Suicide and community care

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.

Suicide and the elderly

Impending demographic changes mean that the proportion of the elderly in the population will increase. Suicide rates increase with age. The literature on elderly suicide, with emphasis on methodology, cross-national rates and trends, correlates, cultural factors, location and method, attempted suicides and prevention, is critically reviewed in this paper.

Challenges in preventing suicide

The success of traditional suicide prevention efforts is evaluated and found wanting. Some encouraging recent developments are noted, and it is suggested that suicidologists might also profitably consider the strategies used by professionals dealing with other public health and social problems, such as drug abuse and delinquency.

Clinical management of parasuicides: critical issues in the 1990s

In view of recent rises in suicide rates of males aged 15-29 years, the literature on the specialised clinical management of parasuicides presenting at hospital is reviewed. Few studies demonstrate reduction in suicidal behaviour with such services, although substantial psychosocial benefits have been shown. These negative results with respect to suicidal behaviour partly relate to methodological problems such as small sample sizes, the exclusion of high risk subjects, short follow-up and confusing outcome measures. We cannot be confident that existing clinical practices have been effective in reducing suicide. Hence this paper focuses on selected issues of critical importance. Clinically, risk assessment is a problematic area worthy of clear understanding. There is a continuing confusion over the nature of affective disturbance associated with parasuicide and whether it might benefit from pharmacotherapy. Recent studies on the prevalence of psychological disorder in suicidal youth are discussed. Child abuse might usefully be screened for in parasuicidal patients, although this may be overlooked because of unfamiliarity with the association. New developments in cognitive and pharmacotherapies offer hope for suicidal rate reduction. There is a pressing need for further intervention studies. In particular, community and inpatient care of high risk patients require urgent evaluation. Further study of the role of depression and its appropriate management is needed. Although depression seems a significant factor, the recent rise in youth suicide remain largely unexplained.

Evaluation of suicide intervention effectiveness

Considering the prevalence of suicide and other forms of self-injurious behavior, it is ironic that relatively little attention has been paid to the training of mental health workers in suicide intervention. Still less effort has been spent in evaluating the effectiveness of such workers or the agencies in which they serve. We review the evaluation strategies that have been used to assess the process and outcome of suicide intervention, ranging from macroanalyses of the impact of crisis services on suicide rates in the community to microanalyses of the competence of individual suicide interventionists. Particular attention is paid to the Suicide Intervention Response Inventory, a self-administered test of suicide counseling skills whose validity, reliability, and practical utility suggest the benefit of its use in a broader range of research and applied settings. The advantages and disadvantages of each evaluation strategy are discussed, and guidelines are offered for the sophistication of future research and program evaluation efforts.

Suicide in psychiatric patients: risk and prevention

The prevention of suicide requires an understanding of protective as well as risk factors, and the recognition of high-risk groups. Factors which increase the risk in patient populations include previous parasuicide, recent relapse or discharge, features of mental state (depression, psychosis), social circumstances (isolation, unemployment), and demographic characteristics (male sex, young age). Protective factors are under-researched but are likely to lie in the nature of psychiatric care. Consequently, community care may affect suicide by altering the level of protection at critical periods in an episode of illness. The clinical prevention of suicide should therefore be a priority for community services, and the relationship between suicide and mental health care should be researched by a national process of monitoring.

Does telephone counselling have preventive value?

Major developments in health care frequently result not from careful planning by professional health care providers, but from social processes whereby a heightened awareness of need leads to new strategies and resources for community support. The development of a network of hospitals in eighteenth-century England was 'the outcome of individual initiative and of coordinated voluntary effort and subscription'. The evolution of mental health care in the United States was influenced greatly by the enthusiasm and advocacy of reformers such as Dorothea Dix and Clifford Beers. The development of telephone counselling services, now an integral part of community mental health care, resulted from a recognition that the psychosocial stresses of twentieth-century life could perhaps be alleviated through support offered by telephone. This recognition has led to the mobilising of many thousands of volunteers who serve in hundreds of telephone counselling services worldwide. For telephone counselling as for many other new developments, the initial period of growth has been followed by one of reflection and evaluation. That telephone counselling services have earned a place in the community mental health network and are here to stay is beyond doubt, though the ways in which they can be used to greatest advantage are still being clarified. At the level of primary prevention there is as yet no convincing evidence that telephone counselling services have reduced the incidence of psychological disorder. It must be added, however, that mental health professionals have also had relatively little success in reducing the occurrence of psychological disorder, and only with carefully designed programs directed toward specific at-risk groups. The evidence is more encouraging at the level of secondary prevention.(ABSTRACT TRUNCATED AT 250 WORDS)

Association between changes in psychiatric services and increases in suicide rates

The purpose of the study is to discover whether there is an association between changes in the psychiatric services offered by the largest psychiatric hospital in Iceland during the period 1955-1978 and changes in the rate of suicide. Marked changes occurred in the services after 1965. The rate of suicide in the patient population was significantly higher during 1965-1978 than during 1955-1964. It is concluded that the changes in the psychiatric services are associated with an increase in the rate of suicide and that this increase may to some extent be a side effect of therapeutic methods introduced after 1965. The conclusion is thought to imply the necessity for further evaluation of those therapeutic methods as applied in the hospital and increasing the application of measures for the prevention of suicide.

Influence of experience and nationality on assessment and outcome of parasuicide

In Sheffield 544 consecutive cases of attempted suicide (parasuicide) were seen at 2 large hospitals over a 12-month period, and allocated in sequence to the junior and senior psychiatric staff, of British and foreign origin. During the follow-up period of 12 months, 31 patients had a further episode of parasuicide and 5 patients committed suicide. The outcome (as measured by repeat parasuicide or suicide) was not significantly affected by the country of origin of the psychiatrist, nor his length of training in psychiatry.

Suicide and prevention centres

Summary

Suicide and parasuicide rates have been underestimated in the past although there is evidence to show that the individuals in the official statistics are representative of the suicidal population as a whole. Both medical and non-medical agencies are involved in suicide prevention and while their effectiveness is uncertain their efforts should be judged by the same criteria with the whole spectrum ideation taken into account.

"Suicidal behaviour" in New South Wales

For about fifteen years now a tradition has been evolving in the psychiatric literature towards a taxonomic separation of suicides and attempted suicides, on the assumption that they involve distinct psychogenic factors (Stengel and Cook, 1958; Farberow and Schneidman, 1961). However, even the originator of the distinction agreed that a better understanding of attempted suicide could be gained if it is regarded as conveying a degree of uncertainty that the attempt will succeed or fail (Stengel, 1958), and that the separation of ‘… suicide and attempted suicide … is artificial (as) … it is possible to view suicidal acts as a whole and irrespective of outcome’ (Stengel, 1969, p. 121). The latter view has been reflected in the recent introduction and usage of the term ‘suicidal behaviour’ which includes both suicides and attempted suicides (Hetzel, 1971).

A hundred cases of suicide: clinical aspects

Historically, doctors have not always acknowledged that they have an obligation to prevent suicide, partly because they shared the prevalent idea that most suicides were caused by moral crises, no concern of theirs—and indeed suicide was a criminal matter until quite recently; but more, perhaps, because a fatalism has characterized their attitudes to its prevention, even where the suicide was clearly suffering from mental illness. Yet two recent American studies have shown more than 90 per cent of suicides to be mentally ill before their death (17, 8); this finding and the familiar clinical observation that suicidal thoughts disappear when the illness is successfully treated provide a strong case for a medical policy of prevention.

The epidemiology of self-poisoning in Hobart, 1968-1972

Continued monitoring of the rates for treated self-poisoning in Hobart over a five year period has revealed a marked increase in this behaviour. Attention is drawn to the load this places on medical and psychiatric services. The present study has shown that the rise in self-poisoning was statistically significant among young males and females of most age-groups. This rise was particularly notable in senior secondary schoolgirls. In terms of geographical distribution, significant increases were observed in the economically depressed central areas of Hobart and in satellite towns. The need for greater emphasis on primary prevention is discussed.

Suicide frequency before and after introduction of community psychiatry in a Danish island

The present study was made within the framework of the Sams⊘-project, a psychiatric service and research project in the Danish island of Sams⊘, which had a population of 6,823 in 1957 when the project was started.

A comparison between 'Samaritan suicides' and living Samaritan clients

‘The Samaritans' were founded in 1953 to help ‘the suicidal and despairing’. As with similar lay agencies abroad, their growth in the past ten years has been vigorous; they now have more than 120 branches in the United Kingdom and these branches attracted over 50,000 clients in 1969. The Samaritans' aims have been described in detail by Fox (1968), but their most important aim is still the prevention of suicide. Their success in attracting the suicidal and preventing their subsequent death must therefore be the criteria of their effectiveness.

Medical Research Council Clinical Psychiatry Unit

The Clinical Research Department was started at Graylingwell Hospital, Chichester, Sussex, by Dr. J. Carse in 1947, when the hospital was administered by Sussex County Council. The first director was Dr. (now Professor) E. Stengel, and he undertook the first systematic follow-up of leucotomized patients. From 1950 to 1955 the director was Dr. Martin Roth; his studies on the psychoses of old age, and especially those delineating depressive psychoses, are now a landmark in clinical research. At about this time, the means by which clinical research in the National Health Service hospitals should be administered was reviewed and a policy evolved whereby departments in which clinical research was prospering and whose further development would make financial demands beyond those available to the regional hospital boards would be considered for support by the Medical Research Council.

Geographical location of callers to a suicide prevention center: note on the evaluation of suicide prevention programs

A method of evaluating the effectiveness of suicide prevention centers is described in which the location of callers to the center is compared with the location of suicides in the community. This can serve to inform an agency whether it is reaching into the appropriate areas of a community and the agency can adjust its out-reaching activities accordingly.

Suicide in Western Australia, 1967. An analysis of coroners' records

This paper reports an analysis of the police and coroners' records of all suicides in Western Australia in 1967 Where necessary, previous medical records of inpatient treatment were also scrutinized by the author. The findings are set out and discussed. It is concluded that the medical profession has much to learn in the detection of suicidal risk.

Effect of psychiatric intervention in attempted suicide: a controlled study

All patients presenting at the casualty department of King's College Hospital during the first six months of 1968 with deliberate self-poisoning or self-injury were followed up. Of 211 patients 204 (97%) were traced after a mean interval of 18 months (range one to two years). Despite official hospital policy, 22% had not been seen by a psychiatrist before discharge; these 44 untreated patients were compared with the remaining 160 who had received either brief (one or two interviews) or more prolonged psychiatric and social help.Subsequent suicidal attempts occurred significantly more often among untreated than among treated patients, prolonged treatment being associated with the best prognosis. The same trend was observed in respect of actual suicide, though the numbers were small and differences did not reach statistical significance. These findings held good when the untreated and treated groups were controlled for other variables which were found to be correlated with outcome. These results indicate that psychiatric intervention is associated with a significant reduction in subsequent suicidal behaviour.