities, and facilitate interventions for those at risk.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00013100 (OID survey, ArSemü); Date of registration: 23.10.2017; Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Risk factors for suicide in rural Italy: a case-control study

PURPOSE

Increased frequency of suicide in rural areas of Tuscany has been described since the 1970s. A case-control study was conducted in 2014 and 2015. The objective of this study was to identify major individual risk factors related to suicides in six rural districts of Tuscany.

METHODS

Cases were identified as all 128 suicides occurred in six rural districts between 2009 and 2013. Controls (three for each case) were matched for age, sex, and general practice. Information was collected from GPs using a structured questionnaire. Univariate and multivariate analyses were carried out to investigate the association between individual risk factors and suicide.

RESULTS

Informants for 91 cases of the 128 identified cases were successfully interviewed (response rate 71.1%). About 40.5-65.9% suicide cases and 11.4-20.0% of controls had some psychiatric pathology, accordingly to different definitions. Univariate conditional regression analysis showed that living in isolated houses (OR 2.48), living alone (OR 2.97), not being married (OR 2.63), low income (OR 2.73), psychiatric pathology (OR 9.70), psychotropic medication (OR 5.58), problems with relatives (OR 14.78), psychiatric family history (OR 5.67), and suicidal ideation (OR 15.61) were all risk factors. Practising religion (OR 0.27) was the only protective factor identified. Multivariate regression identified two independently and significantly associated variables namely, psychiatric pathology (OR 8.87) and living alone (OR 2.30).

CONCLUSIONS

Results of this study showed, similarly to recent research, that not all suicide events are the results of psychiatric pathology. Prevention strategies should, therefore, target both socio-economic and clinical risk factors.

Evidence-Based Suicide Prevention: Collective Impact of Engagement with Community Stakeholders

Purpose: In response to the rising suicide trend in Hong Kong, the Centre for Suicide Research and Prevention ("CSRP") was established in 2002, with the aim to capitalize on the collective impact of research-support practices to prevent suicides.Method: The CSRP has since become an international knowledge hub that applies a public health approach and innovative strategies to address suicide-related problems at multiple levels.Results: The CSRP actively engages in research, teaching, and knowledge exchange with community stakeholders. These effort are associated with Hong Kong's more than 30% reduction in suicide rates between 2003 and 2016.Discussion: The rationale for and examples of the CSRP's practices in face of the suicide prevention challenges lay ahead were also discussed.Conclusion: The outcomes of these practices, which hold great potential for suicide prevention worldwide, have contributed to important academic debates in the field of suicidology.

Relationship between mortality in people with mental disorders and suicide mortality in China during 2000 to 2014: An observational study

Suicide is one of the top 10 causes of death in many countries. Although there are many studies on mental disorders, few studies have examined mortality in suicide population and mentally ill population. This study examined the association between mortality and mental disorders using data on suicides and mental disorders in China. Data from China's Health and Family Planning Statistical Yearbook for 2000 to 2014 were used to analyze the relationship between mortality associated with suicide and mental disorders. The analyses found that mortality among people with mental disorders dropped from 5.42/10 million in 2000 to 2.68/10 million in 2014, decreased more among females than males, and differed between urban and rural areas; that suicide mortality dropped from 10.79/10 million in 2000 to 6.79/10 million in 2014; the decrease was greater in women than in men, with suicide being highest among male residents of cities; and no significant correlation was found between mortality among persons with mental disorders and suicide mortality. There was no correlation between suicide mortality and mental-disorder mortality during 2000 to 2014; however, overall mortality decreased more among females than males during this period.

Prevalence of psychiatric diagnoses in individuals who die by suicide or attempt suicide in China based on independent structured diagnostic interviews with different informants

Many individuals who die by suicide or attempt suicide have no pre-existing psychiatric record. In these cases determination of the presence of mental illness at the time of the suicidal act depends on diagnostic interviews with different informants, but the reliability of such interviews is unknown. To address this issue, the current study from northern China conducted independent diagnostic interviews (by different psychiatrists) with a co-resident family member and another associate of 151 suicide decedents, with 120 individuals who attempted suicide, and with two proxy informants for each suicide attempter. In the suicide decedent group, 56% of interviews with family members and 50% with other associates resulted in one or more psychiatric diagnosis; the concordance (kappa) of these two respondents for the presence of any current psychiatric disorder, any mood disorder and any other psychiatric disorder were 0.35, 0.32 and 0.41, respectively. In the suicide attempt group, 47% of interviewers with suicide attempters, 31% with family members, and 15% with other associates resulted in a psychiatric diagnosis; the concordance for any current psychiatric disorder, any mood disorder and any other psychiatric disorder between the interview with the suicide attempter and the combined result of the two separate proxy informant interviews were 0.31, 0.34 and 0.39, respectively. We conclude that the concordance of the presence and type of psychiatric diagnosis of individuals with suicidal behavior based on independent structured interviews by psychiatrists with different informants is low to fair and that using multiple informants will increase the identification of psychiatric disorders.

What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland

OBJECTIVES

Research focussing on the impact of suicide bereavement on family members' physical and psychological health is scarce. The aim of this study was to examine how family members have been physically and psychologically affected following suicide bereavement. A secondary objective of the study was to describe the needs of family members bereaved by suicide.

DESIGN

A mixed-methods study was conducted, using qualitative semistructured interviews and additional quantitative self-report measures of depression, anxiety and stress (DASS-21).

SETTING

Consecutive suicide cases and next-of-kin were identified by examining coroner's records in Cork City and County, Ireland from October 2014 to May 2016.

PARTICIPANTS

Eighteen family members bereaved by suicide took part in a qualitative interview. They were recruited from the Suicide Support and Information System: A Case-Control Study (SSIS-ACE), where family members bereaved by suicide (n=33) completed structured measures of their well-being.

RESULTS

Qualitative findings indicated three superordinate themes in relation to experiences following suicide bereavement: (1) co-occurrence of grief and health reactions; (2) disparity in supports after suicide and (3) reconstructing life after deceased's suicide. Initial feelings of guilt, blame, shame and anger often manifested in enduring physical, psychological and psychosomatic difficulties. Support needs were diverse and were often related to the availability or absence of informal support by family or friends. Quantitative results indicated that the proportion of respondents above the DASS-21 cut-offs respectively were 24% for depression, 18% for anxiety and 27% for stress.

CONCLUSIONS

Healthcare professionals' awareness of the adverse physical and psychosomatic health difficulties experienced by family members bereaved by suicide is essential. Proactively facilitating support for this group could help to reduce the negative health sequelae. The effects of suicide bereavement are wide-ranging, including high levels of stress, depression, anxiety and physical health difficulties.

An exploratory study of illegal gamblers in Hong Kong

This study investigates the nature and behaviour of illegal gamblers in Hong Kong. A face-to-face street survey of 512 gamblers was conducted in Hong Kong between September and December 2015 with supplementary convenience sampling allowing for analysis of a total sample of 103 illegal gamblers. 56% of illegal gamblers recorded results consistent with this study’s definition of ‘excessive gambling’ [i.e. moderate risk and problem gamblers under the Problem Gambling Severity Index (PGSI)]. 81% of surveyed illegal gamblers were male, 77% were aged between 30 and 49 and 67% were in blue collar occupations. Illegal gamblers bet more frequently on both legal and illegal games than their legal counterparts and spent more when they did bet. While this research did not indicate the direction of causality between illegal and excessive gambling, international work (de Bruin et al. in verslingerd aan meer dan een spel: Een onderzoek naar de aard en omvang van kansspelproblematiek in Nederland, WODC/CVO, Utrecht, http://www.lexandgaming.eu/nl/wp-content/uploads/2015/01/Verslingerd-aan-meer-dan-een-spel.pdf, 2005; Binde in What are the most harmful forms of gambling? Analysing problem gambling prevalence surveys, http://www.utbildning.gu.se/digitalAssets/1327/1327132_cefos-wp12.pdf, 2011) suggests that excessive gamblers are drawn to illegal gambling. Reform could allow excessive gambling by illegal gamblers to be better addressed and initial work suggests some financial benefits to Hong Kong.

Media effects on suicide methods: A case study on Hong Kong 1998-2005

Background

Previous studies have suggested that mass media’s reports of new suicide methods will increase suicides using the same method. The same pattern seems not to apply to a conventional suicide method, unless it was used by a celebrity.

Objective

1) to examine media effects on both new and non-new suicide methods during 1998 and 2005 in Hong Kong (HK), when a new method by burning charcoal (CB suicide) was spreading in the region. 2) to examine how CB competed with non-CB methods in terms of media coverage and “recruiting” suicidal persons in the socio-economic context.

Methods

A self- and mutual- exciting process model was fitted to the data, adjusting for divorce rate, unemployment rate, and property price index. Breaking the whole period into onset, peak, and post-peak stages, the model was fitted again to examine the differences.

Results

Comparable copycat effects were found on both CB and non-CB suicide news. The only cross-method media effects were found in the onset stage when non-CB suicide news showed suppressing effect on CB suicides. CB suicides reported a significant self-excitation effect. A higher divorce rate and lower property price index were associated with significantly more suicides incidences and more suicide news.

Conclusions

The emerging of CB suicide method did not substitute media coverage of non-CB suicide in HK. Media effects in this case were not limited to new suicide method or celebrity suicide. The effects were further fueled by adverse socio-economic conditions.

Mixed Methods Analysis of Sex Differences in Life Stressors of Middle-Aged Suicides

INTRODUCTION

Between 1999 and 2013, rates of suicide in mid-life increased more than 30%. The purpose of this study is to examine life stressors impacting middle-aged suicide, to determine whether these stressors vary by sex, and to explore their co-occurrence.

METHODS

A random sample of 315 men and 315 women aged 35-64 years was selected from 17 states implementing the National Violent Death Reporting System from its inception in 2003 to 2011. Data collection took place between 2003 and 2011 and analysis occurred in 2015. Analysis included coding circumstances of death noted in the law enforcement and coroner/medical examiner reports using an investigator-designed coding instrument. Using the most commonly cited life stressors as a basis, thematic analyses were conducted for cases. Quantitative comparisons of the most common circumstances by sex were calculated via multivariable logistic regression.

RESULTS

The five most common life stressors of suicide included intimate partner, job/financial, health, family, and criminal/legal problems. In adjusted analyses, job/financial problems and criminal/legal problems were more common among men, whereas health and family problems were more common among women. Men and women had similar rates of intimate partner problems. Life stressors also co-occurred, as found per qualitative and quantitative analyses.

CONCLUSIONS

Men and women in mid-life have both common and unique circumstances preceding suicide. Prevention strategies that consider these circumstances and co-occurring circumstances are warranted.

EPA guidance on mental health and economic crises in Europe

This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.

The association of suicide risk with negative life events and social support according to gender in Asian patients with major depressive disorder

We investigated the associations between negative life events, social support, depressive and hostile symptoms, and suicide risk according to gender in multinational Asian patients with major depressive disorder (MDD). A total of 547 outpatients with MDD (352 women and 195 men, mean age of 39.58±13.21 years) were recruited in China, South Korea, Malaysia, Singapore, Thailand, and Taiwan. All patients were assessed with the Mini-International Neuropsychiatric Interview, the Montgomery-Asberg Depression Rating Scale, the Symptoms Checklist 90-Revised, the Multidimensional Scale of Perceived Social Support, and the List of Threatening Experiences. Negative life events, social support, depressive symptoms, and hostility were all significantly associated with suicidality in female MDD patients. However, only depressive symptoms and hostility were significantly associated with suicidality in male patients. Depression severity and hostility only partially mediated the association of negative life events and poor social support with suicidality in female patients. In contrast, hostility fully mediated the association of negative life events and poor social support with suicidality in male patients. Our results highlight the need of in-depth assessment of suicide risk for depressed female patients who report a number of negative life events and poor social supports, even if they do not show severe psychopathology.

Acute and Chronic Risk Preceding Suicidal Crises Among Middle-Aged Men Without Known Mental Health and/or Substance Abuse Problems: An Exploratory Mixed-Methods Analysis

BACKGROUND

Suicides among men aged 35-64 years increased by 27% between 1999 and 2013, yet little research exists to examine the nature of the suicide risk within this population. Many men do not seek help if they have mental health problems and suicides may occur in reaction to stressful circumstances.

AIMS

We examined the precipitating circumstances of 600 suicides without known mental health or substance abuse (MH/SA) problems and with a recent crisis. Whether these suicides occurred within the context of an acute crisis only or in the context of chronic circumstances was observed.

METHOD

Using data from the National Violent Death Reporting System and employing mixed-methods analysis, we examined the circumstances and context of a census of middle-aged male suicides (n = 600) in seven states between 2005 and 2010.

RESULTS

Precipitating circumstances among this group involved intimate partner problems (IPP; 58.3%), criminal/legal problems (50.7%), job/financial problems (22.5%), and health problems (13.5%). Men with IPP and criminal/legal issues were more likely than men with health and/or job/financial issues to experience suicide in the context of an acute crisis only.

CONCLUSION

Suicides occurring in reaction to an acute crisis only or in the context of acute and chronic circumstances lend themselves to opportunities for intervention. Further implications are discussed.

Systematic review of suicide in economic recession

AIM: To provide a systematic update of the evidence concerning the relationship between economic recession and suicide.

METHODS: A keyword search of Ovid Medline, Embase, Embase Classic, PsycINFO and PsycARTICLES was performed to identify studies that had investigated the association between economic recession and suicide.

RESULTS: Thirty-eight studies met predetermined selection criteria and 31 of them found a positive association between economic recession and increased suicide rates. Two studies reported a negative association, two articles failed to find such an association, and three studies were inconclusive.

CONCLUSION: Economic recession periods appear to increase overall suicide rates, although further research is warranted in this area, particularly in low income countries.

Developing the Pieta House Suicide Intervention Model: a quasi-experimental, repeated measures design

BACKGROUND

While most crisis intervention models adhere to a generalised theoretical framework, the lack of clarity around how these should be enacted has resulted in a proliferation of models, most of which have little to no empirical support. The primary aim of this research was to propose a suicide intervention model that would resolve the client's suicidal crisis by decreasing their suicidal ideation and improve their outlook through enhancing a range of protective factors. The secondary aim was to assess the impact of this model on negative and positive outlook.

METHODS

A quasi-experimental, pre-test post-test repeated measures design was employed. A questionnaire assessing self-esteem, depression, and positive and negative suicidal ideation was administered to the same participants pre- and post- therapy facilitating paired responses.

RESULTS

Multiple analysis of variance and paired-samples t-tests were conducted to establish whether therapy using the PH-SIM had a significant effect on the clients' negative and positive outlook. Analyses revealed a statistically significant effect of therapy for depression, negative suicidal ideation, self-esteem, and positive suicidal ideation. Negative outlook was significantly lower after therapy and positive outlook significantly higher.

CONCLUSIONS

The decreased negative outlook and increased positive outlook following therapy provide some support for the proposed model in fulfilling its role, though additional research is required to establish the precise role of the intervention model in achieving this.

Patterns of stressful life events: distinguishing suicide ideators from suicide attempters

BACKGROUND

Suicidal ideation is an important indicator for subsequent suicidal behaviour, yet only a proportion of ideators transit from thought to action. This has led to interest surrounding the factors that distinguish ideators who attempt from non-attempters. The study aimed to identify distinct classes of life event categories amongst a sample of ideators and assess the ability of the classes to predict the risk of a suicide attempt.

METHODS

A subsample of ideators was extracted based on responses to the suicidality section of the Adult Psychiatric Morbidity Survey (N=7403). Fifteen stressful life events (SLEs) were grouped into six broad categories.

RESULTS

Using Latent Class Analysis (LCA), three distinct classes emerged; class 1 had a high probability of encountering interpersonal conflict, class 2 reported a low probability of experiencing any of the SLE categories with the exception of minor life stressors, whereas class 3 had a high probability of endorsing multiple SLE categories. The Odds Ratio for attempted suicide were highest among members of Class 3.

LIMITATIONS

The use of broad event categories as opposed to discrete life events may have led to an underestimation of the true exposure to SLEs.

CONCLUSIONS

The findings suggest the experience of multiple types of SLEs may predict the risk of transitioning towards suicidal behaviour for those individuals who have contemplated suicide. In application, this re-emphasises the need for a routine appraisal of risk amongst this vulnerable group and an assessment of the variety of events which may signal the individuals who may be at immediate risk.

"Geography of suicide in Hong Kong: spatial patterning, and socioeconomic correlates and inequalities"

Past urban research on Western nations tends to show high suicide rates in inner city and socioeconomically deprived areas. However, little is known about geographic variations in suicide in non-Western cities. We used Bayesian hierarchical models to estimate smoothed standardised mortality ratios (2005-2010) for suicide in people aged 10 years or above in each geographic unit in Hong Kong at two levels, i.e. large street block (n = 1639; median population = 1860) and small tertiary planning unit group (n = 204; median population = 14,850). We further analysed their associations with a range of area socioeconomic characteristics and a deprivation index. The "city centre" of Hong Kong, a generally non-deprived area, showed mostly below average suicide rates. However, there were high rates concentrating in some socioeconomically deprived, densely populated areas, including some inner city areas, across the city. Males had greater geographic variations in rates than females, except the elderly group. The use of smaller geographic units revealed finer detailed suicide distribution than the use of larger units, and showed that suicide rates were associated with indicators of socioeconomic deprivation (population with non-professional jobs and low median household income), and social fragmentation (proportions of unmarried adults and divorced/separated adults), but not with Gini coefficient. Sex/age groups had different associations with suicide rates. Areas in the most deprived quintile had a suicide rate more than two times higher than the least deprived. The association between suicide and deprivation was stronger in males than females and more marked in the younger populations compared to the elderly. The spatial distribution of suicide in Hong Kong showed distinct patterning and a stronger association with income compared to findings from Western countries. Suicide prevention strategies should consider tackling the marked socioeconomic gradient in suicide and high risk in young and middle-aged males living in deprived areas.

Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries

BACKGROUND

While numerous past reviews of psychological autopsy (PA) studies have examined the relationship between mental disorder and suicide, there has been little systematic investigation of suicide occurring in the absence of any identifiable psychiatric condition.

AIM

This article reviews available literature on the topic by considering Axis I, sub-threshold, mild disorders and personality disorders.

METHOD

We conducted a systematic review of PA studies from 2000 onwards. Studies included in the review had to clearly describe the proportion of suicide cases without a classifiable mental disorder or sub-threshold condition.

RESULTS

Up to 66.7% of suicide cases remained without diagnosis in those studies that only examined Axis I disorders (n = 14). Approximately 37.1% of suicide cases had no psychiatric condition in research papers that assessed personality and Axis I disorders (n = 9), and 37% of suicides had no Axis I, sub-threshold/mild conditions (n = 6). In general, areas in China and India had a higher proportion of suicides without a diagnosis than studies based in Europe, North America or Canada.

CONCLUSION

Variation in the proportion of suicide cases without a psychiatric condition may reflect cultural specificities in the conceptualization and diagnosis of mental disorder, as well as methodological and design-related differences between studies.

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

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

[Recommendations for the prevention and management of suicidal behaviour]

INTRODUCTION

Suicidal behaviour is a major public health issue. Suicidal behaviour is one of the main causes of years of life lost and it is the third leading cause of death among young adults. This project was initiated by the Spanish Society of Psychiatry and the Spanish Society of Biological Psychiatry with the aim of providing a document containing the main recommendations on the prevention and management of suicidal behaviour; these recommendations should be based on the best available evidence and the experts' opinion.

MATERIAL AND METHODS

In this article we summarize the review of the available evidence on the epidemiology and impact of suicidal behaviour, risk and protective factors, evaluation tools for the assessment of suicide risk, international and local preventive protocols, educational interventions for health professionals, and potential interventions for at risk populations.

RESULTS

Based on this review, a panel of psychiatrists summarized and agreed a set of recommendations about the impact, prevention and management of suicidal behaviour.

CONCLUSION

The recommendations on the prevention and management of suicidal behaviour were summarized in the ten conclusions reported in this article.

Mortality from suicide and other external cause injuries in China: a prospective cohort study

BACKGROUND

Premature death from suicide is a leading cause of death worldwide. However, the pattern and risk factors for suicide and other external cause injuries are not well understood. This study investigates mortality from suicide and other injuries and associated risk factors in China.

METHODS

A prospective cohort study of 169,871 Chinese adults aged 40 years and older was conducted. Mortality due to suicide or other external cause injuries was recorded.

RESULTS

Mortality from all external causes was 58.7/100,000 (72.3 in men and 44.4 in women): 14.1/100,000 (14.2 in men and 14.2 in women) for suicide and 44.6/100,000 (58.1 in men and 30.2 in women) for other external cause injuries. Transport accidents (17.2/100,000 overall, 23.4 in men and 10.8 in women), accidental poisoning (7.5/100,000 overall, 10.2 in men and 4.8 in women), and accidental falls (5.7/100,000 overall, 6.5 in men and 5.0 in women) were the three leading causes of death from other external cause injuries in China. In the multivariable analysis, male sex (relative risk [RR] 1.56, 95% confidence interval [CI] 1.03-2.38), age 70 years and older (2.27, 1.29-3.98), living in north China (1.68, 1.20-2.36) and rural residence (2.82, 1.76-4.51) were associated with increased mortality from suicide. Male sex (RR 2.50, 95% CI 1.95-3.20), age 60-69 years (1.93, 1.45-2.58) and 70 years and older (3.58, 2.58-4.97), rural residence (2.29, 1.77-2.96), and having no education (1.56, 1.00-2.43) were associated with increased mortality from other external cause injuries, while overweight (0.60, 0.43-0.83) was associated with decreased risk of mortality from other external cause injuries.

CONCLUSIONS

External cause mortality has become a major public health problem in China. Developing an integrated national program for the prevention of mortality due to external cause injuries in China is warranted.

Research Participation Experiences of Informants of Suicide and Control Cases

Background: Ethical issues have been raised about using the psychological autopsy approach in the study of suicide. The impact on informants of control cases who participated in case-control psychological autopsy studies has not been investigated. Aims: (1) To investigate whether informants of suicide cases recruited by two approaches (coroners’ court and public mortuaries) respond differently to the initial contact by the research team. (2) To explore the reactions, reasons for participation, and comments of both the informants of suicide and control cases to psychological autopsy interviews. (3) To investigate the impact of the interviews on informants of suicide cases about a month after the interviews. Methods: A self-report questionnaire was used for the informants of both suicide and control cases. Telephone follow-up interviews were conducted with the informants of suicide cases. Results: The majority of the informants of suicide cases, regardless of the initial route of contact, as well as the control cases were positive about being approached to take part in the study. A minority of informants of suicide and control cases found the experience of talking about their family member to be more upsetting than expected. The telephone follow-up interviews showed that none of the informants of suicide cases reported being distressed by the psychological autopsy interviews. Limitations: The acceptance rate for our original psychological autopsy study was modest. Conclusions: The findings of this study are useful for future participants and researchers in measuring the potential benefits and risks of participating in similar sensitive research. Psychological autopsy interviews may be utilized as an active engagement approach to reach out to the people bereaved by suicide, especially in places where the postvention work is underdeveloped.

Suicide with psychiatric diagnosis and without utilization of psychiatric service

Background

Considerable attention has been focused on the study of suicides among those who have received help from healthcare providers. However, little is known about the profiles of suicide deceased who had psychiatric illnesses but made no contact with psychiatric services prior to their death. Behavioural model of health service use is applied to identify factors associated with the utilization of psychiatric service among the suicide deceased.

Methods

With respect to completed suicide cases, who were diagnosed with a mental disorder, a comparison study was made between those who had (contact group; n = 52; 43.7%) and those who had not made any contact (non-contact group; n = 67; 56.3%) with a psychiatrist during the final six months prior to death. A sample of 119 deceased cases aged between 15 and 59 with at least one psychiatric diagnosis assessed by the Structured Clinical Interview for DSM-IV-TR (SCID I) were selected from a psychological autopsy study in Hong Kong.

Results

The contact and non-contact group could be well distinguished from each other by "predisposing" variables: age group & gender, and most of the "enabling", and "need" variables tested in this study. Multiple logistic regression analysis has found four factors are statistically significantly associated with non-contact suicide deceased: (i) having non-psychotic disorders (OR = 13.5, 95% CI:2.9-62.9), (ii) unmanageable debts (OR = 10.5, CI:2.4-45.3), (iii) being full/partially/self employed at the time of death (OR = 10.0, CI:1.6-64.1) and (iv) having higher levels of social problem-solving ability (SPSI) (OR = 2.0, CI:1.1-3.6).

Conclusion

The non-contact group was clearly different from the contact group and actually comprised a larger proportion of the suicide population that they could hardly be reached by usual individual-based suicide prevention efforts. For this reason, both universal and strategic suicide prevention measures need to be developed specifically in non-medical settings to reach out to this non-contact group in order to achieve better suicide prevention results.

Suicide and employment status during Ireland's Celtic Tiger economy

BACKGROUND

 Studies have identified employment as a protective factor against suicide. We examined employment status and risk of suicide in Ireland during the 11-year period 1996-2006, a period of economic boom commonly known as the Celtic Tiger. 

METHODS

 Data relating to the 5270 suicides and 789 deaths of undetermined intent registered as occurring in Ireland in 1996-2006 and relevant population data were obtained from the Irish Central Statistics Office and analysed using Poisson regression. 

RESULTS

 Unemployment fell from 12% in 1996 to 4% in 2000, a level at which it remained until 2006. Male and female rates of suicide and undetermined death were stable during 1996-2006 though suicide among unemployed men increased. Relative to employment, unemployment was associated with a 2-3-fold increased risk of male suicide and undetermined death but generally a 4-6-fold increased risk in women. Unemployment was associated with greater increased risk of suicide and undetermined death when its level was low (2001-06) than in the period of decreasing unemployment (1996-2000). Unemployment was a stronger risk factor in men aged 35-54 years and with increasing age in women. Retired persons aged >55 years had a similar risk to their employed counterparts. Being a homemaker was associated with increased risk in women aged >35 years. 

CONCLUSION

 The current Irish context of rapidly increasing unemployment suggests that rates may rise again as in previous recessions. Appropriate social policy responses are required to mitigate the potential impact of unemployment on suicides.

Risk factors for suicide in Bali: a psychological autopsy study

Background

The suicide rate in Bali has significantly increased in recent years. However, to date, there have been no case-control studies investigating risk factors for suicide.

Methods

A psychological autopsy study was conducted comparing 60 suicide cases and 120 living controls matched in age, sex, and area of residence.

Results

Multiple logistic regression analysis identified the following risk factors for suicide: at least one diagnosis of axis-I mental disorder (OR: 14.84 CI: 6.12 - 35.94); low level of religious involvement (OR: 7.24 CI: 2.28 - 22.95); and severe interpersonal problems (OR: 3.86 CI: 1.36 - 11.01). Forty-eight (80.0%) of the suicide cases were diagnosed with mental disorders; however, only 16.7% visited a primary care health professional and none received psychiatric treatment during the 1 month prior to death.

Conclusion

Clinical, religious, and psychosocial factors were associated with suicide. These results highlight the significance of early recognition and treatment of mental disorders, religious activities, and interpersonal problem-solving strategies for suicide prevention in Bali.

Risk factors for suicide in Hungary: a case-control study

BACKGROUND

Hungary previously had one of the highest suicide rates in the world, but experienced major social and economic changes from 1990 onwards. We aimed to investigate the antecedents of suicide in Hungary. We hypothesised that suicide in Hungary would be associated with both risk factors for suicide as identified in Western studies, and experiences related to social and economic restructuring.

METHODS

We carried out a controlled psychological autopsy study. Informants for 194 cases (suicide deaths in Budapest and Pest County 2002-2004) and 194 controls were interviewed by clinicians using a detailed schedule.

RESULTS

Many of the demographic and clinical risk factors associated with suicide in other settings were also associated with suicide in Hungary; for example, being unmarried or having no current relationship, lack of other social contacts, low educational attainment, history of self-harm, current diagnosis of affective disorder (including bipolar disorder) or personality disorder, and experiencing a recent major adverse life event. A number of variables reflecting experiences since economic restructuring were also associated with suicide; for example, unemployment, concern over work prospects, changes in living standards, practising religion. Just 20% of cases with evidence of depression at the time of death had received antidepressants.

CONCLUSION

Suicide rates in Hungary are falling. Our study identified a number of risk factors related to individual-level demographic and clinical characteristics, and possibly recent societal change. Improved management of psychiatric disorder and self-harm may result in further reductions in suicide rates.

Suicides by jumping from iconic bridges in Hong Kong

BACKGROUND

Three bridges in Hong Kong have become iconic sites for suicide since their openings 11 years ago.

AIMS

This retrospective record-based study aimed to examine suicides by jumping from a group of three iconic bridges in Hong Kong, and to explore potential preventive strategies on these bridges to prevent future suicide.

METHODS

We examined the Coroner's files of 12 people who killed themselves by jumping from the bridges between 1997 and 2007. We also examined the Coroner's files of other suicides in 2003, and compared them with the bridge suicides.

RESULTS

The majority of the suicides were male, middle-age (40-59 years), married or cohabiting, not living alone, employed or self-employed, and in financial difficulty. None of these cases had a reported psychiatric diagnosis or psychiatric care history, and only one case had a history of suicidal attempt. Compared with other suicides in Hong Kong, the bridge jumpers were more likely to be younger, holding a job, indebted, free from a psychiatric and attempt history, and to leave a suicide note (p < .05). The bridge suicide cases in Hong Kong also appeared to be different from the profiles of bridge jumpers in other countries.

CONCLUSIONS

Erection of an effective safety barrier has been found to prevent bridge suicides in many countries. Given the different characteristics of bridge jumpers in Hong Kong and the technical difficulties, more innovative ways may be needed to prevent suicides by such means. Potential prevention measures are discussed and, hopefully, will better inform the future design and development of bridges of significance.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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