Suicide in psychiatric patients: risk and prevention

Association Between Endometriosis and Mental Disorders Including Psychiatric Disorders, Suicide, and All-Cause Mortality -A Nationwide Population-Based Cohort Study in Taiwan

Objective

A multitude of previous studies has substantiated that endometriosis correlated highly with psychiatric health. This study aims to investigate the association between endometriosis and psychiatric health.

Methods

Utilizing the National Health Insurance Research Database of Taiwan, 100,770 enrolled participants, including 20,154 patients with endometriosis and 80,616 in the control group (1:4), matched for age, and index date from Taiwan's Longitudinal Health Insurance Database between January 1, 2000, and December 31, 2015. The Cox proportional regression model was used to compare the risk of mental disorders during the 16 years of follow-up after adjusting for confounding factors.

Results

Of the study patients, 4083 (20.26%) developed mental disorders; 9225 of the 80,616 controls (11.44%) developed mental disorders. The Cox regression demonstrated that, after adjusting for age, monthly income, urbanization level, etc., people with endometriosis are more likely to suffer from mental disorders compared to those without endometriosis (hazard ratio [HR]=2.131; 95% confidence interval [CI]= 1.531-2.788; p<0.001). The result illustrated that women over 40 years old had a more significant risk.

Conclusion

Compared to people without endometriosis, this study provides evidence that patients with endometriosis are at a 2.131-fold higher risk of developing mental disorders, especially in elder women. Regular psychiatric follow-up might be needed for those patients.

Suicidality in the Light of Schema Therapy Constructs, i.e., Early Maladaptive Schema and Schema Modes: A Longitudinal Study

(1) Background: The search for new strategies to diagnose people at risk of suicide and to help them is highly significant in view of the still high rate of suicidality. Schema therapy and its core constructs, i.e., early maladaptive schemas (EMSs) and schema modes, correspond to both directions. (2) Methods: This study compared the severity of EMSs and schema modes in a clinical group of suicide risk, a clinical non-suicidal group, and a control group. Intragroup comparisons were also conducted between times of crisis and psychological stability. The evaluation was supported by controlling for the psychopathological symptoms presented, following the dimensional concept. (3) Results: The unquestionable relevance of the disconnection/rejection domain in suicidality has been proven. The importance of EMSs from other domains, especially during psychiatric crises, was confirmed. Among the schema modes, child and Punitive Parent modes proved to be the most significant. There were changes in coping modes but of a lesser effect size. The protective importance of the Healthy Adult and Happy Child modes was also proven. (4) Conclusions: The results provide an indication for practitioners about the EMSs and schema modes most associated with suicide risk. They can also serve as a framework for deepening the issue of identifying and preventing suicidality in schema therapy.

Motivations for Suicide Attempts amongst Psychiatric Inpatients: Associations with Risk Factors and Recent Suicide Attempt Characteristics

Suicide is a major and preventable public health issue and research has identified several distal risk factors for determining individuals at risk for a suicide attempt. However, understanding imminent processes could enhance individualized safety plan formulations and interventions. Motivation for suicide attempt (MfSA) reflects why an individual engages in a specific attempt. Research indicates such motives can be organized into major factors, but consensus on the number, and their correlates, has not been reached. The sample consisted of 190 patients who attempted suicide within 24 hours of hospitalization and completed the MfSA within the Suicide Attempt-Self Injury Interview. Exploratory factor and correlational analyses were conducted to identify the factors that underlie MfSA. Regression analyses were conducted to examine the relations of MfSA factors to distal suicide risk factors and suicide-related attempt characteristics. Two underlying MfSA factors were identified. Interpersonal MfSA was associated with lower age and higher problematic alcohol use. Intrapersonal MfSA was related to having previous suicide attempts, more past year negative life events, and higher depressive symptoms. The modified MfSA is easy to administer, and its factors show unique associations with important suicide-related constructs. The results could inform safety planning procedures to prevent future death by suicide.

Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences

AIM

The aim of this study was to explore suicidal patients' experiences of safe clinical practice during hospitalisation in mental health wards. The study was guided by the following research question: How do suicidal patients experience safe clinical practice during hospitalisation in mental health wards?

DESIGN, SETTING AND PARTICIPANTS

A qualitative design with semistructured individual interviews was applied. Eighteen patients hospitalised with suicidal behaviour in specialised mental health wards for adults at a Norwegian hospital participated in the study. Data were analysed thematically and inductively using qualitative content analysis.

RESULTS

Patients in a suicidal crisis experienced safe clinical care in mental health wards characterised by the following three themes: (1) being recognised as suicidal, (2) receiving tailor-made treatment and (3) being protected by adaptive practice.

CONCLUSION

This study illuminates the experiences of safe clinical practice for patients in a suicidal crisis. The patient group was multifaceted, with variable experiences of how safe clinical practice affected their subjective experience of safety and suicidal behaviour. The finding highlights the importance of embracing personalised activities in all parts of safe clinical practice and to recognise rather than efface patients' variability in patient safety efforts.

Feasibility of using a smartphone app to assess early signs, basic symptoms and psychotic symptoms over six months: A preliminary report

BACKGROUND

Psychosis relapses are common, have profound adverse consequences for patients, and are costly to health services. 'Early signs' have been used to predict relapse, in the hope of prevention or mitigation, with moderate sensitivity and specificity. We investigated the feasibility and validity of adding 'basic symptoms' to conventional early signs and monitoring these using a smartphone app.

METHODS

Individuals (n = 18) experiencing a relapse within the past year were asked to use a smartphone app ('ExPRESS') weekly for six months to report early signs, basic symptoms and psychotic symptoms. Above-threshold increases in app-reported psychotic symptoms prompted a telephone interview (PANSS positive items) to assess relapse.

RESULTS

Participants completed 65% app assessments and 58% telephone interviews. App items showed high concurrent validity with researcher-rated psychotic symptoms and basic symptoms over six months. There was excellent agreement between telephone call and face-to-face assessed psychotic symptoms. The primary relapse definition, based on telephone assessment and casenotes, compared well with a casenote-only definition but had better specificity. Mixed-effects models provided preliminary evidence of concurrent and predictive validity: early signs and basic symptoms were associated with most app-assessed psychotic symptom variables the same week and with a number of psychotic symptoms variables three weeks later; adding basic symptoms to early signs improved model fit in most of these cases.

CONCLUSIONS

This is the first study to test a smartphone app for monitoring early signs and basic symptoms as putative relapse predictors. It demonstrates that weekly app-based monitoring is feasible, valid and acceptable over six months.

Development and Long-Term Acceptability of ExPRESS, a Mobile Phone App to Monitor Basic Symptoms and Early Signs of Psychosis Relapse

BACKGROUND

Schizophrenia relapses are common, have profound, adverse consequences for patients and are costly to health services. Early signs interventions aim to use warning signs of deterioration to prevent full relapse. Such interventions show promise but could be further developed. This study addresses 2 developments: adding basic symptoms to checklists of conventional early signs and using a mobile phone app ExPRESS to aid early signs monitoring.

OBJECTIVE

This study aimed to (1) design a pool of self-report items assessing basic symptoms (Basic Symptoms Checklist, BSC); (2) develop and beta test a mobile phone app (ExPRESS) for monitoring early signs, basic symptoms, and psychotic symptoms; and (3) evaluate the long-term acceptability of ExPRESS via qualitative feedback from participants in a 6-month feasibility study.

METHODS

The BSC items and ExPRESS were developed and then adjusted following feedback from beta testers (n=5) with a schizophrenia diagnosis. Individuals (n=18) experiencing a relapse of schizophrenia within the past year were asked to use ExPRESS for 6 months to answer weekly questions about experiences of early signs, basic symptoms, and psychotic symptoms. At the end of follow-up, face-to-face qualitative interviews (n=16; 2 were uncontactable) explored experiences of using ExPRESS. The topic guide sought participants' views on the following a priori themes regarding app acceptability: item content, layout, and wording; app appearance; length and frequency of assessments; worries about app use; how app use fitted with participants' routines; and the app's extra features. Interview transcripts were analyzed using the framework method, which allows examination of both a priori and a posteriori themes, enabling unanticipated aspects of app use experiences to be explored.

RESULTS

Participants' mean age was 38 years (range 22-57 years). Responses to a priori topics indicated that long-term use of ExPRESS was acceptable; small changes for future versions of ExPRESS were suggested. A posteriori themes gave further insight into individuals' experiences of using ExPRESS. Some reported finding it more accessible than visits from a clinician, as assessments were more frequent, more anonymous, and did not require the individual to explain their feelings in their own words. Nevertheless, barriers to app use (eg, unfamiliarity with smartphones) were also reported. Despite ExPRESS containing no overtly therapeutic components, some participants found that answering the weekly questions prompted self-reflection, which had therapeutic value for them.

CONCLUSIONS

This study suggests that apps are acceptable for long-term symptom monitoring by individuals with a schizophrenia diagnosis across a wide age range. If the potential benefits are understood, patients are generally willing and motivated to use a weekly symptom-monitoring app; most participants in this study were prepared to do so for more than 6 months.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03558529; https://clinicaltrials.gov/ct2/show/NCT03558529 (Archived by WebCite at http://www.webcitation.org/70qvtRmZY).

Young children with psychotic symptoms and risk for suicidal thoughts and behaviors: a research note

Objective

Suicidal thoughts and behaviors (STBs) are prevalent among youth with psychotic disorders (PD) relative to the general population. Recent research now suggests that STBs may present during the prodromal phase of the disease, or the clinical high risk (CHR) state. While this knowledge is important for the development of suicide prevention strategies in adolescent and adult populations, it remains unclear whether risk for suicide extends to children with or at risk for psychosis. The current study is an extension of previous work assessing STBs in youth across the psychosis continuum. We examine STBs in 37 CHR and PD children ages 7–13 years old, and further explore the prodromal symptom correlates of STB severity among CHR children.

Results

CHR and PD children endorsed STBs with a frequency and severity similar to what is observed in older CHR and PD populations. A number of children had never previously vocalized their suicidal plans or intent. Among CHR children, Social Anhedonia and Odd Behavior or Appearance were significantly correlated with STB severity. These findings underscore the importance of screening for STBs even in young children presenting with psychotic symptoms.

Comparing early signs and basic symptoms as methods for predicting psychotic relapse in clinical practice

BACKGROUND

Early signs interventions show promise but could be further developed. A recent review suggested that 'basic symptoms' should be added to conventional early signs to improve relapse prediction. This study builds on preliminary evidence that basic symptoms predict relapse and aimed to: 1. examine which phenomena participants report prior to relapse and how they describe them; 2. determine the best way of identifying pre-relapse basic symptoms; 3. assess current practice by comparing self- and casenote-reported pre-relapse experiences.

METHODS

Participants with non-affective psychosis were recruited from UK mental health services. In-depth interviews (n=23), verbal checklists of basic symptoms (n=23) and casenote extracts (n=208) were analysed using directed content analysis and non-parametric statistical tests.

RESULTS

Three-quarters of interviewees reported basic symptoms and all reported conventional early signs and 'other' pre-relapse experiences. Interviewees provided rich descriptions of basic symptoms. Verbal checklist interviews asking specifically about basic symptoms identified these experiences more readily than open questions during in-depth interviews. Only 5% of casenotes recorded basic symptoms; interviewees were 16 times more likely to report basic symptoms than their casenotes did.

CONCLUSIONS

The majority of interviewees self-reported pre-relapse basic symptoms when asked specifically about these experiences but very few casenotes reported these symptoms. Basic symptoms may be potent predictors of relapse that clinicians miss. A self-report measure would aid monitoring of basic symptoms in routine clinical practice and would facilitate a prospective investigation comparing basic symptoms and conventional early signs as predictors of relapse.

Constant Observation of Suicidal Patients: The Intervention We Love to Hate

Constant observation (CO) of psychiatric inpatients at risk for suicidal behavior has been criticized in the literature because of the absence of demonstrable effectiveness, associated costs, staff and patient acceptance, and related issues. Our inability to demonstrate effectiveness, however, is an ethical conundrum that cannot readily be solved. Frequent and often vociferous references in the literature to the absence of an evidence base for this intervention carries the risk that CO may be underutilized in particular clinical circumstances with untoward results. A case is made for shifting focus from the lack of evidence supporting CO to agreement on an observation protocol that achieves the desired goal of maximizing patient safety. A sample protocol is presented.

People living in community with a severe mental illness: utilization and satisfaction with care and support

The object of this paper was to investigate the experiences of patients with severe mental illness (SMI) living in a community, including their utilization of care and treatment services. Psychiatric care and social services staff members were asked to make an inventory of those they served in two districts of Malmö, Sweden. Participants had to be over 18 years of age and unable to manage their daily lives without help from others. Almost all of the 80 participants (95 %) were under psychiatric care. A majority (86 %) was receiving dental treatment, and 61 % were supported by social services. Fifty-four percent of the participants received somatic care on an ongoing basis. Although the majority reported the care given as sufficient, one-third of this SMI population considered the care and support they received to be insufficient. Satisfying those who are dissatisfied with the care they are being given would be a significant challenge for service providers, since the unsatisfied are shown to have more difficult lives.

A study of psychiatric inpatient suicides

Objective: The aim of this paper was to elucidate factors associated with inpatient suicide.

Method: A retrospective review of inpatient suicides over a 20 year period in the Cavan/Monaghan mental health service was undertaken. Clinical files, statutory reports and Central Statistics Office returns were studied and information was obtained on demography, diagnosis and circumstances of the event.

Results: Eight patients committed suicide, giving a rate of 0.55/1,000 discharges and 0.39/100,000 population per year. Depressive illness and Schizophrenia were the diagnoses found. Repeated admissions and long duration of illness were noted. Previous suicidal behaviour was common. Four of the patients were considered a suicide risk at some time during the index admission. Underreporting of the suicides and inaccurate registration of institutional location by the Central Statistics Office were found.

Conclusion: More formal clinical procedures in registering suicide risk are recommended. New procedures for investigating inpatient suicides are suggested. Largescale studies at a national level are essential in defining more specific and sensitive risk factors. Procedural changes involving accurate central registration of data are required.

Adolescents with suicidal behaviour: attendance at A&E and six month follow-up

Objectives: To review the clinical presentation, and Accident and Emergency Department clinical response to 14-20 year olds in suicidal crisis in inner city Dublin and to carry out a six month follow up of these young people.

Method: A retrospective review of the case notes of all 14-20 year olds who had attended the Mater Hospital A&E department between June 2001 and May 2002 with suicidal behaviour or ideation was carried out in order to establish socio-demographic information, type of suicidal or self-harming behaviour, intervention in the A&E department, and discharge plan. Active outreach attempts were made to trace, contact and interview these young peoples at least six months after the initial presentation. Quantitative measures of psychological functioning at follow-up included the General Health Questionnaire, The Beck Depression Inventory and The Scale for Suicidal Ideation. A qualitative interview covered their recall of the reasons for their deliberate self harm, their view of their current psychological functioning and personal relationships, reported repetition of deliberate self harm, and their views of what type of services would be useful for young people with suicidal ideation or behaviour.

Results: A total of 89 young people aged 14-20 years (male: female ratio = 2:3) presented to the Mater A&E department between June 2001 and May 2002 with deliberate self-harm, deliberate self-poisoning and/or suicidal ideation, and accounted for 108 presentations. They showed high levels of psychosocial disadvantage. Almost half had a history of previous contact with mental health services, while the same proportion had a history of previous deliberate self-harm. Drug overdose using paracetamol was the most common method used. Psychiatric assessment was documented in 66% of cases, and documented follow up recommendations were made in 60% of cases. Two thirds of the 89 young people who formed the study population were traced. Half of those contacted agreed to be interviewed and half refused. The majority of those interviewed described themselves as functioning better psychologically than at the time of the index attendance at the A&E department The quantitative measures supported this. One third of those interviewed reported repeated deliberate self-harm since their index attendance, for which most did not seek medical intervention. Many of the young people had clear views about the importance of talking to someone when in crisis. They described a service, which was informal, accessible on a 24-hour basis, and staffed by people with experience of mental health, alcohol and drug related disorders.

Conclusions: This is a particularly vulnerable group of patients from a socio-demographic and mental health perspective. Their attendance at the A&E department provides a unique opportunity for an in-depth psychosocial assessment, which should be recorded in a systematic way to assist clinical audit, facilitate strategic mental health planning and may confer some therapeutic clinical benefit to at risk young people. An easily accessible, active DSH team specifically tailored for young people in the A&E department could provide assessment and short-term follow-up. This is the approach recommended by young people in suicidal crisis, whose views need to be heard.

Deliberate self-harm in young people: attendance at a paediatric emergency department

OBJECTIVES

Deliberate self-harm (DSH) is the strongest predictor of suicidal behaviour. This retrospective study reviewed all DSH presentations to our Paediatric Emergency Department between 2002-2006.

METHOD

Using database and medical records we profiled these presentations. Data was coded and statistically analysed.

RESULTS

There were 253 DSH attendances. Twenty-four percent were living in care, 15% were under 12 years and 14% presented more than once. Overdoses (61%) were more common than cutting (16%) and 56% had a psychiatric condition.

CONCLUSIONS

DSH presents an ongoing challenge to child and adolescent mental health services and those working in suicide prevention. Identifying the characteristics of these young people is essential to providing appropriate treatment for this high-risk group.

Suicide as altruism: A Darwinian perspective

There has been increased interest recently in the implications of Darwinian theory on psychology, psychiatry and in medicine generally. As a result a large number of publications have appeared that attempt to reformulate a range of psychiatric disorders in the light of evolutionary theory. However, relatively little attention has been paid to the subject of suicide from the evolutionary perspective with some notable exceptions. The purpose of this brief paper is to bring the Darwinian perspective to the notice of a wider psychiatric readership hoping that this will add a further dimension to the debate on suicide and selfdestructive behaviour. Darwinia n theory had found it difficult to account for the existence of altruistic behavioural strategies in social animals until it was explained by Hamilton that the focus for selection was not the individual but the gene. Altruism here refers to any behaviour that reduces the reproductive fitness of the donor while increasing the reproductive fitness of the recipient. According to Hamilton's formulation (the kin selection theory) the individual will behave in a nepotistic manner (ie. altruistically towards kin) as this will enhance the overall chances of his genes to pass to the next generation not only through his own descendants but through non-descendant kin, a measure he termed ‘inclusive fitness’. Therefore it would not be surprising that individuals would be more likely to behave altruistically towards kin than non-kin.

Why are people with mental illness excluded from the rational suicide debate?

The topic of rational suicide is often approached with some trepidation by mental health professionals. Suicide prevention strategies are more likely to be seen as the domain of psychiatry and a wealth of psychiatric literature is devoted to identifying and managing suicide risk. Whether or not suicide can be deemed permissible is ostensibly linked to discussions of autonomy and mental capacity, and UK legislation directs that a patient's wishes must be respected with regard to treatment refusal where decisional capacity is intact. In the context of the care and treatment of those with physical disorders, extreme and untreatable physical suffering is likely to be accepted as rational grounds for suicide, where the person possesses cognitive coherence and an ability to realistically appreciate the consequences of his or her actions. In the case of those with serious mental disorder, the grounds for accepting that suicide is rational are however less clear-cut. Serious mental illness is typically conceived of as a coercive pressure which prevents rational deliberation and as such, the suicides of those with serious mental illness are considered to be substantially non-voluntary acts arising from constitutive irrationality. Therefore, where an appropriate clinician judges that a person with serious mental disorder is non-autonomous, suicide prevention is likely to be thought legally and morally justified. There are arguably, two questionable assumptions in the position that psychiatry adopts: Firstly, that psychogenic pain is in some way less real than physical pain and secondly, that mental illness invariably means that a desire to die is irrational and inauthentic. If it can be shown that some people with serious mental illness can be rational with regard to suicide and that psychological pain is of equal significance as physical suffering, then it may be possible to conclude that some persons with serious mental illness should not by definition be excluded from the class of those for whom rational suicide may be a coherent choice.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders

OBJECTIVES

This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions.

METHODS

The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force.

RESULTS

This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults.

CONCLUSIONS

To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.

Suicidal behaviour among youths associated with psychopathology in both parents and youths attending outpatient psychiatric clinic in Kenya

BACKGROUND

Suicide is a major cause of death among youths particularly with psychiatric, alcohol abuse and substance abuse disorders. There are relatively few studies on the relationship between psychiatric and substance abuse disorders with suicidal behaviour from low-income countries. This study examines the relationship between suicidal behaviour and co-existing psychiatric or substance disorders among youths and depressive and alcohol use disorders in their parents.

METHOD

The study sample had 678 respondents: 250 youths and 226 and 202 biological mothers and fathers, respectively.

RESULTS

This study found a significant statistical association between depressive (p < 0.001), alcohol abuse (p <0.001) and substance abuse (p < 0.001) disorders and suicidal behaviour in youths. There was a significant relationship between maternal depressive disorder (p < 0.001) and perceived maternal rejecting parenting behaviour (p < 0.001) with suicidal behaviour in youths. There was a greater odds of a youth with two to three (odds ratio (OR) = 3.63; p = 0.009) and four or more (OR = 8.23; p < 0.001) co-existing psychiatric disorders to have suicidal behaviour than a youth with only one psychiatric disorder. The results also indicate that a higher proportion of youths between ages 16-18 years had suicidal behaviour than youths below 16 years or above 18 years of age (p = 0.004).

CONCLUSION

These findings suggest that youths with psychiatric and substance abuse disorders have mothers living with a depressive disorder. Also, perceived maternal rejecting parenting behaviour contributes significantly to the development of suicidal behaviour later in adolescent years.

Rural-urban differences in suicide rates for current patients of a public mental health service in Australia

Rural versus urban rates of suicide in current patients of a large area mental health service in Australia were compared. Suicide deaths were identified from compulsory root cause analyses of deaths, 2003-2007. Age-standardized rates of suicide were calculated for rural versus urban mental health service and compared using variance of age-standardized rates with 95% confidence intervals. There were 44 suicides and the majority (62%) were rural. Only urban patients used jumping from heights as a method of suicide (4/17; p = 0.02). Rural patients had 2.7 times higher rates of suicide, similar to findings for rural versus urban community suicides and may reflect the underlying community rates, differences in mental health service delivery, or socioeconomic disadvantage.

Inpatient suicide: preventing a common sentinel event

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Community mental-health services and suicide rate in Finland: a nationwide small-area analysis

BACKGROUND

In many countries, psychiatric services have been reformed by reducing the size of hospitals and developing community mental-health services. We investigated this reform by assessing the relation between suicide risk and different ways of organising mental-health services.

METHODS

We did a nationwide comprehensive survey of Finnish adult mental-health service units between Sept 1, 2004, and March 31, 2005. From health-care or social-care officers of 428 municipalities, we asked for information, classified according to the European service mapping schedule, about adult mental-health services. For each municipality, we measured age-adjusted and sex-adjusted suicide risk, pooled between 2000 and 2004, and then adjusted for register-derived socioeconomic factors.

FINDINGS

A wide variety of outpatient services (relative risk [RR] 0.92, 95% CI 0.87-0.96), prominence of outpatient versus inpatient services (0.93, 0.89-0.97), and 24-h emergency services (0.84, 0.75-0.92) were associated with decreased death rates from suicide. However, after adjustment for socioeconomic factors, only the prominence of outpatient services was associated with low suicide rate (0.94, 0.90-0.98). We replicated this finding even after adjustment for organisational changes and inpatient treatment.

INTERPRETATION

Well-developed community mental-health services are associated with lower suicide rates than are services oriented towards inpatient treatment provision. These data are consistent with the idea that population mental health can be improved by use of multifaceted, community-based, specialised mental-health services.

FUNDING

Academy of Finland.

Predicting inpatient suicides and suicide attempts by using clinical routine data?

OBJECTIVE

The study aimed at exploring prevalence and risk factors of inpatient suicides and attempted suicides in a psychiatric hospital.

METHOD

Based on the German psychiatric basic documentation system, 20,543 patients with 40,451 episodes of inpatient care (1995-2004) in a psychiatric state hospital were included. Besides univariate analyses, multivariate logistic regression analyses and classification and regression tree analyses were performed.

RESULTS

Forty-one inpatient suicides were recorded. Risk of inpatient suicide is increased for patients with resistance to psychopharmacological treatment, previous suicide attempt, severe side effects and supportive psychotherapy before admission. Two hundred fourteen inpatient suicide attempts occurred during the 10-year period. Risk factors of inpatient suicide attempt are assault, personality disorder, previous suicide attempt, psychopharmacological treatment resistance, suicidal thoughts at admission, schizophrenia, depression, female sex and length of stay.

CONCLUSION

The identified risk factors underline the need for a cautious investigation of previous suicide attempts as well as for giving special attention to patients who have problems with psychopharmacotherapy during hospitalization.

Suicide in psychiatric patients: case-control study in Singapore

OBJECTIVE

Persons with psychiatric illness, especially depression and schizophrenia, are at relatively high risk of suicide, but there are few studies that look at the Asian population. The aim of the present study was to identify the risk period and risk factors for suicide in psychiatric patients in Singapore. The nature of psychiatric care that was provided, both inpatient and outpatient, was also explored.

METHOD

This is a case-control study of 123 patients who committed suicide from 2003 to 2004. Controls were 123 surviving patients who were individually matched for age, gender, principal diagnosis and calendar time.

RESULTS

The most common principal diagnoses among the suicide subjects were schizophrenia (46.3%) and depression (26.8%). Numerous factors were associated with significantly increased suicide risk. Stepwise conditional logistic regression showed that the following three independent factors best predicted suicide: history of attempted suicide using highly lethal means; coexisting significant physical illness; and delusions. Suicides occur mainly soon after discharge and after an outpatient consult. Subgroup analyses were done to distinguish between subjects who suicided early and late following discharge.

CONCLUSIONS

Suicidal risk remains high in Singaporean psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but the lower prevalence of substance abuse and comorbidity in Singaporean suicide subjects was one notable difference. The phenomena of suicides soon after discharge and outpatient review suggest the need for proper identification and more intensive follow up during this period.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care

These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).

Moral perspectives on the prevention of suicide in mental health settings

The response to suicidal clients is a recurrent and deep ethical problem in mental health practice. Rational suicide is rarely considered in relation to psychological suffering and is generally only discussed within the literature in connection with terminal illness. Focusing on a case example derived from a composite of patient experiences, this paper considers the premise that suicidal ideation may not be an irrational belief arising from mental disorder and analyses the ethical aspects of nursing care through the competing moral frameworks of the care-based and principle-based approaches to nursing ethics. We conclude that when the client is not capable of autonomous decision making, the two approaches lead to the same response. But when the client is capable of autonomous decision making, the two approaches lead to different responses. Specifically, from the care-based perspective, intervention to prevent suicide is easier to justify and helps formulate a nursing response, which promotes hope through the engagement.

Treating incarcerated women: gender matters

Research on incarcerated women has shown they have a high degree of comorbid psychopathology, including substance dependence, posttraumatic stress disorder (PTSD), antisocial personality disorder (ASPD), and major depression. Incarcerated women differ from their community peers by having more symptoms related to addiction, ASPD, and PTSD. At the same time, incarcerated women are every bit as likely as incarcerated men to be dependent on drugs and almost as likely to be dependent on alcohol. What emerges is a picture of the incarcerated woman far more likely to have had traumatic experiences, including early sexual and physical abuse, than her male peers but every bit as likely to have substance dependence and, in some correctional populations (eg, sentenced felons), antisocial personality disorder. Central to the discussion of how best to treat female offenders is the need to address how programs would best be structured for women with severe substance dependence, substantial trauma histories, and personality pathology, including ASPD. Incarcerated women are a population with complex medical and mental health needs and are likely to be high users of services within the correctional system. This poses challenges to a system already stretched thin in caring for these complex inmates. This article emphasizes that gender differences need to be appreciated, and that service delivery to male and female inmates needs to be structured with gender in mind. The article recommends case management, treatment in highly structured therapeutic communities, and emphasizing abstinence from substances and development of skill sets to engage in healthy relationships.A major future challenge lies in researching treatment interventions for women in the correctional system. There are few existing trials of treatment efficacy and, as previously noted, the incarcerated female population differs from populations of incarcerated men and women in the community. Opiate-dependent women undergoing treatment in the community may prove to be a reasonable comparison group in beginning to develop evidence-based treatment for female offenders in prisons and jails. Ultimately, the development of services for incarcerated women will consider gender, race, and psychopathology in determining treatment setting and modalities. We are on new ground. It is a promising and exciting time to be involved with treatment of female offenders.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Suicide in depressive disorders: a retrospective case-control study of 127 suicides

BACKGROUND

Depressive disorders are associated with a significant risk of suicide. Inpatient status and recent discharge from hospital have been identified as times of high risk of suicide within the course of illness.

METHOD

A matched retrospective case control study of 127 patients with depression requiring inpatient care who died by suicide as inpatients or in the 12 months following discharge from hospital. Single and multivariable conditional logistic regression identified independent risk and protective factors for suicide.

RESULTS

A history of deliberate self harm is a significant risk factor for suicide in patients with depression (OR 6.96; 95% CI 3.41-14.19), as is living alone (OR 2.11; 95% CI 1.15-3.87) and paid employment (OR 2.80; 95% CI 1.48-5.32). Admission to hospital during social crisis is associated with a reduction in suicide risk (OR 0.43; 95% CI 0.24-0.75).

LIMITATIONS

This is a retrospective case-control study, using clinical data not originally collected for research purposes.

CONCLUSIONS

General population risk factors for suicide are less predictive of suicide in patients with depression requiring inpatient treatment. Clinicians need to be aware of factors which increase or reduce the risk of suicide in this group.

Factors related to suicide in New York state prisons

OBJECTIVE

Examine factors related to prison suicides to aid prevention.

METHOD

Review the mental health records of all 76 suicides that occurred between 1993 and 2001 in New York State Department of Correctional Services (NYSDOCS) prisons that had some contact with mental health services during their incarceration. (This represented 84% of all NYSDOCS suicides.) Extract data from the psychological autopsies for a sample of 40 of these suicides.

RESULTS

Of the suicide victims with some mental health contact, 95% had a substance abuse history, 70% displayed agitation or anxiety prior to the suicide, and 48% had a behavioral change. Common stressors preceding the suicide were inmate-to-inmate conflict (50%), recent disciplinary action (42%), fear (40%), physical illness (42%), and adverse information (65%) such as loss of good time or disruption of family/friendship relationships in the community. Forty-one percent had received a mental health service within 3 days of the suicide. Compared to the about 7200 inmates actively receiving mental health services in state prison, African-Americans and patients with a Major Mood (Bi-polar or Major Depression) were under-represented. Adjustment Disorder, Schizophrenia, and Personality Disorder diagnoses were over-represented. Suicide victims were more likely to have been incarcerated for a violent crime.

CONCLUSION

Mental illness, anxiety/agitation, behavior change, stressors, history of substance abuse, and non-African-American were important risk factors.

Long- and Short-Term Risk Factors in the Prediction of Inpatient Suicide

Abstract. The prediction of suicide remains a major challenge for health care professionals in inpatient settings. A clearer identification of factors specific to inpatient suicide is required to improve both practice and research within this area. This paper provides an overview of the inpatient suicide literature to date focusing on two particularly salient themes: Long term and short term prediction of suicide. Since the concept of short-term suicide risk dominates clinical practice, issues in relation to dynamic risk factors are emphasized.

Regionale und �rtliche Verteilungsmuster von Bahnsuiziden

BACKGROUND AND METHOD

Suicide research has identified regional and local clusters of increased suicide prevalence. As part of a comprehensive prevention strategy to fight railway suicides, we sought to identify such particular clusters on the German Railway net (total length 37,080 km) during a 6-year observation period (1997-2002). Data stem from the central registry of all person accidents on the German Railway net.

RESULTS

During the observation period, a total of 5,731 suicides (in average 18 cases per week) were registered. Against expectation derived from distribution patterns in the general suicide research, we found a preponderance in the southern part compared to the northern part of Germany and a significant downward trend from west to east ( p=0.004). Most suicides occurred on open track (66%) compared to suicides at railway platforms (34%). We identified 16 places of high risk with 6 to 29 suicides per railway km. Of these high risk places, 75% were in the proximity of psychiatric hospitals.

CONCLUSION

Increased awareness for regional and local suicide clusters, initiatives to reduce the accessibility and warning infra-red beams are among recommendations for suicide prevention derived from these data.

Suicide risk in patients hospitalised because of an affective disorder: a follow-up study, 1973-1993

The aim of this study was to identify risk factors for suicide related to the course of treatment.

METHODS

All persons in Denmark hospitalised for the first time because of an affective disorder during the period 1973-1993 were included.

RESULTS

In 53466 patients, suicide was the cause of death in 3141 (6%) cases. The risk of suicide was high both immediately after admission and immediately following discharge. Increased risk was also associated with short duration of affective disorder, a history of multiple admissions, male gender, and increasing age.

LIMITATIONS

We were not able to distinguish with certainty between manic and depressive episodes in bipolar disorder. Prior suicide attempts could not be included in the analyses. Lack of operationalised diagnostic criteria.

CONCLUSIONS

Patients hospitalised because of an affective disorder are a highly relevant target group for suicide prevention. There is a need for improvement of preventive measures during admission and at discharge. Likewise, there is a need for preventive measures which can minimize the risk of relapse in affective disorders.

Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong

OBJECTIVE

To identify the risk period and the risk factors for suicide in Chinese psychiatric patients after discharge from inpatient psychiatric treatment. The nature of psychiatric aftercare provided to these patients was also explored.

METHOD

A case control study with 73 patients who were discharged from a large psychiatric unit in Hong Kong between January 1996 and December 1999 and had received coroners' verdict of suicide or undetermined death within the same period. Controls were 73 surviving patients discharged from the same unit. They were individually matched for sex, age, psychiatric diagnosis, and date of discharge.

RESULTS

Post-discharge clustering of suicides was observed among the cases. Nearly 80% of them died within 1 year of discharge. The most common principal diagnosis among the cases was schizophrenia and related psychotic disorders. Multivariate analysis showed that suicide was associated with: unemployment (OR = 12.2, 95% CI = 2.1 - 70.4), past suicidal attempts (OR = 3.4, 95% CI = 1.2 - 9.6), maternal mental illness (OR = 13.4, 95% CI = 1.0 - 170.0), and suicidal ideation or attempt before the last admission (OR = 5.0, 95% CI = 1.4 - 18.0). The psychiatric aftercare received by cases and controls were generally similar. However, cases were more likely to have had contact with health care services in the last week before death (OR = 4.0, 95% CI = 1.3 - 11.9).

CONCLUSIONS

Suicidal risk is high in Chinese psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but several differences are evident: the predominance of schizophrenia in the suicides; the lower prevalence of substance abuse and comorbidity; the low proportion of patients living alone; and the increased clinical contact before death but the less suicidal intent expressed in Chinese patients. It is necessary to consider these socio-cultural factors in assessment of suicidal risk and implementation of suicide prevention strategies in Chinese psychiatric patients.

Comparative study of suicide potential among Pakistani and American psychiatric patients

This study compared suicide potential and suicide attempts in 50 Pakistani and 50 American psychiatric patients all of whom reported a positive history of suicide attempts during the past 1-5 years. It further explored the role of nationality, gender, diagnosis, and marital status in respondents' potential for suicide and suicide attempts. The American sample reported a higher degree of suicide potential on the Firestone Assessment of Self-Destructive Thoughts (FAST), more suicide attempts, and a larger number of suicide precipitants (family conflicts, work pressure, wish for death, loneliness, financial problems, and mental disorders/drug withdrawal) than did the Pakistani sample. For suicide attempts, effects of 3-way interaction for gender, marital status and nationality were found significant. However, these effects were non-significant for respondent's potential for suicide. In addition, the FAST was found to have a significantly high correlation with suicide attempts. Thus, it may be inferred that the FAST can be used as a valuable screening instrument for the identification of patients at risk for suicide in diverse cultural settings. However, more prospective validity studies are needed to enhance our cross-cultural understanding of suicide; identification of psychiatric patients at risk for suicide by the FAST; and for effective treatment and prevention programs for Eastern and Western societies.

A Case Series of 44 Completed Gambling-Related Suicides

This paper presents an analysis of 44 case records of suicide occurring between 1990 and 1997 in the State of Victoria, Australia, in which the State Coroner identified the presence of a putative gambling problem. Analysis of demographic data revealed that the majority of suicidal gamblers were male with a mean age of 40 years with 84% of the sample being either unemployed or from lower socioeconomic backgrounds. The most common method of suicide was carbon monoxide poisoning. A quarter of the victims left a suicide note. Evidence was found indicating that almost a third (31.8%) of cases had previously attempted suicide and one in four had sought some form of mental health assistance for their gambling problem. A number of putative risk factors were identified including comorbid depression, large financial debts and relationship difficulties. The relationship between crime, suicide and gambling and gender differences among suicidal gamblers was also examined. The authors conclude that further research is required to substantiate these initial findings which are based on retrospective accounts and secondary sources of evidence.

Suicide prevalence in chemical dependency programs: preliminary data from a national sample, and an examination of risk factors

Completed suicides over a one year period of time were reported from a nationwide survey of Department of Veteran Affairs medical centers. Of a total of 248 completed suicides, 11 occurred in outpatient substance abuse programs, and an additional 5 occurred among patients receiving combined outpatient substance abuse and psychiatric treatment. There were no inpatient suicides. During this time, there were 7 suicide attempts on inpatient units and 37 suicide attempts in outpatient chemical dependency treatment. The majority of suicides were committed by males who had a primary alcohol addiction (63%). Thirty-eight percent of the sample had a comorbid mood disorder and 38% had a comorbid personality disorder. Risk factors relating to the potential for suicide in chemical dependency programs are discussed.

Suicide among psychiatric patients: a case-control study

OBJECTIVE

To examine patient- and treatment-based differences between psychiatric patients who do and do not die by suicide.

METHOD

By linking databases of deaths and psychiatric service use in Victoria, we compared 597 cases who suicided over 5 years with individually matched controls.

RESULTS

Cases and controls could not be distinguished on the majority of patient- or treatment-based characteristics. The exceptions were that cases were more likely to be male, less likely to be outside the labour force, more likely to have recent contact with inpatient and community services, and more likely to have a registration as their last contact.

CONCLUSION

Patients who suicide 'look' similar to those who do not, suggesting prevention approaches should ensure that all psychiatric patients receive optimal care, including appropriate detection, diagnosis, assessment and treatment of mental health problems, and careful, individualised assessment of suicide risk.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Increasing rates of suicide in Western Australian psychiatric patients: a record linkage study

OBJECTIVE

To investigate the risk of suicide following contact with mental health services and whether it has changed over time.

METHOD

Record linkage was used to obtain the records of previous hospital admissions and mental health service contacts for deaths due to suicide in the period 1980-98. Standardized incidence rates were calculated for the general population and for users of mental health services. Proportional hazards regression was used to assess risk factors within the cohort of people with mental health service contact.

RESULTS

Suicide risk was significantly increased in users of mental health services (rate ratio 6.66 in males and 7.52 in females). Suicide risk was highest in the first 7 days after discharge from in-patient care, and decreased exponentially with time since discharge. Suicide risk in users of mental health services has increased over the study period.

CONCLUSION

These results highlight the importance of adequate follow-up of patients discharged from in-patient services, and the need for adequate resources for community-based services.

Modelling suicide risk in affective disorders

BACKGROUND

The lifetime risk of suicide in affective disorders is commonly quoted as 15%. This stems from hospital populations of affective disorders.

AIMS

To model the lifetime prevalence of suicide using data on completed suicides from one English Health District and community-based rates of prevalence of affective disorders.

METHODS

A secondary analysis of a primary data set based on 212 suicides in North Staffordshire was undertaken. The population rates of psychiatric morbidity were obtained from the National Comorbidity Survey.

RESULTS

The model suggests a lifetime prevalence rate of suicide for any affective disorder at 2.4%, with a rate for those uncomplicated by substance abuse, personality disorder or non-affective psychosis at 2.4%, and a rate for uncomplicated cases who had no mental health service contact at 1.1%.

CONCLUSIONS

Lifetime prevalence rates of suicide in subgroups of affective disorders may be lower than the traditional rates cited for hospital depression. This has implications for primary care projects designed to investigate the occurrence of and the prevention of suicide.

The Wessex Recent In-Patient Suicide Study, 1. Case-control study of 234 recently discharged psychiatric patient suicides

BACKGROUND

Psychiatric patients have a higher suicide risk following hospital discharge.

AIMS

To identify social, clinical and health-care delivery factors in recently discharged patients.

METHOD

Retrospective case-control study of 234 patients who died within 1 year of hospital discharge, matched for age, gender, diagnosis and admission period with 431 controls. Odds ratios for identified risk factors were calculated using conditional multiple logistic regression.

RESULTS

Independent increased-risk factors were: not being White; living alone; history of deliberate self-harm (DSH); suicidal ideation precipitating admission; hopelessness; admission under different consultant; onset of relationship difficulties; loss of job; in-patient DSH; unplanned discharge; significant care professional leaving/on leave. Reduced-risk factors were: shared accommodation; delusions at admission; misuse of non-prescribed substances; and continuity of contact.

CONCLUSIONS

Continuity of contact may reduce suicide risk. Discontinuity of care from a significant professional is associated with increased risk of suicide.

A continuum of premature death. Meta-analysis of competing mortality in the psychosocially vulnerable

BACKGROUND

Suicide may be an extreme expression of liability to death of any type. If true, suicide risk factors should also increase other mortality, and, given exposure, excess risk should be higher for suicide than for other mortality.

METHODS

Of 304 publications identified in Index Medicus (1966-June 1988) by the string (suicide) and (mortality or death) and (accidental or natural), 24 reported total and cause-specific mortality associated with exposure to 16 established suicide risk factors; reference scanning yielded 122 more. These 146 publications reported on 163 cohorts (total subjects = 1179 126) mortality. Meta-analysis gave random effects standardized mortality ratios (SMR) for natural, accidental and suicidal death, stratified over the 16 risk groups.

RESULTS

Overall, SMR were 8.6 (95% CI : 7.1-10.4) for suicide, 3.4 (95% CI : 2.9-4.0) for accidental and 2.1 (95% CI : 1.9-2.3) for natural death. Compatible with the first hypothesis, in most groups, mortality of any type was raised. Supporting the second hypothesis, excesses increased from lowest for natural death to highest for suicide. This trend was most pronounced following deliberate self-harm, intermediate in substance abusers, and weakest, but present, in bereaved and low social class cohorts and reversed in smokers and epileptic people.

CONCLUSIONS

Many suicide risks apply to any type of premature death, whilst also retaining some specificity for suicide. Primary prevention, targeting such generic risk factors, will not only reduce rates of suicide but also of other types of death. Conversely, when prevention focuses on specific outcomes-such as suicide-only, other types of mortality may increase.

The Clarke Institute experience with completed suicide: 1966 to 1997

OBJECTIVES

To describe the caseload of completed suicides at a single psychiatric facility and to review the perceived deficiencies in the care of those patients.

METHOD

Demographic and diagnostic data, clinical circumstances, and the deficiencies in care and documentation or both were extracted from medical records and post-suicide audit reports.

RESULTS

There were 276 completed suicides over the period reviewed, yielding suicide rates of 206 per 100,000 registered patients and 123.5 per 100,000 inpatient discharges. The male to female ratio was 2:1, and patients with schizophrenia or depression accounted for 63.7% of the caseload. Only 18% of inpatients were involuntary, and only 10% were under individual observation at the time of suicide. Individual psychiatrists had up to 15 suicides in their caseloads. Deficiencies and recommendations pursuant to case audits are summarized.

CONCLUSION

This is the first report of the entire cumulative experience with completed suicide, including audited deficiencies in the care and documentation of that caseload, at a single Canadian psychiatric facility.

Completed suicide: an update for the general psychiatrist

Objectives: To review the most recent information on completed suicide for the general adult psychiatrist.

Methods: Literature review.

Results: Suicide is the result of a complex interaction of multiple variables. Prediction is highly dependent on clinical evaluation. Predictive factors identify groups better than individuals. Prevention has both clinical and political implications.

Conclusions: Reduced access to lethal methods (historically, from barbiturates to modified vehicle exhaust systems and paracetamol), attention to social factors (such as alcohol availability and employment levels) and clinical vigilance, coupled with adequate treatment of psychiatric disorders and close follow-up, should help to reduce suicide rates. Wider cultural issues (eg. religion) are poorly understood and require further research.