Why parasuicides repeat despite problem resolution

A Study of the Relationship between the Patterns of Planned Activity and Incidents of Deliberate Self-Harm within a Regional Secure Unit

Within a 77-bed Regional Secure Unit, there has been an increase in the number of patients admitted who deliberately do themselves harm, although this Is generally not the primary reason for admission. During this 9-month study, 307 incidents of self-harm were recorded on the clinic's information system; a subgroup of seven patients was responsible for 77.5% of these incidents.

Whilst there is a perception among rehabilitation staff that activity has a role in reducing the incidence of deliberate self-harm, this study Identifies no correlation between the patterns of structured activity and the patterns of deliberate self-harm. This does not suggest, however, that occupational therapy is ineffective with this client group, particularly given the potentially addictive nature of deliberate self-harm behaviour even after problem resolution. The study identifies areas for further research, focusing on qualitative rather than quantitative study.

Risk factors for repetition of self-harm: a systematic review of prospective hospital-based studies

BACKGROUND

Self-harm entails high costs to individuals and society in terms of suicide risk, morbidity and healthcare expenditure. Repetition of self-harm confers yet higher risk of suicide and risk assessment of self-harm patients forms a key component of the health care management of self-harm patients. To date, there has been no systematic review published which synthesises the extensive evidence on risk factors for repetition.

OBJECTIVE

This review is intended to identify risk factors for prospective repetition of self-harm after an index self-harm presentation, irrespective of suicidal intent.

DATA SOURCES

PubMed, PsychInfo and Scirus were used to search for relevant publications. We included cohort studies which examining factors associated with prospective repetition among those presenting with self-harm to emergency departments. Journal articles, abstracts, letters and theses in any language published up to June 2012 were considered. Studies were quality-assessed and synthesised in narrative form.

RESULTS

A total of 129 studies, including 329,001 participants, met our inclusion criteria. Some factors were studied extensively and were found to have a consistent association with repetition. These included previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, drug abuse/dependence, and living alone. However, the sensitivity values of these measures varied greatly across studies. Psychological risk factors and protective factors have been relatively under-researched but show emerging associations with repetition. Composite risk scales tended to have high sensitivity but poor specificity.

CONCLUSIONS

Many risk factors for repetition of self-harm match risk factors for initiation of self-harm, but the most consistent evidence for increased risk of repetition comes from long-standing psychosocial vulnerabilities, rather than characteristics of an index episode. The current review will enhance prediction of self-harm and assist in the efficient allocation of intervention resources.

Payment source and emergency management of deliberate self-harm

OBJECTIVES

We investigated whether health insurance type (private vs Medicaid) influences the delivery of acute mental health care to patients with deliberate self-harm.

METHODS

Using National Medicaid Analytic Extract Files (2006) and MarketScan Research Databases (2005-2007), we analyzed claims focusing on emergency episodes of deliberate self-harm of Medicaid- (n=8,228) and privately (n=2,352) insured adults. We analyzed emergency department mental health assessments and outpatient mental health visits in the 30 days following the emergency visit for discharged patients.

RESULTS

Medicaid-insured patients were more likely to be discharged (62.7%), and among discharged patients they were less likely to receive a mental health assessment in the emergency department (47.8%) and more likely to receive follow-up outpatient mental health care (52.9%) than were privately insured patients (46.9%, 57.3%, and 41.2%, respectively).

CONCLUSIONS

Acute emergency management of deliberate self-harm is less intensive for Medicaid- than for privately insured patients, although discharged Medicaid-insured patients are more likely to receive follow-up care. Programmatic reforms are needed to improve access to emergency mental health services, especially in hospitals that serve substantial numbers of Medicaid-insured patients.

Suicide attempts: prevention of repetition

OBJECTIVE

To present an overview of promising strategies to prevent repetition of suicidal behaviours.

METHOD

This literature review on tertiary preventive interventions of suicide attempts was produced using the computerized databases PubMed and PsycINFO from January 1966 to September 2010, using French- and English-language limits and the key words: suicid* or deliberate self-harm and treatment* or therapy or intervention* or management.

RESULTS

Thirteen of the 35 included studies showed statistically significant effects of fewer repeated attempts or suicides in the experimental condition. Overall, 22 studies focused on more traditional approaches, that is, pharmacological or psychological approaches. Only 2 of the 6 pharmacological treatments proved significantly superior to a placebo- a study of lithium with depression and flupenthixol with personality disorders. Eight out of 16 psychological treatments proved superior to treatment as usual or another approach: cognitive-behavioural therapy (CBT) (n = 4), (including dialectical behaviour therapy [n = 2]); psychodynamic therapy (n = 2); mixed (CBT plus psychodynamic therapy [n = 1]); and motivational approach and change in therapist (n = 1). Among the 8 studies using visit, postal, or telephone contact or green-token emergency card provision, 2 were significant: one involving telephone follow-up and the other telephone follow-up or visits. Hospitalization was not related to fewer attempts, and 1 of the 4 outreach approaches had significant results: a program involving individualized biweekly treatment. The rationale behind these single or multiple approaches still needs to be clarified. There were methodological flaws in many studies and some had very specific limited samples.

CONCLUSIONS

There is a need for more research addressing the problem in definitions of outcomes and measurement of the dependent variables, gender-specific effects, and inclusion of high-risk groups. There is a need for the development and evaluation of new approaches that support collaboration with community resources and more careful assessment and comparisons of existing treatments with different populations.

Optional thinking ability among hospital-treated deliberate self-harm patients: A 1-year follow-up study

OBJECTIVES

To investigate the association between optional thinking (the ability to generate alternative solutions to interpersonal problems) in deliberate self-harm (DSH) patients and repeated self-harm.

DESIGN

A prospective study of the association between optional thinking in interpersonal problem solving and repeated DSH within 12 months.

METHOD

A non-consecutive sample (N=152) of DSH patients presenting to the Accident and Emergency department of an acute hospital in Cork city, Ireland, was assessed using a structured interview schedule including the Suicide Intent Scale, the Hopelessness Scale, and the Optional Thinking Test. Repetition within 1 year was established by checking Accident and Emergency records at all three city hospitals. Participants were categorized as repeaters if they engaged in at least one further hospital-treated DSH episode, or non-repeaters.

RESULTS

Approximately two-thirds (63.1%) of the sample had engaged in at least one act of DSH prior to their index episode. During follow-up 31 individuals (20.4%) repeated. History of self-harm was significantly associated with prospective repetition when considered alongside all the other predictor variables. Among first evers, low scores on the optional thinking test were significantly associated with the increased risk of repetition within 12 months. Among those with previous DSH, there was no evidence of an association between optional thinking and repetition within 12 months.

CONCLUSIONS

Poor optional thinking is associated with increased risk of repeated deliberate self-harm in those who present with a first self-harm episode. Interventions to improve optional thinking skills, delivered soon after a first DSH presentation, may be useful in preventing repetition.

Non-fatal repetition of self-harm: population-based prospective cohort study in Taiwan

BACKGROUND

Repeated self-harm is relatively common and is linked with an elevated risk of eventual suicide. There has been no study of this involving a large sample from the Far East.

AIMS

To estimate the risk over the medium term of non-fatal repetition of self-harm and identify predictive factors in those carrying out self-harm.

METHOD

A total of 970 individuals who had self-harmed were recruited from a community-based suicide behaviour register system in Nantou, Taiwan from July 2000 to February 2003. Information regarding demography and suicide methods was collected. Individuals were followed-up until December 2005 to examine the risk of repeated self-harm and independent predictive factors.

RESULTS

Ninety cohort members had repeated self-harm during the follow-up period (accounting for 131 repeated self-harm episodes in all). The cumulative risks were 5.7% for the first year, 7.8% for the second year and 9.5% for the fourth year. The risk was highest within the first year after the self-harm event. Independent risk factors included female gender and self-cutting as well as self-poisoning with drugs. Effect of younger age was mediated through the choice of methods.

CONCLUSIONS

Individuals with self-harm have a high risk of repetition, especially within the first year. Suicide prevention strategies need to focus on intervening with this population to reduce their repetition.

Outcomes of liver transplantation for paracetamol (acetaminophen)-induced hepatic failure

Paracetamol (acetaminophen) hepatotoxicity, whether due to intentional overdose or therapeutic misadventure, is an indication for liver transplantation in selected cases. However, there is a concern that long-term outcomes may be compromised by associated psychopathology that may predispose patients to further episodes of self-harm or poor treatment adherence. We therefore undertook a retrospective analysis of patients transplanted for paracetamol-induced fulminant hepatic failure (FHF) to determine their long-term outcomes, psychiatric problems, and compliance and whether these issues could be predicted from pretransplant information. Records from patients undergoing liver transplantation for paracetamol-associated liver failure in this unit and 2 comparison groups (patients undergoing liver replacement for FHF from other causes and for chronic liver diseases) were examined. Of 60 patients transplanted for paracetamol-induced FHF between 1989 and 2007, 44 (73%) survived to discharge. Currently, 35 patients (58%) are surviving at an average of 9 years post-transplantation. The incidence of psychiatric disease (principally depression) and 30-day mortality were greatest in the paracetamol group, but for those who survived 30 days, there was no difference in long-term survival rates between the groups. Adherence to follow-up appointments and compliance with immunosuppression were lowest in the paracetamol overdose group. Poor adherence was not predicted by any identifiable premorbid psychiatric conditions. Two patients grafted for paracetamol FHF died from self-harm (1 from suicide and 1 from alcoholic liver disease after 5 years). This study suggests that, notwithstanding the shortage of donor liver grafts, transplantation is an appropriate therapy in selected patients, although close follow-up is indicated.

Repetition and severity of suicide attempts across the life cycle: a comparison by age group between suicide victims and controls with severe depression

BACKGROUND

Suicide attempts have been shown to be less common in older age groups, with repeated attempts generally being more common in younger age groups and severe attempts in older age groups. Consistently, most studies have shown an increased suicide risk after attempts in older age. However, little is known about the predictive value of age on repeated and severe suicide attempts for accomplished suicide. The aim of the present study was to investigate the reduced incidence for initial, repeated, or severe suicide attempts with age in suicide victims and controls by gender.

METHODS

The records of 100 suicide victims and matched controls with severe depression admitted to the Department of Psychiatry, Lund University Hospital, Sweden between 1956 and 1969, were evaluated and the subjects were monitored up to 2006. The occurrence of suicide attempts (first, repeated, or severe, by age group) was analysed for suicide victims and controls, with gender taken into consideration.

RESULTS

There was a reduced risk for an initial suicide attempt by older age in females (suicide victims and controls) and male controls (but not suicide victims). The risk for repeated suicide attempts appeared to be reduced in the older age groups in female controls as compared to female suicide victims. The risk for severe suicide attempts seemed reduced in the older age groups in female suicide victims. This risk was also reduced in male controls and in male controls compared to male suicide victims.

CONCLUSION

In the older age groups repeated attempts appeared to be predictive for suicide in women and severe attempts predictive in men.

Factors Associated with Repeated Suicide Attempts

Background: This study compares sociodemographic and clinical characteristics of 102 first-time hospital-treated suicide attempters (first-evers) with a group of 101 repeat suicide attempters (repeaters) consecutively admitted to a general hospital in Brazil, during the intake phase of the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS). Aims: To compare sociodemographic and clinical characteristics of first-time hospital-treated suicide attempters (first-evers) with a group of repeat suicide attempters (repeaters). Methods: A standardized interview and psychometric scales were administered to all patients. Results: Repetition was associated with being of female sex (OR = 2.7; 95% confidence interval (CI) = 1.2–6.2), a housewife (OR = 3.8; 95% CI = 1.2–11.8), and having a score above median on the Beck Depression Inventory (OR = 5.2; 95% CI = 1.7–15.6). Conclusions: The findings suggest that repeaters, namely, depressed housewives who have attempted suicide previously, need specific treatment strategies in order to avoid future suicide attempts.

Broad and narrow personality traits as markers of one-time and repeated suicide attempts: a population-based study

BACKGROUND

Studying personality traits with the potential to differentiate between individuals engaging in suicide attempts of different degrees of severity could help us to understand the processes underlying the link of personality and nonfatal suicidal behaviours and to identify at-risk groups. One approach may be to examine whether narrow, i.e., lower-order personality traits may be more useful than their underlying, broad personality trait dimensions.

METHODS

We investigated qualitative and quantitative differences in broad and narrow personality traits between one-time and repeated suicide attempters in a longitudinal, population-based sample of young French Canadian adults using two multivariate regression models.

RESULTS

One broad (Compulsivity: OR = 2.0; 95% CI 1.2-3.5) and one narrow personality trait (anxiousness: OR = 1.1; 95% CI 1.01-1.1) differentiated between individuals with histories of repeated and one-time suicide attempts. Affective instability [(OR = 1.1; 95% CI 1.04-1.1)] and anxiousness [(OR = .92; 95% CI .88-.95)], on the other hand, differentiated between nonattempters and one-time suicide attempters.

CONCLUSION

Emotional and cognitive dysregulation and associated behavioural manifestations may be associated with suicide attempts of different severity. While findings associated with narrow traits may be easier to interpret and link to existing sociobiological theories, larger effect sizes associated with broad traits such as Compulsivity may be better suited to objectives with a more clinical focus.

Assessing the wish to die: a 30-year review of the suicide intent scale

This analysis drew from decades of published research to evaluate the Suicide Intent Scale (SIS), the dominant research tool for assessing intent to die in apparent suicide attempts. The review sought to 1) synthesize findings related to the scale's normative scores, reliability, and validity (factorial, convergent, and predictive), and 2) examine the objective and subjective subscales' performance. A literature search yielded 158 studies reporting findings for the SIS. Psychometric properties were summarized. Studies supported the scale's reliability, especially that of the subscale assessing self-reported (versus circumstantial indicators) of intent. Mixed findings emerged regarding convergent and predictive validity. The review identified shortcomings in factorial validity and the subscales' performance, especially for adolescents. The Suicide Intent Scale has some strengths, but the weaknesses require further investigation into how to better measure intent to die in attempted suicide.

Repetition of deliberate self-harm as seen in Uganda

Described is the presentation of repetition of deliberate self-harm (DSH) as seen in an African population in urban Uganda. A Luganda version (local language in study area) of the modified European Parasuicide Interview Schedule I (EPSIS I) was used to collect the data. An univariate analysis was conducted. Results indicated that repeaters of DSH differed significantly from non-repeaters on several dimensions. The factors included were: more often single, less often had children, staying alone or with their parents, reported sexual problems as a precipitant of current DSH event, more negative life events in childhood and less negative life events in the last year. Furthermore, a multivariate analysis was conducted resulting in only sexual problems and the psychological factor of trait anger, which retained statistical significance. The significance of these findings is discussed.

A multivariate study of predictors of repeat parasuicide

OBJECTIVE

To identify variables which differentiate future repeaters of parasuicide from non-repeaters in a multivariate analysis.

METHOD

Interviews were conducted with 507 parasuicide cases; data were collected on precipitating factors for the index parasuicide, psychiatric and medical history, stressful life events, prior history of parasuicide, hopelessness, anger, self-esteem and social adjustment. Individuals were followed for 1-2 years to determine if a repeat parasuicide occurred.

RESULTS

A logistic regression model identified four significant predictors of repeat parasuicide: prior history of parasuicide, a history of depression, a history of schizophrenia and poor physical health. A risk factor scale constructed from these four variables showed that the risk of repeat parasuicide increases as the number of risk factors increases.

CONCLUSION

This study identifies four key predictors of repeat parasuicide, and provides evidence that the risk of repeat parasuicide increases when multiple risk factors are present.

Prävention parasuizidalen Verhaltens in der Adoleszenz: Möglichkeiten und Grenzen

Zusammenfassung. In der vorliegenden Arbeit wird ein Literaturüberblick über Charakteristiken von jugendlichen Parasuizidenten gegeben und Möglichkeiten von Präventionen für Parasuizide werden aufgezeigt. Eine Metaanalyse randomisierter Studien, die die Effektivität von psychosozialer Therapie auf die Wiederholungsrate von Parasuiziden prüfte, ergab, dass zwei von zwölf Studien einen kleinen positiven Effekt zeigten. Basierend auf diesen beiden Studien wurde eine randomisierte klinische Studie mit dem Schwerpunkt auf intensiver psychosozialer Intervention gestartet. Die psychologische Intervention wurde mit der üblichen Standardbehandlung verglichen und alle Patienten (n = 274) wurden über ein Jahr lang nach dem Index-Parasuizid nachuntersucht. Kaplan-Meyers Survival Analysen zeigten keinen signifikanten Unterschied zwischen den beiden Behandlungsansätzen. Möglichkeiten für zukünftige Studien werden diskutiert.

The ultimate resignation: suicide and search activity

This paper presents an integrative approach to suicidal behavior in terms of search activity concept. Search activity concept displays a broad and holistic approach to behavior, adaptation to environment, body resistance, brain amine metabolism, and REM-sleep functions. Search activity is defined as activity that is oriented to change the situation (or at least the subject's attitude to it) in the absence of a precise prediction of the outcome of such activity, but taking into consideration outcomes at all previous stages of activity. According to the proposed hypothesis, renunciation of search (a state opposed to search activity) leads to a feeling of helplessness, problem-solution deficits, inefficient coping, dreams that represent renunciation of search, and a drop in the activity of amines. All these factors further exacerbate the state of renunciation of search and elevate suicidal risk. In addition, the remnants of search activity are misdirected to self-defeating behaviors that increase mental pain and contribute to renunciation of search. This hypothesis integrates findings from a number of fields of study of suicidal behavior, resolves some paradoxes, suggests new lines of research, and raises suggestions for assessment and treatment of suicidal behavior.

Association between multiple suicide attempts and negative affects in adolescents

OBJECTIVE

To compare the level of negative emotions-anxiety, depression, aggression, and impulsivity-in hospitalized adolescents with a history of either a single or multiple suicide attempts.

METHOD

Thirty-two adolescents hospitalized for a first suicide attempt, 19 hospitalized for a repeated attempt (fifth or more), 109 nonsuicidal psychiatric inpatients, and 85 community controls were assessed for level of depression, anxiety, aggression, and impulsivity with the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Multidimensional Anger Inventory, and the Suicide Potential Scale.

RESULTS

Both suicidal groups demonstrated higher levels of most of the negative emotions than both the normal controls and the nonsuicidal inpatients. When the first attempters were compared with the multiple attempters, similarly high levels were noted for most dimensions of anxiety and depression. A trend toward increased aggression was noted among the multiple suicide attempters on all parameters evaluated; some of these differences were significant.

CONCLUSION

In already highly anxious and depressed suicidal inpatients, a high level of aggression might significantly increase the risk of recidivism.

Characteristics of suicidal attempts in major depression versus adjustment reactions

BACKGROUND

The aim of this present study was to compare the characteristics of suicidal attempts of patients with major depression (MD) and adjustment reaction (AR).

METHOD

Sixty-nine patients with MD and 86 with AR admitted to the Moscow Institute of Emergency Help after the first suicide attempts were studied. All the attempters were interviewed by at least by two psychiatrists and the diagnosis was made according to agreement and to ICD-9CM criteria.

RESULTS

Differences between the two groups were found with regard to social-demographic, clinical-psychological and suicidal characteristics: the AR patients were less educated, had lower social status and in most cases were unmarried, compared with the MD patients. A large number (51.2% of the attempters in the AR group and 34.8% in the MD group) had an unstable parental family, early orphanhood or an emotionally deprived childhood. No differences were found in the methods of the suicidal attempts between the groups. Suicidal attempts under alcohol abuse occurred more often among the AR group (34.9 vs. 10.1%). The interval from the beginning of the disorder until the suicidal attempt was significantly shorter within the AR group. In this group the suicidal attempts were not planned, in comparison with the MD group.

LIMITATION

The sample is a selected study, because the research included only inpatients with AR and MD after their first suicidal attempt.

CONCLUSION

We believe that our data may be important for improving the assessment of suicidal risk and in planning treatment strategies for prevention of repeated suicidal attempts.

Intensive in-patient and community intervention versus routine care after attempted suicide. A randomised controlled intervention study

BACKGROUND

A randomised clinical trial was carried out in suicide attempters to assess clinical efficacy of an intensive psychosocial intervention compared with treatment as usual.

METHOD

Two hundred and seventy-four suicide attempters presenting for medical treatment were randomly assigned to either intensive psychosocial treatment or 'care as usual'. Intensive psychosocial treatment consisted of brief admission to a special crisis-intervention unit and problem-solving aftercare. 'Care as usual' included any form of treatment the assessing clinicians thought appropriate. Psychological well-being was evaluated by the SCL-90 and the Hopelessness Scale at 3, 6 and 12 months following entry in the study.

RESULTS

No differences in outcome were found. The probability of repeat suicide attempts in the 12-month follow-up was 0.17 for patients in the experimental group and 0.15 for the control group. There were no differences in ratings on the SCL-90 and the Hopelessness Scale. Patients in the experimental group attended significantly more out-patient treatment sessions.

CONCLUSIONS

General implementation of an intensive in-patient and community intervention programme for suicide attempters does not seem justified.

Suicidality in eating disorders: clinical and psychological correlates

Although many authors have described eating disorders as often being associated with suicidal feelings and behavior, few studies to date have evaluated the prevalence and characteristics of suicidal behaviour in eating disordered patients. In the present study, in which a consecutive series of 495 out-patients was studied, 13% of the patients reported at least one suicide attempt and 29% reported current suicidal ideation; 26% of attempters reported multiple attempts. A history of suicide attempt was more prevalent among binge-eating/purging anorexics and among purging bulimics than in the other subgroups. In cases with anorexia nervosa, suicide attempters were older, had a longer illness duration, weighed less, had more often used drugs and/or alcohol and tended to be more obsessive than non-attempters. In cases with bulimia nervosa, attempters presented with more psychiatric symptoms and had more frequently been sexually abused.

Near-Death Experiences and Antisuicidal Attitudes

Near-death experiences (NDEs) have been reported to decrease fear of death and foster a “romanticized” view of death, yet also promote antisuicidal attitudes. This study was an empirical investigation of psychodynamic hypotheses suggested to explain that paradoxical effect, using a thirty-six-item questionnaire constructed for this purpose. One hundred-fifty near-death experiencers (NDErs) and forty-three individuals who had come close to death but not had NDEs (nonNDErs) rated as true or false twelve antisuicidal attitudes that have been hypothesized to result from NDEs. NDErs endorsed significantly more of the antisuicidal statements than nonNDErs, and among NDErs, number of statements endorsed was positively associated with depth of experience. Those antisuicidal attitudes that showed the greatest difference in endorsement rate between NDErs and nonNDErs related to transpersonal or transcendental beliefs. These data support prior naturalistic observations that NDEs foster antisuicidal attitudes by promoting a sense of purpose in life.

The epidemiology of parasuicide in Edmonton

The objective of this study was to examine some of the characteristics of parasuicides in Edmonton and to calculate rates of parasuicide. The method involved examining all records of parasuicides attending the University of Alberta Hospitals for a six month period (20% of all parasuicides in Edmonton are treated at the University of Alberta Hospitals). The results indicated that 58% of 275 subjects were single. The most frequent method (88.6%) of parasuicide was overdose. The peak age group was 25 to 29 years of age. The age range was 12 to 80 years (six percent < 15 years), mean age 30.2. The female to male ratio (cases) was 1.6:1; 30.2% were admitted; 46.5% received psychiatric emergency consultation; 41% had made a previous parasuicide. Calculated rates of parasuicide in Edmonton were at 448/100,000/year for those 15 years and older (men 357, women 534). The overall rate is higher than that found in any centre in the WHO/EURO investigation. The conclusion is that parasuicide presents a significant public health problem, and a cost burden on the health care system.

Deliberate self-poisoning: treatment follow-up of repeaters and nonrepeaters

Since 1986 psychiatrists and social workers of the Lund Suicide Research Center have investigated subjects admitted to the medical intensive care unit after a suicide attempt. Fifty-nine of 79 deliberate self-poisoners were interviewed 12 months after a suicide attempt. Twenty-one had previously been interviewed 6 months after the index suicide attempt. We obtained minor information on 8 subjects. Two patients had committed suicide. Sixteen subjects (27%) of those who were interviewed showed repeated suicidal behavior (repeaters) during the 1-year follow-up, and their psychiatric diagnoses at the index attempt were most commonly alcohol abuse and dysthymia (DSM-III, Axis I). Compared with nonrepeaters, repeaters had more often made previous suicide attempts, their index attempt was less serious and they were more often in psychiatric treatment at index. At follow-up, repeaters more often than nonrepeaters expressed the need for professional mental health support. Two-thirds of the patients were in treatment at follow-up. About half had remained in continuous treatment and most in psychiatric care for more than 1 year. Repeated self-poisoning occurred despite ongoing treatment. In view of the fact that numerous suicide attempters obviously remain in treatment for several years, we suggest further development and evaluation of long-term treatment strategies.

Deliberate self-poisoning: repeaters and nonrepeaters admitted to an intensive care unit

Seventy-nine patients admitted to the Lund Intensive Care Unit after deliberate self-poisoning were investigated by a psychiatrist and a social worker by means of a semistructured interview. Suicide risk evaluation included statistical risk factors according to the SAD PERSONS Scale, severity of suicidal intent according to the Suicidal Intent Scale, and interviewer reaction according to Motto. Two-thirds of the patients were in treatment or had had counselling with a social worker. More than half of the sample were repeaters. Compared with nonrepeaters, repeaters were less often employed, lacked social support and more often had relational problems. The majority of the repeaters had ongoing treatment, mostly psychiatric treatment. Repeaters more often acted impulsively, and their suicidal intent tended to be less severe than those of nonrepeaters. Interviewers more often reacted with negative or neutral feelings towards repeaters. Our results indicate that those who repeat suicidal behaviour differ from nonrepeaters. Self-poisoners, and especially repeaters, often had ongoing or previous psychiatric treatment. For the repeater group it is important to consider their impulse dyscontrol and their hostile attitude when alternative treatment strategies are devised and evaluated.