Role of psychiatrists in the prediction and prevention of suicide: a perspective from north-east Scotland

Exploring the Role of Coping Strategies on the Impact of Client Suicide: A Structural Equation Modeling Approach

Client suicide refers to cases where a mental health practitioner is exposed, affected, or bereaved by a client's suicide and is known to have a profound impact on MHPs. The current study investigated the role of coping styles in understanding short- and long-term impact of client suicide. An international sample of 213 mental health practitioners who experienced a client suicide completed a survey on coping strategies (i.e., Brief-COPE) and the impact of traumatic events (i.e., impact of event scale-revised, long-term emotional impact scale and professional practice impact scale). Results indicate coping strategies explain 51% of the short-term, 64% of the long-term emotional and 55% of the long-term professional differences in impact of client suicide. Moreover, while an Avoidant coping style predicted more impact of client suicide, Positive coping and Humor predicted less impact of client suicide. Social Support coping did not predict impact of client suicide. Implications for both research and clinical practice are discussed.

Coping with suicide: a perspective from Scotland

Procedures following suicide differ in Scotland from elsewhere in the UK and we describe the investigation of deaths by procurators fiscal and fatal accident inquiries that may ensue. Higher Scottish suicide rates, and possible reasons for these, are mentioned. Suicide risk cannot be accurately quantified in individual patients but psychiatrists should take the view that good management can collectively reduce the risk among all patients. We comment on practical and emotional issues for clinicians who are coping with the suicide of a patient.

From Querulous to Suicidal: Self-immolation in Public Places as a Symbolic Response to the Feeling of Injustice

Aim: This paper sheds light on the context that leads some querulous patients to self-immolate in front of, or into, public buildings (e.g., tribunals, city halls, and employment agencies). Method: The author defines paranoid querulousness. A psychoanalytic perspective, but also a judicial and a psychiatric point of view, over querulous claimants is presented. The links between political or social claims and self-immolation are studied. The expression of suicidal thoughts voiced by four querulous subjects is analyzed. Eight examples of self-immolation are presented. Results: The querulous subjects' self-aggressive behaviors seem to be caused by a loss of hope to obtain compensation for a prejudice they allegedly suffered. Querulous individuals tend to self-immolate in front of, or into, public buildings when no answer is given to their claims. These gestures may be both a consequence of some personal distress and triggered by a difficult social or professional context. Discussion: Five sets of assumptions derived from Freudian and Lacanian psychoanalytic theories are advanced. The status of the object over which the querulous claimants wish to assert their rights is clarified. The meaning of self-aggressive gestures is outlined by making reference to the concepts of instinct for mastery, symbolic other, chain of signifiers, masochism, pleasure principle, and reality principle. Conclusion: Prevention of self-immolation could involve that members of the legal professions, social workers, civil servants, and mental health professionals in contact with querulous subjects openly show their will to listen to these claimants' voice: self-aggressive gestures might be avoided by supporting the querulous person's hope to obtain compensation for the prejudice allegedly suffered.

Temperament traits in suicidal and non-suicidal mood disorder patients in Taiwan

Suicide is a major social and clinical problem in Asia. Although studies have suggested that personality traits are possible risk factors for suicide, no study has been conducted among Chinese to compare the temperament traits of suicidal and non-suicidal mood disorder patients with those of healthy controls. This study compared temperament traits of two patient groups, those with a mood disorder who have attempted suicide (n=204), and those with a mood disorder who have not attempted suicide (n=160), and compared the traits of these patients to those of healthy controls (n=178), assessed by Cloninger's Tridimensional Personality Questionnaire and the Brown-Goodwin Aggression Inventory. Patients with suicidal attempts had significantly higher novelty seeking and aggression scores than healthy controls and patients without suicidal attempts. Two groups of patients with mood disorder had significantly higher harm avoidance scores than the healthy controls. However, patients with suicidal attempts did not have higher harm avoidance scores than patients without suicidal attempts. This study confirms findings that harm avoidance and mood disorder are related, and extends them by suggesting that those with a mood disorder and suicide attempts have higher novelty seeking and lifetime aggression scores than those without suicidal attempt, either patients or healthy controls.

Death by Suicide in Grampian 1991–1999: Comparison with a Previous Study

Objectives: To review the changes in suicide and undetermined death rates in Grampian between 1991–1999 and to make comparisons with a previous study on the same population. Design: All suicide and undetermined deaths in Grampian recorded by the General Register Office for Scotland were included and linked with the psychiatric case records from Grampian Health Board. Results: The high suicide and undetermined death rates in Grampian are accounted for by the excess of deaths in males. In males there has been a change in the method used to commit suicide with hanging now being the commonest method used. Firearm deaths have reduced dramatically since legislation was introduced in 1997 (RR = 0.21, 95% CI [0.05,0.91]). For those with previous psychiatric contact,-a greater proportion were drug users than in 1974–1990 (OR = 3.75,95% CI [2.7, 5.2]). A higher percentage of suicides have a history of more than one previous attempt at suicide than in 1974–1990. In Grampian there is a lower percentage of in patient suicide than the rest of Scotland. Conclusion; There have been changes in suicide trends in Grampian and these are similar to elsewhere in Scotland. Strategies to address this are discussed.

Validation of the Chinese SAD PERSONS Scale to predict repeated self-harm in emergency attendees in Taiwan

BACKGROUND

Past and repeated self-harm are long-term risks to completed suicide. A brief rating scale to assess repetition risk of self-harm is important for high-risk identification and early interventions in suicide prevention. The study aimed to examine the validity of the Chinese SAD PERSONS Scale (CSPS) and to evaluate its feasibility in clinical settings.

METHODS

One hundred and forty-seven patients with self-harm were recruited from the Emergency Department and assessed at baseline and the sixth month. The controls, 284 people without self-harm from the Family Medicine Department in the same hospital were recruited and assessed concurrently. The psychometric properties of the CSPS were examined using baseline and follow-up measurements that assessed a variety of suicide risk factors. Clinical feasibility and applicability of the CSPS were further evaluated by a group of general nurses who used case vignette approach in CSPS risk assessment in clinical settings. An open-ended question inquiring their opinions of scale adaptation to hospital inpatient assessment for suicide risks were also analyzed using content analysis.

RESULTS

The CSPS was significantly correlated with other scales measuring depression, hopelessness and suicide ideation. A cut-off point of the scale was at 4/5 in predicting 6-month self-harm repetition with the sensitivity and specificity being 65.4% and 58.1%, respectively. Based on the areas under the Receiver Operating Characteristic curves, the predictive validity of the scale showed a better performance than the other scales. Fifty-four nurses, evaluating the scale using case vignette found it a useful tool to raise the awareness of suicide risk and a considerable tool to be adopted into nursing care.

CONCLUSIONS

The Chinese SAD PERSONS Scale is a brief instrument with acceptable psychometric properties for self-harm prediction. However, cautions should be paid to level of therapeutic relationships during assessment, staff workload and adequate training for wider clinical applications.

Patient suicide: the experience of Flemish psychiatrists

The experience of the most distressing patient suicide on Flemish psychiatrists is described. Of 584 psychiatrists, 107 filled a self-report questionnaire. Ninety-eight psychiatrists had been confronted with at least one patient suicide. Emotional suffering and impotence were the most common feelings reported. Changes in professional practice were described and included a more structured approach to the management of suicidal patients. Colleagues and contact with the patient's family were the most frequently used sources of help, whereas team case review and colleagues were rated as the most useful ones. Patient suicide leads to emotional suffering and has a considerable professional impact.

Addressing Self-Directed Violence Prevention for Preventive Medicine Practitioners

This article summarizes the field of self-directed violence and its prevention focusing on suicidal behavior. Then it describes ways in which health care practitioners, especially preventive medicine specialists, can play a role in preventing these injuries whether they practice in clinical or community based settings. A review of the importance of suicidal behavior as a public health problem, its epidemiology, and prevention approaches are discussed. Suicidal behavior results from an interaction of risk factors but much is known about these factors and many of the injuries due to this phenomenon are preventable. Prevention of suicidal behavior requires collaboration from many sectors, including health care practitioners. Preventive medicine specialists can address this problem that affects individuals, families, and communities by taking an active part as practitioners, researchers, advocates, and through education.

Impact of biopsychosocial factors on psychiatric training in Japan and overseas: are psychiatrists oriented to mind, brain, or sociocultural issues?

AIM

To clarify the impact of biopsychosocial factors on psychiatric training under the new and traditional postgraduate medical education system in Japan and to compare them with young psychiatrists from other countries.

METHODS

Psychiatric residents and early-career psychiatrists were recruited in Japan and other countries. Using mail-based and web-based self-administered questionnaires, we evaluated participants' demographic information, motivation to become psychiatrists, interest and commitment to various aspects of psychiatry, and reactions to a case vignette, focusing on biopsychosocial factors.

RESULTS

A total of 137 responses, 81 from Japan and 56 from other countries, were collected. Before starting psychiatric training, Japanese participants showed a strong interest in 'mind' and less interest in 'brain' and 'environmental factors', while the interest in 'brain' and 'environmental factors' is presently as high as that in 'mind.' Japanese participants reported less commitment to their training toward ICD/DSM-based diagnosis, interview, pharmacotherapy, psychosocial treatment and epidemiology, compared with participants from other countries. In particular, Japanese participants showed less commitment to their training in suicide prevention, despite their perception of its high importance due to a high suicide rate in Japan. Suicide risk of a case vignette proved to be differently assessed according to participants' commitment levels to each aspect of psychiatry.

CONCLUSION

Our results suggest that young psychiatrists' attitudes concerning the biopsychosocial model generally become well-balanced with psychiatric training, however sociocultural factors do not seem to be well represented in the Japanese psychiatric training system. Additional training on sociocultural issues, such as suicide in Japan, should be considered.

Suicide prevention in the psychiatric hospital

It is currently impossible to distinguish between patients with depression who will make a suicide attempt and those who will not. Prevention, therefore, must be based on the assumption that any patient with more than mild symptoms of depression is at risk of suicide, and can only be effective if it is applicable to all patients with moderate to severe depression. A treatment strategy that differentiated between regressive and progressive therapeutic measures was developed for patients admitted to a psychiatric hospital. Regressive, as opposed to progressive, treatment meant that the patient was temporarily relieved of virtually all responsibilities for self and others. Progressive measures were strictly avoided for all patients with symptoms of depression, regardless of the primary diagnosis. This strategy was tested on 5,149 inpatients and day patients over a period of 6.25 years and compared with 6,891 patients over the 15.75 years prior to this period. The suicide rate was 97 (per 100,000 admissions) compared with 319 in the previous period. The treatment method appears to be able to reduce the suicide rate. Although this result was achieved with hospital patients, it suggests that a regressive treatment method could be promising if developed for outpatient treatment as well.

Suicide for scrutinizers

OBJECTIVES

The aim is to present information which may be useful to those who scrutinize mental health professionals and systems in the aftermath of completed suicide.

CONCLUSION

Suicide has been known in all cultures, throughout history, and may be committed in the absence of mental disorder. Risk factors for suicide are known but they are of limited clinical utility. Prediction and prevention of suicide are beyond current abilities. Criticism of mental health professionals and systems in the aftermath of suicide may be destructive and work to the disadvantage of patients.

Repeated self-poisoning: increasing severity of self-harm as a predictor of subsequent suicide

BACKGROUND

Prediction of suicide risk is difficult in clinical practice.

AIMS

To identify changes in clinical presentation predictive of suicide in patients treated for repeated episodes of self-poisoning.

METHOD

A nested case-control study used the Hunter Area Toxicology Service database to identify exposure variables and the National Death Index to identify suicide. Cases were patients who had hospital treatment on more than one occasion between 15 January 1987 and 31 December 2000.

RESULTS

There were 31 cases, for which 93 controls were selected. Study variables associated with an increased risk of subsequent suicide were an increase in the number of drugs ingested (odds ratio 2.59, 95% CI 1.48-4.51), an increase in the dose ingested (OR 1.33, 95% CI 1.01-1.76), an increase in coma score (OR 1.71, 95% CI 1.11-2.66), a decrease in Glasgow Coma Score (OR 1.21, 95% CI 1.03-1.43) and an increase in drug or alcohol misuse (OR 2.33, 95% CI 1.06-5.10).

CONCLUSIONS

Patients who have escalating severity of self-poisoning episodes are at high risk of completed suicide.

Suicide outside the care of mental health services: a case-controlled psychological autopsy study

BACKGROUND

Three-quarters of people who commit suicide are not in contact with mental health services at the time of death. No previous UK study has focused specifically on this group of suicides.

AIMS

To identify the characteristics of people who commit suicide while outside the care of mental health services.

METHOD

A case-control study was conducted in SW England involving 100 individuals who committed suicide while not in contact with mental health services and 100 age-sex matched controls drawn from the living population. Data were collected by means of semistructured interviews with key informants and from medical records.

RESULTS

Key predictors of suicide were previous attempted suicide, social and interpersonal problems, current mental illness, past mental illness, and previous contact with specialist services. However, nearly a third of cases (32%) appeared to have no current mental disorder.

CONCLUSION

This group is distinguished by a markedly lower rate of mental illness than has previously been recorded. The findings highlight the difficulty of identifying individuals outside specialist mental health care who are at risk of suicide and therefore support the continued development of broad population-based measures rather than the targeting of high-risk groups.

Suicide prevention: a study of patients' views

BACKGROUND

Suicide prevention strategies are usually formulated without seeking the views of people with psychiatric illnesses.

AIMS

To establish what helped patients with severe psychiatric illness when they felt suicidal.

METHOD

A semi-structured interview was constructed following transcribed interviews with 12 patients. This was administered to 59 out-patients with serious and enduring mental illness, focusing on factors they found helpful or unhelpful when at their most despairing.

RESULTS

Three-quarters of patients were in contact with psychiatric services when feeling at their lowest, and this contact was generally deemed to be helpful. Social networks were considered just as helpful as psychiatric services by the half of patients who discussed their feelings with friends or relatives. Religious beliefs and affiliations were helpful. Negative influences included the media and the stigma of psychiatric illness.

CONCLUSIONS

Efforts at suicide prevention might usefully focus on enhancing patients' social networks, increasing the likelihood of early contact with psychiatric services and decreasing the stigma attached to psychiatric illness. Larger studies of patients exposed to different service models would be informative.