Cohort-specific risk of suicide for different mental disorders in China

Risk factors for suicide in adults: systematic review and meta-analysis of psychological autopsy studies

QUESTION

Effective prevention of suicide requires a comprehensive understanding of risk factors.

STUDY SELECTION AND ANALYSIS

Five databases were systematically searched to identify psychological autopsy studies (published up to February 2022) that reported on risk factors for suicide mortality among adults in the general population. Effect sizes were pooled as odds ratios (ORs) using random-effects models for each risk factor examined in at least three independent samples.

FINDINGS

A total of 37 case-control studies from 23 countries were included, providing data on 40 risk factors in 5633 cases and 7101 controls. The magnitude of effect sizes varied substantially both between and within risk factor domains. Clinical factors had the strongest associations with suicide, including any mental disorder (OR=13.1, 95% CI 9.9 to 17.4) and a history of self-harm (OR=10.1, 95% CI 6.6 to 15.6). By comparison, effect sizes were smaller for other domains relating to sociodemographic status, family history, and adverse life events (OR range 2-5).

CONCLUSIONS

A wide range of predisposing and precipitating factors are associated with suicide among adults in the general population, but with clear differences in their relative strength.

PROSPERO REGISTRATION NUMBER

CRD42021232878.

Risk factors for suicide in psychiatric emergency patients in Beijing, China: A large cross-sectional study

Psychiatric emergency patients constitute a population at high risk of suicidal thoughts and behaviors (STB). However, the risk factors for STB in this population have not been clearly defined. This study aimed to explore the risk factors for STB in psychiatric emergency patients in China. A cross-sectional analysis was conducted at the emergency department of psychiatry, Anding Hospital, Capital Medical University from 2015 to 2017. The Chinese suicide risk factors scale was used to test the STB of the patients. Multivariable logistic regression analysis was used to determine the risk factors of STB. A total of 12,345 patients were included. Their average age was 36 years. According to the suicide risk scale, 3436 cases (27.83%) were at risk of STB, mainly young adults. The multivariable analysis showed that urban residence, years of education, living in Beijing, ethnic Han, living alone, unemployment, poor relationship with parents, one or more siblings, visit time in the night, family history, disease course, total duration, the total number of psychiatric hospitalizations, a clear diagnosis, Brief Psychiatric Rating Scale total score ≥28.5, Hamilton Depression Rating Scale total score ≥20, and Young Mania Rating Scale total score ≥12 were independent risk factors for STB.

Introducing the Psychological Autopsy Methodology Checklist

OBJECTIVE

Case-control psychological autopsy studies are the research standard for the postmortem, quantitative study of ongoing or recent risk factors for suicide. We aimed to develop a reliable checklist of methodological quality of these studies.

METHOD

We adapted items from a validated checklist to address general methodological elements and created novel items to address the unique aspects of psychological autopsy research to generate a 16-item checklist assessing reporting, external validity, internal validity, and power. We used percent agreement and kappa to evaluate inter-rater reliability of the items and overall checklist based on independent ratings of 26 case-control psychological autopsy studies conducted internationally. We also summed the items to generate overall quality ratings, assessing internal consistency with coefficient alpha (α).

RESULTS

Inter-rater reliability for the overall checklist was high (percent agreement, 86.5%) and that based conservatively on kappa was substantial (κ .71) whereas internal consistency was low (α = 0.56). The inter-rater reliability of the individual items showed acceptable to high agreement.

CONCLUSION

A novel checklist provides a reliable means to assess the methodological quality of specific elements of quantitative case-control psychological autopsy studies, providing detailed guidance in planning such studies. Lower internal consistency may limit its utility as a summary measure of study quality.

Estimating the risk of suicide associated with mental disorders: A systematic review and meta-regression analysis

BACKGROUND

Mental disorders (MDs) are known risk factors for suicide. This systematic review updates the evidence base for this association and improves upon analytic approaches by incorporating study-level and methodological variables to account for measurement error in pooled suicide risk estimates.

METHODS

A systematic review was conducted to review studies on MDs as risk factors for suicide. Relevant studies were searched using PubMed, Embase, PsychINFO, and existing reviews from 2010 to 19. Studies were eligible if they were longitudinal/case-control studies, representative of the general population, used diagnostic instruments, and quantified suicide risk. The outcome assessed was relative risks (RRs) for suicide due to MDs. A multi-level meta-regression approach was used to obtain pooled RRs adjusted for covariates and between-study effects.

FINDINGS

We identified 20 eligible studies yielding 69 RRs. Disorder type, age, sex, use of psychological autopsy, study design, and adjustment for confounders were tested as predictors of pooled suicide risk. Overall, all disorders were significant predictors of suicide with predicted adjusted RRs ranging from 4·11 [2·09, 8·09] for dysthymia to 7·64 [4·3, 13·58] for major depressive disorder.

INTERPRETATION

Our results indicate that MDs are important risk factors for suicide. This systematic review provides pooled RRs that have been adjusted for methodological sources of bias. Findings from our paper may inform suicide prevention strategies as part of national health agendas.

The association between self-reported mental health, medication record and suicide risk: A population wide study

Suicide mortality and mental ill health are increasing globally. Mental ill health can be measured in multiple ways. It is unclear which measure is most associated with suicide risk. This study explored the association between self-rated mental health and medication record and death by suicide. The 2011 Northern Ireland Census records of adults aged 18-74 years (n=1,098,967) were linked to a centralised database of dispensed prescription medication and death registrations until the end of 2015. Mental health status was ascertained through both a single-item self-reported question in the Census and receipt of psychotropic medication. Logistic regression models examined the association between indicators of mental ill health and likelihood of suicide mortality. Of the 1,098,967 cohort members, 857 died by suicide during the study period. Just over half of these deaths (n=429, 50.1%) occurred in individuals with neither indicator of mental ill health. Cohort members with both self-reported mental ill health and receipt of psychotropic medication had the highest risk of suicide (OR=6.13, 95%CI: 4.94–7.61), followed by those with psychotropic medication record only (OR=4.00, 95%CI: 3.28–4.88) and self-report only (OR=2.88, 95%CI: 2.16–3.84). Individuals who report mental ill health and have a history of psychotropic medication use are at a high risk of suicide mortality. However, neither measure is particularly sensitive, as both failed to signal over half of subsequent suicides. Some individuals who report poor mental health but are not in receipt of psychotropic medication are at increased risk of suicide, indicating possible unmet treatment need. The combination of the two indicators offers more precision for identifying those most at risk for targeted interventions.

•

Mental ill health is associated with an increased risk of suicide, but measuring population mental health is difficult.

•

The suicide risk associated with both subjective and objective indicators of mental ill health have not been examined.

•

Most individuals who die by suicide have no indicator of mental ill health.

•

Having both self-reported poor mental health and psychotropic medication record carried the highest risk of suicide death.

•

Increased risk of suicide in individuals who report poor mental health but are not on medication may indicate unmet need.

Socio-Demographic and Clinical Characteristics of Psychiatric Patients Who Have Committed Suicide: Analysis of Bulgarian Regional Suicidal Registry for 10 Years

Introduction: Suicide is a major public health problem but factors determining suicide risk are still unclear. Studies in this field in Bulgaria are limited, especially on a regional level. Methods: By a cross-sectional design, we accessed the medical records of all psychiatric patients committed suicide over a 10-year period (2009-2018) in one major administrative region of Bulgaria. A statistical analysis was performed of the association between age of suicide as an indirect yet measurable expression of the underlying suicidal diathesis and a number of socio-demographic and clinical characteristics. Results: Seventy-seven of 281 suicides (28%) had psychiatric records. Most common diagnoses were mood disorders (44%), followed by schizophrenia (27%), anxiety disorders (10%), substance use disorders (9%) and organic conditions (8%). Male gender, single/divorced marital status, early illness onset, co-occurring substance misuse and lower educational attainment (for patients aged below 70) were significantly associated with earlier age of suicide whereas past suicide attempts and psychiatric hospitalizations, comorbid somatic conditions and unemployment showed insignificant association. Substantial proportion of patients (60%) had contacted psychiatric service in the year preceding suicide, with nearly half of these encounters being within 30 days of the accident. Conclusion: Severe mental disorders are major suicide risk factor with additional contribution of certain socio-demographic and illness-related characteristics. Monitoring for suicidality must be constant in chronic psychiatric patients. Registration of suicide cases in Bulgaria needs improvement in terms of information concerning mental health. More studies with larger samples and longitudinal design are needed to further elucidate distal and proximal suicide risk factors.

Risk factors for suicide in Bangladesh: case-control psychological autopsy study

BACKGROUND

Suicide is an important, understudied public health problem in Bangladesh, where risk factors for suicide have not been investigated by case-control psychological autopsy study.

AIMS

To identify the major risk factors for suicide in Dhaka, Bangladesh.

METHODS

We designed a matched case-control psychological autopsy study. We conducted a semi-structured interview with the next-of-kin of 100 individuals who died by suicide and 100 living controls, matched for age, gender and area of residence. The study was conducted from July 2019 to July 2020.

RESULTS

The odds ratios for the risk factors were 15.33 (95% CI, 4.76-49.30) for the presence of a psychiatric disorder, 17.75 (95% CI, 6.48-48.59) for life events, 65.28 (95% CI, 0.75-5644.48) for previous attempts and 12 (95% CI, 1.56-92.29) for sexual abuse.

CONCLUSIONS

The presence of a psychiatric disorder, immediate life events, previous suicidal attempts and sexual abuse were found as significant risk factors for suicide in Dhaka, Bangladesh.

Gender-specific risk for late-life suicide in rural China: a case-control psychological autopsy study

BACKGROUND

despite unique gender patterns of suicide among older people in rural China, research addressing this issue is scarce. This study aims to clarify the gender-specific risk factors of late-life suicide in rural China.

METHODS

the study included 242 persons (51% male) aged 60 and above who had committed suicide between June 2014 and September 2015 in the rural areas of three provinces of China. Using 1:1 matched case-control design, 242 living controls matched in age, gender and neighbourhood were randomly selected. Psychological autopsy interviews and psychological assessments were conducted with two informants for each suicide and living control, respectively.

RESULTS

men used alcohol before suicide more than women (12.6 versus 4.7%, P < 0.05). There was no gender difference in suicide method, suicide intent and previous attempts. Univariate analysis showed that married status, mental disorder, depressive symptoms, hopelessness, impulsivity, loneliness, social support, family function and quality of life were associated with suicide in both genders. For men, other risk factors were chronic physical illness and functions of daily living. Variables remaining in the multivariable model for both men and women were depressive symptoms and hopelessness.

DISCUSSION

depression and hopelessness are the two major risk factors for suicide among both older men and woman in rural China. Suicide prevention programmes focusing on depression and hopelessness in this population are indicated. Also needed are continued efforts to develop and refined gender-specialised strategies to identify high-risk individuals or groups and to enhance targeted support in the rural community.

A unified model of shared brain structural alterations in patients with different mental disorders who experience own-thought auditory verbal hallucinations-A pilot study

OBJECTIVE

To explore shared brain structural alterations in patients diagnosed with mental disorders who experience own-thought auditory verbal hallucinations (OTAVHs).

METHODS

A cohort of 143 first-diagnosis, nonmedicated patients with OTAVHs was enrolled: 25 with schizophrenia (FUSCH-OTAVH), 20 with major depression disorder (FUMDD-OTAVH), 28 with bipolar disorder (FUBD-OTAVH), 22 patients with posttraumatic stress disorder (FUPTSD-OTAVH), 21 with anxiety disorder (FUAD-OTAVH), and 27 with borderline personality disorder (FUBPD-OTAVH); 25 healthy controls (HCs) participated. The Auditory Hallucinations Rating Scale (AHRS), multiple psychometric scales, voxel-based morphometry (VBM), tract-based spatial statistics (TBSS), and multiple regression were used.

RESULTS

Compared with HCs, patients had increased occipital cortex, dorsal prefrontal cortex (PFC), and striatum gray matter volumes (GMVs), a reduced insular cortex (IC) GMV, and an impaired frontooccipital fasciculus. The following differences were found versus HCs: FUSCH-OTAVH, reduced PFC and occipital GMVs, increased striatum and thalamus GMVs, impaired arcuate fasciculus, u-shaped bundle, optic tract, and upper longitudinal fasciculus (LF); FUMDD-OTAVH, increased posterior frontotemporal junction and hippocampus GMVs; FUMN-OTAVH, increased posterior frontotemporal junction and parietal cortex GMVs, reduced hippocampus GMV, impaired upper LF; FUPTSD-OTAVH, increased temporal, hippocampus, and nucleus accumbens GMVs; FUBPD-OTAVH, increased frontotemporal junction and hippocampus GMVs, impaired upper/lower LF; and FUAD-OTAVH, increased frontal and temporal cortex, hippocampus GMVs.

CONCLUSIONS

The present findings provide evidence consistent with a bottom-up and top-down reciprocal action dysfunction hypothesis of AVHs and with the dopamine hypothesis of AVHs. We observed specific features related to OTAVHs in patients with different mental disorders. The findings, though complex, provide clues for further studies of specific mental disorders.

Unified and disease specific alterations to brain structure in patients across six categories of mental disorders who experience own-thought auditory verbal hallucinations: A pilot study

OBJECTIVE

To explore the unified and disease specific structural features of the brain in patients spanning six mental disorders who experience own-thought auditory verbal hallucinations (OTAVH).

METHODS

A pilot study was conducted on 25 patients with schizophrenia (FUSCH-OTAVH), 20 patients with major depression disorder (FUMDD-OTAVH), 28 patients with bipolar disorder (FUBD-OTAVH), 22 patients with posttraumatic stress disorder (FUPTSD-OTAVH), 21 patients with anxiety disorder (FUAD-OTAVH), and 27 patients with borderline personality disorder (FUBPD-OTAVH). Twenty-five healthy controls (HCs) were also recruited. Auditory Hallucinations Rating Scale (AHRS) multiple psychometric scales were adopted to assess the clinical features of voxel-based morphometry (VBM), tract-based spatial statistics (TBSS), and multiple regression in all patients. Common and specific brain features of OTAVH among these mental disorders were investigated.

RESULTS

Compared to HCs, GMV aberrant pattern across all the six categories patients with OTAVH decreased in the occipital cortex, left parietal lobe, prefrontal cortex (PFC), and insular cortex (IC). Aberrant patterns in white matter (WM) were detected in the corpus callosum and impairment of the fronto-occipital fasciculus. Structural differences in the brain were observed for each mental disorder versus HCs.

CONCLUSIONS

The unified brain aberrant features of OTAVH across six mental disorders were characterized by decreased GMV and WM impairments in some regions and the specific brain features of each disease were also characterized. In conclusion, this study provides evidence for the structural basis of OTAVH and potential avenues for investigating disease specific brain features of OTAVH.

Psychiatric disorders and suicide risk among adults with disabilities: A nationwide retrospective cohort study

BACKGROUND

Adults with disabilities demonstrate a higher suicide risk than the general population; however, the association between mental illness and death by suicide among disabled adults remains relatively unknown. We aimed to explore the relationship between psychiatric disorders and suicide risk in adults with disabilities.

METHODS

We used nationally representative cohort data and included adults who registered as having a disability from 2004 to 2012, following up with them throughout 2013. We used the clinical diagnoses of all psychiatric disorders as an independent variable and death by suicide as a dependent variable to estimate the adjusted hazard ratio (AHR) of suicide risk using a Cox proportional hazards model.

RESULTS

Among adults with disabilities (n = 30,386), those who had any psychiatric disorder were at an increased risk of death by suicide compared to those without mental illness (AHR 1.42; 95% confidence interval [CI] 1.02-1.99). Adults with mild disabilities who had psychiatric or mood disorders were more likely to commit suicide than the comparison group (AHR 1.67, 3.00; 95% CI 1.13-2.46, 1.95-4.61, respectively).

LIMITATIONS

The actual time of disability onset could differ from the time of disability registration.

CONCLUSIONS

Adults with disabilities who have psychiatric disorders are at increased risk of suicide compared to those without mental illness. During rehabilitation treatment after disability diagnosis, mental health support should be provided to those who have psychiatric illnesses to potentially reduce the risk of death by suicide.

The WHO/START study in New Caledonia: A psychological autopsy case series

BACKGROUND

Limited information is available about suicidal behavior in the Pacific Islands. Forty percent of the New Caledonian population is indigenous Kanak; insights into the characteristics of suicide deaths in this population compared to other ethnic groups would be valuable. The aim of this paper is to deepen our understanding of the cultural underpinnings of suicide in New Caledonia by presenting the results of the WHO/START psychological autopsy study.

METHOD

A case-series psychological autopsy study was conducted based on medical, police files, and interviews with relatives of 52 individuals who died by suicide in 2014 and 2015 in New Caledonia.

RESULTS

Kanak indigenous individuals represented more than half of suicides. Prevalence of mental disorders was identified in 62% of suicide decedents; a previous suicide attempt was frequent (37% of cases). A serious argument with a partner was the most prevalent life event (60%). Few warning signs were present among young people and Kanak in general.

CONCLUSION

Comparison with information on the general population suggests indigenous Kanak are more vulnerable and that having a mental health disorder plays an important role in suicide. Violent arguments with a partner could also be a major risk factor. Traditional protective factors (being employed, living with their family or partner, religion) appeared to have limited effect on suicide. Mental health promotion, prevention, and care should be prioritized. Prevention strategies, including domestic violence prevention are recommended in New Caledonia. Further research is needed to better identify young and Kanak subjects at risk of suicide.

Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC.

METHODS AND FINDINGS

PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals.

CONCLUSIONS

Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.

Metaanalysis of Mood and Substance Use Disorders in Proximal Risk for Suicide Deaths

Evidence for proximal risk factors for suicide is based on case-control psychological autopsy studies, with these reports showing that mood and substance use disorders are the most prevalent mental disorders among suicide decedents worldwide and are associated with marked risk. However, moderators of risk and the degree of risk associated with (nonalcohol) drug use disorder are unknown. A comprehensive search was used to identify 35 case-control psychological autopsy studies published worldwide over a 30-year period that were metaanalyzed using random effects models. Major depression, odds ratio (95% confidence interval) = 9.14 (5.53, 15.09), and drug use disorder, OR (95% CI) = 7.18 (3.22, 16.01), had large effect sizes, among other results. Risk estimates associated with major depression were greater in studies with a larger proportion of women and those conducted in Asia compared with other regions. There was no evidence of publication bias or that any one study had a disproportionate impact on findings. Risk for suicide associated with major depression appears to be moderated by sex and/or world region. Drug use disorder is a potent risk factor, illustrating the importance of assessing drug use in clinical risk assessment.

Disability in Daily Living Activities, Family Dysfunction, and Late-Life Suicide in Rural China: A Case-Control Psychological Autopsy Study

Background: Although late-life suicide in rural China is a matter of concern, research is scarce addressing the association between capability of daily living activities, family function, and late-life suicide. We conducted this psychological autopsy study to explore associations between disability in daily living activities, family dysfunction, and late-life suicide in rural China. Methods: Using a 1:1 matched case-control design, we collected data from 242 elderly suicide cases and 242 living community controls in rural China using the psychological autopsy method. We used Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID), Activities of Daily Living Scale (ADL), and Family Adaptive, Partnership, Growth, Affection and Resolve scale (APGAR) to assess the presence of mental disorders, capability of daily living activities, and family function, respectively. Results: Compared with the living controls, suicide cases presented more severe impairment in capability of daily living activities and poorer family function. After controlling for all other factors, capability of daily living activities and family function remained in the final model. The results of the multivariate analysis also show that the presence of a mental disorder, lower levels of social support, and increased number of life events in the last year were significantly associated with elevated suicide risk. Conclusions: Disability in daily living activities and family dysfunction are associated with elevated risk of late-life suicide in rural China. It is warranted to design programs, including family interventions, peer-support groups, and community programs, to help the rural elderly improve activities of daily living and obtain the social support they need to prevent suicidal behaviors.

Differences between patterns of suicide in East Asia and the West. The importance of sociocultural factors

OBJECTIVE

To compare suicide rates and characteristics in East Asian and Western countries.

METHOD

Data from five East Asian jurisdictions and five English-speaking Western countries were obtained from national offices responsible for collection of statistics. Data were graphed to demonstrate differences between East Asian and Western age patterns of suicide. Relevant literature was reviewed, including observations concerning suicide rates in various non-English-speaking European countries.

RESULTS

Age patterns and rates of suicide differ between East and West and across time, but with Japan's and the United States patterns progressively becoming more similar.

CONCLUSIONS

Sociocultural factors affect suicide patterns and rates; choice of method and cohort effects affect rates. Strategies for prevention of suicide should give attention to culture-related precipitants of suicide.

Substance use and suicidal ideation and behaviour in low- and middle-income countries: a systematic review

Background

Understanding relationships between substance use and suicidal ideation and behaviour (SIB) has important public health implications for suicide prevention in low- and middle-income countries (LMICs), where 75% of suicides occur. This systematic review explored the associations between substance use and SIB in LMICs.

Methods

We searched five databases using a combination of keywords for substance use, SIB and LMICs to identify English-written quantitative studies published between January 2006 and February 2016. Data were extracted to provide an overview of what is known about the topic, highlight gaps in the literature, and explore the implications of current knowledge for suicide prevention. Studies included in the review were assessed for methodological quality using the Scottish Intercollegiate Guidelines Network checklist.

Results

Analysis of included studies (N = 108) demonstrated a consistent positive association between substance use and SIB across all substances (i.e. alcohol, tobacco, cannabis, illicit drugs, non-medical use of prescription drugs), all substance use dimensions (i.e. intoxication, use, and pathological use) and all SIB dimensions (i.e. suicidal ideation, non-fatal suicidal behaviour, and suicide). Most of the available research evidence comes from upper-middle-income countries, only 22% comes from lower-middle-income and low-income countries. Most studies focused on alcohol and tobacco, while neglecting substances such as cannabis, opioids, sedatives, stimulants, misuse of prescription medication, inhalants, and hallucinogens. Most of the studies employed a cross-sectional design, were conducted within a risk-factor paradigm, and provided little information about the potential interaction between variables.

Conclusions

Public health suicide prevention policy and research in LMICs should take account of the fact that: substance use is a potentially modifiable risk factor; assessment and management of substance use is integral to the care of at-risk patients; reducing consumption and hazardous use of substances in LMICs is important for suicide prevention; and research needs to be expanded to include more theory driven research that focuses on all substance use dimensions and SIB dimensions, while employing more sophisticated statistical methods.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5425-6) contains supplementary material, which is available to authorized users.

Mental disorders and suicide attempt in rural China

The prevalence of various mental disorders and their age and gender specific characteristics among suicide attempters remains unclear in rural China. This study using 1:1 paired case-control design included 409 suicide attempters and 409 paired controls matched on age, gender and place of residence. Mental disorders were assessed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. The prevalence of mental disorders was 32.3% for suicide attempters and 4.9% for paired controls. Mental disorder constituted a significant risk factor for suicide attempt with an adjusted odds ratio of 7.16 (95%CI: 3.65-14.04). The prevalence of mental disorders was higher among male than female suicide attempters. Major depressive disorder was most common in female suicide attempters while alcohol use disorder was most common in the males. The prevalence of mental disorders seemed to increase with age. Suicide attempters of higher ages were more prone to have mood disorders, especially a major depression. Suicide attempters with mental disorders differed from those without mental disorders on a number of socio-economic characteristics and suicidal behavior features. These insights should be taken into account in strategies and efforts to improve mental health care and ultimately to reduce suicidal behavior among residents in rural China.

Geographical and temporal variations in the prevalence of mental disorders in suicide: Systematic review and meta-analysis

BACKGROUND

In contrast to the previous studies reporting that most suicides occur among people with mental disorders, recent studies have reported various rates of mental disorders in suicide in different geographical regions. We aimed to comprehensively investigate the factors influencing the variation in the prevalence of mental disorders reported among suicide victims.

METHOD

The authors searched Embase, Medline, Web of Science, and the Cochrane Library to identify psychological autopsy studies reporting the prevalence of any mental disorders among suicide victims. A meta-regression analysis was conducted to identify the potential effects of geographical regions, the year of publication, measurements of personality disorder, measurements of comorbidity, and the ratio of females on the prevalence of mental disorders in addition to examining the heterogeneity across studies.

RESULTS

From 4475 potentially relevant studies, 48 studies met eligibility criteria, with 6626 suicide victims. The studies from East Asia had a significantly lower mean prevalence (69.6% [95% CI=56.8 to 80.0]) than those in North America (88.2% [95% CI=79.7-93.5]) and South Asia (90.4% [95% CI=71.8-97.2]). The prevalence of any mental disorder decreased according to the year of publication (coefficients=-0.0715, p<0.001).

LIMITATIONS

Substantial heterogeneities were identified within all subgroup analyses.

CONCLUSIONS

The prevalence of mental disorders among suicide cases seemed relatively low in the East Asia region, and recently published studies tended to report a lower prevalence of mental disorders. The link between the risk factors and suicide in the absence of a mental disorder should be examined in different geographical and sociocultural contexts.

Suicidal Behavior in Relatives or Associates Moderates the Strength of Common Risk Factors for Suicide

The prevalence and odds ratios of different suicide risk factors were compared in three pairs of decedents: 80 suicides and 25 injury decedents with blood relatives with suicidal behavior history (biologically exposed); 259 suicides and 126 injury decedents with unrelated acquaintances with suicidal behavior history (socially exposed); and 471 suicides and 523 injury decedents with neither relatives nor acquaintances with suicidal behavior history (unexposed). Negative life events and high psychological stress were more common in socially exposed suicides than in other suicides. The adjusted odds ratios of most established suicide risk factors were higher in unexposed decedents than in biologically or socially exposed decedents, suggesting that the predictive value of established risk factors wanes in individuals who have been exposed to suicidal behavior in family or friends.

Suicide in the global chinese aging population: a review of risk and protective factors, consequences, and interventions

As one of the leading causes of death around the world, suicide is a global public health threat. In the Chinese population, suicides constitute one-fifth of all recorded suicides in the world. Despite the factual data on suicide rates, the understanding of various causal factors behind suicide, including risk and protective factors and adverse health care, remained incomplete among the global Chinese aging population. To fill in the knowledge void, this paper reviews the epidemiology of suicide among Chinese older adults globally as well as explores the existing intervention strategies. Using the PRISMA statement, we performed a systematic review of exiting research on the topic, including studies describing suicide among Chinese older adults in communities outside of Asia. A literature search was conducted online by using both medical and social science data-bases. Our findings highlighted that elderly suicide in Chinese populations is significantly affected by the social, cultural, and familial contexts within which the individual lived prior to committing suicide. Reviewing such research indicated that while reducing risk factors may contribute to lowering suicides amongst Chinese older adults, measures to improve protective factors are also critical. Support through ongoing family and community care relationships is necessary to improve resilience in older adults and positive aging. Future longitudinal studies on the risk factors and protective factors, and adverse health consequences are called for to devise culturally and linguistically appropriate prevention and intervention programs in global Chinese aging populations.

Suicide risk among Thai illicit drug users with and without mental/alcohol use disorders

BACKGROUND

It is not yet known if the increased risk of suicide in substance abusers is caused by the causal and/or coexisting relationship between substance use and psychiatric disorders. This study was designed to estimate the suicide risk among individuals with illicit drug use alone, illicit drug users with mental disorders, and illicit drug users with alcohol use disorders.

METHODS

Subjects were participants of the 2008 Thai National Mental Health Survey. They were asked for their illicit drug use in the past year. The Mini International Neuropsychiatric Interview (MINI), current suicidality (1 month prior to assessment), mood episodes, anxiety disorders, psychotic disorders, and alcohol use disorders were used for assessing mental/alcohol use disorders. A score of 1 or more for the MINI-Suicidality module was defined as the presence of suicide risk.

RESULTS

Of the total 17,140 respondents, 537 currently used illicit drugs, while 1,194 respondents had a suicide risk. Common illicit drugs were kratom (59%) and (meth)amphetamine (24%). Compared with 16,603 Thais without illicit drug use, the illicit drug users with or without mental/alcohol use disorders (n=537) had an increased risk of suicide (adjusted odds ratio [OR], 95% confidence interval [CI] =2.09, 1.55-2.81). While those who used illicit drugs alone (no mental/alcohol use disorder) (n=348) had no increased risk of suicide (adjusted OR, 95% CI =1.04, 0.66-1.65), the illicit drug users with mental or alcohol use disorders (n=27 and n=162, respectively) had significantly increased risk of suicide (adjusted ORs, 95% CIs =14.06, 6.50-30.3 and 3.14, 1.98-4.99, respectively).

CONCLUSION

A key limitation of this study was the combined suicidal behaviors as a suicidality risk. Mental or alcohol use disorders found in this population actually increased the suicide risk. These findings support the coexisting relationship that mental and alcohol use disorders play a vital role in increasing the suicide risk in illicit drug users.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Comparison of impulsive and nonimpulsive suicide attempt patients treated in the emergency departments of four general hospitals in Shenyang, China

OBJECTIVE

The aim of the current study was to compare the sociodemographic and psychological characteristics of impulsive suicide attempters with those of nonimpulsive suicide attempters in the emergency departments of general hospitals in Shenyang, China.

METHODS

A total of 239 consecutive suicide attempters, who were treated in the emergency departments of four randomly selected general hospitals from Shenyang city, were evaluated by the following measurements: a detailed structured questionnaire, Beck Suicide Ideation Scale, Hamilton Depression Rating Scale, a quality of life scale and the Structured Clinical Interview for DSM-IV Axis I Disorders. The patients were categorized as "impulsive suicide attempts" (≤ 2 h) and "nonimpulsive suicide attempts" (> 2 h) based on the hours it takes for a patient to consider suicide before acting, and the characteristics of the two groups of patients were compared.

RESULTS

One hundred seven (44.8%) patients were categorized as impulsive attempters. Compared to nonimpulsive suicide attempters, the impulsive suicide attempters had significantly more self-rescue ideation, their motive was more likely to threaten or express anger at others, and they scored much lower on the intensity of suicidal ideation and depression but higher on life quality; they also had a lower prevalence of psychiatric diagnosis but a higher rate of substance-related disorders. Multivariate logistic regression analysis identified the following independent predictors of impulsive suicide attempts among suicide attempters: having religious beliefs [odds ratio (OR)=4.435, 95% confidence interval (CI)=1.545-12.736], a lower score on the Suicide Ideation Scale (OR=0.952, 95% CI=0.936-0.969) and a lower score on the Hamilton Depression Rating Scale (OR=0.949, 95% CI=0.911-0.989).

CONCLUSIONS

The characteristics of impulsive suicide attempters differed significantly with those of nonimpulsive suicide attempters in emergency departments of urban China. It is important to develop different kinds of interventions for the two types of suicide attempters to prevent more future suicide attempts.

Gender-specific differences among patients treated for suicide attempts in the emergency departments of four general hospitals in Shenyang, China

OBJECTIVE

We aimed to identify gender-specific characteristics of suicide attempters admitted to general hospital emergency departments in urban China.

METHODS

The Structured Clinical Interview for the DSM-IV, the Suicide Ideation Scale, the Hamilton Depression Rating Scale and a quality of life measure were administered to 239 suicide attempters who were treated consecutively in the emergency departments of four general hospitals randomly selected in Shenyang, China.

RESULTS

Among the 239 enrolled subjects, 53 (22.2%) were men, and 186 (77.8%) were women. Compared to women, men were more likely to be a minority, live with their families and/or suffer from substance-related disorders. Men were less likely to be living alone or cohabitating. Women were more likely to express suicide ideation compared with men. Thirty-seven (69.8%) men and 129 (69.4%) women had mental illness. The prevalence of psychiatric diagnosis was not significantly different between men and women (χ(2)=.004, df=1, P=.95).

CONCLUSION

The rate of attempted suicide is higher among women than among men in the emergency departments of urban China. Except for race, living situation and suicide ideation, there are few gender differences regarding socio-demographic and clinical characteristics in the current study that are not consistent with reports from other countries. However, similar to other studies, men are more likely to suffer from substance-related disorders than are women. The unique, gender-specific characteristics pertaining to suicide attempters in urban China emphasizes the need for gender-specific interventions in future clinical treatment.

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti

BACKGROUND

Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti's Central Plateau.

METHODS

We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti's Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively.

RESULTS

The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5).

CONCLUSIONS

A large proportion of Haiti's Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.

Suicides during 7 years among a catchment area cohort of patients with psychoses

OBJECTIVE

To investigate a series of consecutive suicides at a psychosis clinic by using a psychological autopsy technique.

METHOD

The clinic serves an adult population of 225,000 individuals, of whom 0.5% have regular contact with the clinic. During a 7½-year period, 23 men and nine women committed suicide, which corresponds to an odds ratio of 14.

RESULTS

Most patients were schizophrenic, and 24 were outpatients. Suicide methods were violent in all but two cases. Nineteen had a history of at least one suicide attempt, and 24 were known to have had suicidal ideation. More than half had no social contacts over the last year except with psychiatric staff. The median time between the last contact with the psychiatric services and the suicide was 4 days. No warning signs were noted. At the time of death, 3 of the 24 who were prescribed antipsychotics, and none of the 10 who were prescribed antidepressants had plasma levels of the corresponding drug.

CONCLUSION

Findings of special interest are the lack of forewarnings and the poor drug compliance. Patients appear to have played "business as usual" with the care-givers, and did it well. Is it a sign of health and despair, or illness?

Attempted suicide in Shanghai districts: a pilot study

This is a pilot study whose objective was to collect data on attempted suicide in 5 districts of Shanghai and to test the feasibility of introducing an ongoing monitoring of attempted suicide. Data on a total of 363 cases were collected. The mean age of the patients was 33 years, 67% being female. Ingesting drugs or other chemical substances was the main method used for self-harm. Reasons for attempted suicide in these districts of Shanghai often appear to be related to family conflicts and unemployment. In spite of methodological limitations, the recorded data allow some preliminary conclusions regarding the characteristics of patients in districts of Shanghai admitted after a suicide attempt. Continuous monitoring of attempted suicide in this urban area of China should be established and data collection improved to raise awareness in health professionals and to develop preventive measures geared toward the needs of these patients.

Substance use and suicide

PURPOSE OF REVIEW

To address gaps identified in earlier reviews, namely, the comparative influence of substance use on attempted suicide and completed suicide; the proximal role of substance use as a trigger of suicidal behaviour; the association between substances and suicidal behaviour; suicide and substance use disorders in youth; and the influence of combinations of risk factors, including psychiatric morbidity, on suicide.

RECENT FINDINGS

The presence of an alcohol use disorder is confirmed as a distal risk factor for completed suicide, as well as attempted suicide. Alcohol use at the time of the suicide attempt is associated with low-risk methods. The use of other substances as a trigger of suicidal behaviour is highlighted in recent studies, but the circumstances leading to the suicidal act and the direct influence of substances in suicidal behaviour need to be explored further. Inhalant use and cocaine use are particularly associated with suicidal behaviour. Young people with multiple risk behaviours, such as substance use and risky sexual behaviours, are at high risk for suicidal behaviour. Psychiatric comorbidity with substance use escalates the risk for suicidal behaviour. Environmental interventions, such as reduction in the number of bars, may be helpful in reducing alcohol-related morbidity, including suicides.

SUMMARY

Prevention strategies for reducing suicidal behaviour among substance users need to be prioritized at the individual and the national level through effective design, policy and implementation.