Studying survivors of nearly lethal suicide attempts: an important strategy in suicide research

Attempted suicide: does lethality matter?

OBJECTIVES

To investigate whether high-lethality suicide attempters align to the demographic and clinical features observed in completed suicide in the national and international literature, and whether low-lethality attempters more closely align with the clinical profile of non-attempter ideators.

METHODS

A retrospective chart review of adult suicide ideators and attempters presenting to an urban tertiary care hospital was performed. Suicide ideators (n = 50) and attempters (n = 50) were coded for variables including demographics and clinical characteristics (e.g. psychiatric diagnosis and previous suicide attempt). Method and lethality of suicide attempt were coded using the medical Lethality Rating Scale.

RESULTS

High-lethality attempters were more likely to be younger in age than low-lethality attempters (p = 0.026) and ideators (p = 0.041). The lethality scores of suicide attempts were significantly inversely correlated with age (p = 0.017).

CONCLUSIONS

Our study adds to the small but increasing body of literature investigating the characteristics of high-lethality suicide attempters and suggests younger adult age is a risk factor for a high-lethality attempt. Further understanding of this unique group would be aided by widespread agreement on the definition of a high-lethality suicide attempt and longitudinal studies of this cohort.

A comprehensive study of medically serious suicide attempts in France: incidence and associated factors

AIMS

People who make medically serious suicide attempts (MSSAs) share a number of features with those who die by suicide, and are at a high risk of suicide themselves. Studies to date have mostly focused on clinical samples of MSSAs. An epidemiological examination at a national level can help to identify risk profiles and pathways of care in this population.

METHODS

We explored the French nationwide hospital discharge database (Programme de Médicalisation des Systèmes d'Information, PMSI) to identify any MSSA taking place between 2012 and 2019. Relevant demographic and medical information was collected about the first MSSA of each attempter. Data from 2010 and 2011 were used to verify the absence of prior attempts.

RESULTS

First occurrences of MSSAs amounted to 81 959 cases over 8 years, with a mean age of 45.8 years, and 53.6% women. Incidence was higher in women (18.1 v. 17.3 per 1 00 000). The most common suicide method was deliberate self-poisoning (64.9% of cases). In comparison, violent methods associated higher mortality and comorbidity and were more frequent in men. The most common mental disorders were mood disorders (55.6%) and substance use disorders (46.2%). A minority of MSSA survivors were hospitalised in psychiatry (32.5%), mostly women.

CONCLUSIONS

MSSAs are frequent and easy to identify. There is a need to reinforce the continuity of psychiatric care for this population given the high risk of subsequent suicide, and the low rates of psychiatric hospitalisation after an MSSA even if violent methods are used. Specific care targeting this population could reduce treatment gaps.

A comparison of medically serious suicide attempters admitted to intensive care units versus other medically serious suicide attempters

BACKGROUND

Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviours very close to deaths by suicide. A simple definition of an MSSA is a suicide attempt with life-threatening consequences, regardless of the severity of the attempter's mental disorder. Few studies have specifically analysed the heterogeneity of MSSA. Therefore, the aim of this study is to describe the profile of individuals who made a highly severe MSSA and to compare those admitted to Intensive Care Units (ICU) - including Burn Units- with other MSSA admitted to other medical and surgical units.

METHODS

The study sample consisted of 168 patients consecutively admitted to non-psychiatric wards from two public hospitals in Barcelona after an MSSA during a 3-year period. In order to select more severe MSSA, the minimum hospital stay was expanded from Beautrais' definition of ≥ 24 h to ≥ 48 h. Mean hospital stay was 23.68 (SD = 41.14) days. Patients needing ICU treatment (n = 99) were compared to other MSSArs (n = 69) that were admitted to other medical and surgical units, not requiring intensive care treatment, with an initial bivariant analysis followed by a logistic regression analysis using conditional entrance.

RESULTS

Medically serious suicide attempters (MSSArs) spent more time hospitalized, more frequently reported recent stressful life events, were more likely to have at least one prior suicide attempt (SA) and their current attempt was more frequently non-planned, compared to the profile of MSSArs reported in previous studies. The most frequent method was medication overdose (67.3%) and jumping from heights (23.2%). Among those who chose more than one method (37.6%), the most frequent combination was medication overdose and drug use. Affective disorders and personality disorders were the most frequent diagnoses. Higher educational level, history of previous mental disorders and prior lifetime suicide attempts were significantly more frequent among those admitted to ICU compared to other MSSArs. Patients needing admission to ICU less frequently used self-poisoning and cuts.

CONCLUSIONS

MSSA needing ICU admission can be regarded clinically as similar to attempts resulting in suicide. More research on this type of highly severe suicide behaviour is needed due to its serious implications both from a clinical and public health perspective.

The Moderating Effects of Accurate Expectations of Lethality in the Relationships between Suicide Intent and Medical Lethality on Suicide Attempts

OBJECTIVE

The purpose of this study was to explore the accuracy of expectation of medical lethality and to identify characteristics related to high medical lethality in suicide attempters.

METHODS

A total of 370 suicide attempters (173 men, 197 women) who visited the emergency department at one university hospital were interviewed.

RESULTS

Using the Lethality Scale, 103 (27.8%), 114 (30.8%), and 153 (41.4%) suicide attempters were assigned to the low, medium, and high medical lethality groups, respectively. The medium and high medical lethality groups were older, and reported poorer socioenvironmental conditions, compared with the low lethality group. Higher levels of suicide intent were associated with more lethal attempts but only for those attempters who had accurate expectations of the medical lethality of their attempts.

CONCLUSION

The accuracy of expectations about the likelihood of dying was found to moderate the relationships between suicide intent and medical lethality.

Emotion Regulation and Self-Harm Among Forensic Psychiatric Patients

Emotion regulation has been specifically linked to both non-suicidal self-injury (NSSI) and attempted suicide. It is also known that self-harm is disproportionally higher (30–68.4%) in forensic samples than in the general population, yet knowledge about the association between emotion regulation and self-harm in forensic settings is scarce. The purpose of this study was to describe emotion regulation in a sample of forensic psychiatric patients, to explore dimensions and levels of emotion regulation between forensic psychiatric patients with and without self-harm, and to explore associations between forensic psychiatric patients’ self-reported emotion regulation and self-reported functions of NSSI. A cohort of forensic psychiatric inpatients (N=98) was consecutively recruited during 2016–2020 from a high-security forensic psychiatric clinic in Sweden. Data were collected through the self-report measures Difficulties in Emotion Regulation Scale (DERS) and Inventory of Statements About Self-injury (ISAS). In relation to the first aim, median total and subscales scores for DERS were reported. Results showed a statistically significant difference in emotion regulation between participants with and without self-harm (p=0.004), with a medium effect size (Cohen’s d=0.65) for the DERS total scale. The DERS subscales returned large differences for Impulse (p=0.001, d=0.86), Goals (p=0.014, d=0.58), and Strategies (p=0.012, d=0.54) between participants with and without self-harm. Finally, DERS scores were correlated with both the interpersonal (r_s=0.531, p<0.001, n=43) and intrapersonal factors (r_s=0.503, p<0.001, n=43) of NSSI as reported on the ISAS. Participants with self-harm (NSSI and/or suicide attempts) demonstrated significantly more difficulties with emotion regulation than those without self-harm. Emotion dysregulation was associated with both interpersonal and intrapersonal functions of NSSI in the participants. We suggest further studies on forensic psychiatric patients’ maladaptive behaviors that focus on substance abuse, self-harm, and aggressive behaviors in relation to the regulation and expression of emotion.

Task Control Deficit in Individuals With Non-suicidal Self-Injury

Background: Numerous people in clinical settings who have experienced repeated self-injuries explain their non-suicidal self-injury (NSSI) as "habitual" or due to "difficulty avoiding impulses related to NSSI." Previous studies present retrospective reports, where they experience frequent self-injurious urges and try to resist but fail. However, no study has directly investigated repeated behavioral control problems of people who engage in chronic NSSI through behavioral measurements in an experimental setting. The current study sought to investigate whether people who repeatedly attempt NSSI demonstrate deficiency in task control ability called the object-interference (O-I effect). Methods: The current study performed object interference tasks on 90 participants, of which 45 were those who reported repeated NSSI while 45 comprised the control group. Results: We observed delayed reaction times for object stimulus compared to abstract stimulus in the NSSI group, indicative of the object interference effect. This reflects task control deficits and difficulties in NSSI related behavioral control in the repeated NSSI group. When NSSI tools were additionally presented as a target stimulus, longer reaction times and more errors were observed in the NSSI group compared to the control group. Discussion: The current study discusses the clinical implications of the results from diagnostic point of view and provides suggestions for future research for treatment and prevention.

Risk of suicide after attempted suicide in the population of Slovenia from 1970 to 1996

Objective:

All suicide attempts cannot predict suicide, therefore we examined those characteristics of suicide attempt which could most accurately predict completed suicide.

Subject and methods:

Subjects were all individuals registered as committed suicides (N = 16,522) or attempted suicides (N = 15,057) in the register of suicides of the Republic of Slovenia between 1970 and 1996. Log linear analysis of a frequency table was used to uncover relationship between categorical variables.

Results:

The model we found fit between variables: mode, number of repetitions and type, then between number of repetitions, type and gender, and between mode, type and gender.

Discussion:

The risk of suicide in those who previously attempted suicide is approximately 773 times higher than the risk of suicide without a previous suicide attempt. Those who attempt suicide by hanging (hanging being in Slovenia the most frequent mode of completed suicide) are at even greater risk to commit suicide.

Conclusion:

Our data suggests that clinicians should heighten their awareness that any suicide attempt can in some 20% predict suicide. Someone who has attempted suicide by hanging is at the highest risk of suicide.

Risk factors for suicide in the Israeli army between the years 1992–2012: A case-control study

Objective

Young age, availability of weapons, and stressful life events, increase the risk of suicide. The aim of the present study was to assess additional risk factors for suicide in the Israeli army.

Methods

We conducted a case-control study, to assess risk factors for suicide. The cases comprised soldiers who died by suicide during their military service (n = 462; 0.039% of all soldiers in the cohort). The control group consisted of soldiers who did not commit suicide but were in active service during the investigated period (n = 1,170,895; 99.96%). Predictor variables, including socio-demographic and psychiatric diagnoses, were considered.

Results

Using a Generalized Linear Model with a Binary Logistic dependent variable to predict suicide, while controlling the effect of intervening variables, we found the following variables enhanced the risk for committing suicide: male (RR = 6.703; P < 0.001), country of origin: Ethiopia (RR = 4.555; P = 0.014), low socioeconomic status (RR = 1.448; P = 0.016) and low adjustment difficulties (RR = 2.324; P < 0.001). In addition, we found that in males only, Cluster B Personality Disorder (RR = 2.548; P = 0.027), low (RR = 1.657; P = 0.002), to average motivation to serve in a combat unit (RR = 1.322; P = 0.046) increased the risk for suicide.

Conclusions

IDF Soldiers bearing a psychiatric diagnosis or severe adjustment difficulties remained tightly monitored through their military service, and were found to be at a lower risk for suicide. However, those enlisted with mild (low) difficulties, were found to be at greater risk for suicide, as well as soldiers whose country of origin is Ethiopia. Suicide prevention program should focus on monitoring soldiers with these risk factors, together with soldiers’ guidance regarding help seeking and de-stigmatizing suicide.

Why Are Suicide Rates Increasing in the United States? Towards a Multilevel Reimagination of Suicide Prevention

Suicide, a major public health concern, takes around 800,000 lives globally every year and is the second leading cause of death among adolescents and young adults. Despite substantial prevention efforts, between 1999 and 2017, suicide and nonfatal self-injury rates have experienced unprecedented increases across the United States - as well as in many other countries in the world. This chapter reviews the existing evidence on the causes behind increased suicide rates and critically evaluates the impact of a range of innovative approaches to suicide prevention. First, we briefly describe current trends in suicide and suicidal behaviors and relate them to recent time trends in relevant suicide risk markers. Then, we review the existing evidence in suicide prevention at the individual and the population levels, including new approaches that are currently under development. Finally, we advocate for a new generation of suicide research that examines causal factors beyond the proximal and clinical and fosters a socially conscious reimagining of suicidal prevention. To this end, we emphasize the need for the conceptualization of suicide and suicidal behaviors as complex phenomena with causes at several levels of organization. Future interdisciplinary research and interventions should be developed within a multilevel causal framework that can better capture the social, economic, and political settings where suicide, as a process, unfolds across the life course.

Exploring suicidal behaviours by probation clients-a qualitative near-lethal study

Background

Existing research emphasizes that offenders serving community based sentences are at an increased risk of suicide compared with the general population, however, there is little understanding about the causes of this risk. The aim of the current research was to understand how to support probation clients and prevent suicide, by exploring the experiences of probation clients who carried out near-lethal suicide attempts whilst under probation supervision.

Methods

In-depth interviews were carried out with seven probation clients who made near-lethal suicide attempts whilst serving a probation sentence. Data were analysed using Interpretative Phenomenological Analysis.

Results

Participants recounted negative experiences which they perceived to be linked to their suicidal feelings and behaviours, such as experiencing bereavements, perceived loss of control over their mental state or situation, and difficulties relating to stages of their probation sentence. Participants expressed severe difficulties with trusting authorities, making disclosure of suicidal feelings problematic. However, participants emphasized the role that purposeful and meaningful activity can play in suicide prevention.

Conclusions

Suicide prevention strategies must be tailored to the needs of probation clients across the UK. Mandatory training for probation staff is recommended to help reduce suicides, and support from external agencies should be sought where possible.

Fatal and Non-fatal Self-Injury in the USA: Critical Review of Current Trends and Innovations in Prevention

PURPOSE OF REVIEW

To examine current trends in suicide and self-injury in the USA, as well as potential contributors to their change over time, and to reflect on innovations in prevention and intervention that can guide policies and programs to reduce the burden of suicide and self-injury in the USA.

RECENT FINDINGS

Suicide and non-fatal self-injury are on the rise in the USA. Reasons for such trends over time remain speculative, although they seem linked to coincident increases in mood disorders and drug use and overdose. Promising innovative prevention and intervention programs that engage new technologies, such as machine learning-derived prediction tools and computerized ecologic momentary assessments, are currently in development and require additional evidence. Recent increases in fatal and non-fatal self-harm in the USA raise questions about the causes, interventions, and preventive measures that should be taken. Most innovative prevention efforts target individuals seeking to improve risk prediction and access to evidence-based care. However, as Durkheim pointed out over 100 years ago, suicide rates vary enormously between societal groups, suggesting that certain causal factors of suicide act and, hence, should be targeted at an ecological level. In the next generation of suicide research, it is critical to examine factors beyond the proximal and clinical to allow for a reimagining of prevention that is life course and socially focused.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study

BACKGROUND

Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls.

METHODS

The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources.

CONCLUSIONS

The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Beyond the mental pain: A case-control study on the contribution of schizoid personality disorder symptoms to medically serious suicide attempts

BACKGROUND

Clinical and research findings have highlighted the role of interpersonal factors in suicidal behavior with high levels of intent and lethality. Schizoid personality disorder (SPD) is at the extreme end of interpersonal difficulties. Thus, we aimed to understand the contribution of SPD symptoms to suicide behavior and specifically to more lethal suicide attempts.

METHOD

Four groups were investigated (N = 338): medically serious suicide attempters, medically non-serious suicide attempters, psychiatric and healthy controls. SPD symptoms, mental pain variants, and clinical characteristics were assessed.

RESULTS

Overall, attempters were characterized by higher levels of most SPD symptoms. Solitary lifestyle and emotional detachment were higher among medically serious suicide attempters relative to less-serious attempters. Emotional detachment doubled the risk for high lethality, beyond mental pain variables.

CONCLUSIONS

SPD symptoms of interpersonal difficulties and low levels of emotional expressions are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide are discussed.

When the Pain Becomes Unbearable: Case-Control Study of Mental Pain Characteristics Among Medically Serious Suicide Attempters

The unbearable mental pain experience is recognized as a key antecedent of suicidal behavior. We aimed to examine the precise nature of the mental pain among medically serious suicide attempters (MSSAs), a population closely resembling those who died by suicide. We evaluated various factors of mental pain from the Orbach and Mikulincer Mental Pain Scale, as well as medical lethality and suicide intent. MSSAs were higher than non-MSSAs and psychiatric controls for Irreversibility of pain. Moreover, Emptiness predicted medical lethality, while Cognitive Confusion negatively predicted suicide intent level, controlling for hopelessness and depression. high sense of Irreversibility of pain as well as high Emptiness and low Cognitive Confusion are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide as well as for suicide prevention and treatment of suicidal individuals are discussed.

Serious Suicide Attempts: Systematic Review of Psychological Risk Factors

BACKGROUND

One of the main obstacles in studying suicide risk factors is the difference between cases in which the individual died by suicide and those in which the individual engaged in suicidal behavior. A promising strategy that overcomes this obstacle is the study of survivors of serious suicide attempt (SSA), i.e., an attempt that would have been lethal had it not been for the provision of rapid and effective emergency treatment. Serious suicide attempters are epidemiologically very much like those who died by suicide, and thus may serve as valid proxies for studying suicides. This paper aims to define the specific risk factors for SSAs by conducting a qualitative data synthesis of existing studies.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic search of the literature in PubMed, ProQuest, and Psychlit electronic research-literature databases. Search terms were "serious" "OR" "near lethal," combined with the Boolean "AND" operator with "suicide*." In addition, we performed a manual search on Google Scholar for further studies not yet identified.

RESULTS

The preliminary search identified 683 citations. A total of 39 research reports that met the predefined criteria were analyzed. Mental pain, communication difficulties, decision-making impulsivity, and aggression, as well as several demographic variables, were found to be major risk factors for SSAs.

LIMITATIONS

We found a variability of definitions for SSA that hamper the ability to draw a model for the risk factors and processes that facilitate it. Moreover, the role of suicide intent and planning in SSA is still unclear. Further studies should aim to clarify and refine the concepts and measures of SSA, thereby enabling more specific and concrete modeling of the psychological element in its formation.

CONCLUSION

SSA is a distinguishable phenomenon that needs to be addressed specifically within the scope of suicidal behavior. Interpersonal problems, as well as impulsivity and aggression, seem to facilitate SSA when mental pain serves as a secondary factor. Healthcare professionals should be aware of SSA, and familiar with its specific risk factors. Moreover, psychological and suicidal risk assessment should include a designated evaluation of these risk factors as part of intervention and prevention models for SSA.

Aggression, impulsivity, and their predictive value on medical lethality of suicide attempts: A follow-up study on hospitalized patients

BACKGROUND

This study examined the role of aggressive-impulsive variants, and suicide history in predicting the medical severity of follow-up suicide attempts.

METHODS

97 consecutive psychiatric in-patients who participated in earlier study 2-5 years previously. Thirty-three had a history of a medically serious suicide attempt (MSSA), 29 had a history of a medically non-serious suicide attempt (MNSSA), and 35 had no history of suicide. Participants completed a battery of instruments measuring aggressive-impulsive variables, hopelessness and communication difficulties. Findings were analyzed in relation to follow-up suicide attempts and their severity.

RESULTS

32 patients (33%) had attempted suicide: 9 (9.27%) (including one death) MSSSA. Of these, 7 patients were MSSAs in the index attempt and 2 were MNSSAs in the index attempt. 23 (23.7%) MNSSA: Of these, 6 were MSSAs in the index attempt; 13, MNSSAs in the index attempt and 4 from the non-suicidal psychiatric group. 65 patients (67%) did not attempt suicide during the period since the index studies. Anger-out, violence impulsivity and hopelessness had significant positive correlations with medical severity of follow-up suicide attempts. Similar correlations were found between anger-out, violence and the amount of follow-up suicide attempts. A hierarchical regression analysis was conducted to determine contribution of study variables to severity of future suicide attempts. Severity of index attempt, hopelessness aggressive-impulsive variants and two interactions (medical severity of index suicide attempt X impulsivity and self-disclosure X anger-in) accounted for 44.7% of the variance of the medical severity of follow-up suicide attempts.

LIMITATIONS

(i) Possibly incomplete patient information, as some of the patients who participated in the index studies could not be located. (ii) Relatively small group of patients with an index MSSA.

CONCLUSIONS

The major findings of this paper are the predictive value of MSSA vs. MNSSA. The Lethality of future suicide attempt is closely linked to the lethality of former suicide attempt, impulsivity and hopelessness. Thus, patients who have made a suicide attempt should be assessed for medical severity of the attempt, impulsive-aggressive measures hopelessness, and communication difficulties, which are important factors in follow-up attempts.

Is There a Relationship between Suicidal Intent and Lethality in Deliberate Self-Poisoning?

The relationship between suicidal intent and lethality of deliberate self-poisoning (DSP) episodes and their associations with suicide have yielded contradictory findings. The aims of this study were to investigate the association between patients' suicidal intent and independently rated lethality of DSP episodes, and whether the association changes over time. Eighty-nine DSP patients were investigated longitudinally. Self-reported suicidal intent, including perceived likelihood of dying, wish to die, and whether or not the DSP was considered a suicide attempt, was measured at the time of the index episode (t1), 3 months (t2), and 12 months (t3) later. Lethality was assessed independently by three clinical toxicologists. Lethality was significantly associated with patients' reported wish to die (p = .01) and perceived likelihood of dying (p = .04) at t1, but not at t2 and t3. No association was found between whether the episode was considered a suicide attempt or not and lethality at t1, t2, or t3. Lethality and suicidal intent should be considered as largely separate dimensions of self-harm. Clinicians should bear this in mind during clinical assessment, especially regarding historical information.

The contribution of the socio-demographic characteristics on suicidal ideation among Israeli soldiers

Background

Suicidal ideation is a risk factor for suicide attempt. The aim of the present study is to compare suicidal ideation of different groups with different distress.

Methods

100 soldiers, aged 18–21, divided into four research cohorts: soldiers who had carried out a suicide attempt (n = 40); soldiers with a psychiatric diagnosis (n = 20); soldiers having high severity adjustment difficulties (n = 20); and a control group of soldiers, having neither a history of mental health diagnosis, nor adjustment difficulties (n = 20). All completed the suicide ideation scale.

Results

Half of the attempters had a psychiatric diagnosis (depression or anxiety) on the day of their enlistment and 37.5 % of them had a specified personality disturbance. The attempters were characterized by previously-attempted suicide (p < .01). The lowest mean values (M = 1.95, SD = .67) were among the attempter (F = 3.173, df = 3, p = .02) in motivation for military service. The variable expressing low motivation for military service was the sole predictor of suicide ideation (p = .032).

Conclusions

Early diagnosis facilitated better monitoring by military mental health officers.

Differences between female suicidal patients with family history of suicide attempt and family history of completed suicide

BACKGROUND

Family history of suicidal behavior and suicide are both risk factors for suicide. However, the effects of family history of suicide versus suicide attempts on patient suicidal behavior remain unclear. The aim of the present study was to understand if family history of suicide as compared to family history of suicide attempts or no family history of suicidal behavior evidences different associations with suicidal behavior among psychiatric patients.

METHOD

Participants included 157 female patients between the ages of 18 and 65years admitted at the Dr. Braulio A. Moyano Neuropsychiatric Women's Hospital.

RESULTS

Seventy-nine patients (50.3%) reported no family history of suicidal behavior (NFHSB), while 78 patients (49.7%) reported a family history of suicidal behavior. Specifically, 41 patients (26.1%) reported a family history of suicide attempt (FHSA) and 37 patients (23.6%) reported a family history of suicide (FHS). These groups showed significant differences between family history of psychopathology and number of previous suicide attempts. Patients with an FHSA were more likely to present with a greater number of previous suicide attempts as compared to patients with NFHSB and FHS.

CONCLUSION

There is an association between the number of suicide attempts and family history of suicide attempts in female patients hospitalized for suicidal behavior.

Predictive value of psychological characteristics and suicide history on medical lethality of suicide attempts: A follow-up study of hospitalized patients

BACKGROUND

This study examined the role of mental pain, communication difficulties, and suicide history in predicting the medical severity of follow-up suicide attempts.

METHODS

The cohort included 153 consecutive psychiatric in-patients who participated in earlier studies 1-9 years previously. Fifty-three had a history of a medically serious suicide attempt (MSSA), 64 had a history of a medically non-serious suicide attempt (MNSSA), and 36 had no history of suicide. A MSSA was defined as a suicide attempt that warranted hospitalization for at least 24h and extensive medical treatment. Participants completed a battery of instruments measuring mental pain and communication difficulties. Findings were analyzed in relation to follow-up suicide attempts and their severity.

RESULTS

Fifty-three patients (35.5%) had attempted suicide: 15 (9.9%) a MSSA (including 5 fatalities) and 38 (25%) a MNSSA. The medical severity of the index attempt and level of hopelessness at the index attempt were significantly correlated with medical severity of the follow-up attempt. In younger patients, high levels of depression and self-disclosure predicted the medical severity of the follow-up attempt. In patients with relatively low hopelessness, the medical severity of the attempt increased with the level of self-disclosure.

LIMITATIONS

(i) Possibly incomplete patient information, as some of the patients who participated in the index studies could not be located. (ii) Relatively small group of patients with an index MSSA.

CONCLUSIONS

Patients who have made a suicide attempt should be assessed for medical severity of the attempt, hopelessness, and communication difficulties, which are important factors in follow-up attempts.

Serious Suicide Attempts

BACKGROUND

Suicidal behavior comprises a diverse set of behaviors with significant differences among several behavioral categories. One noteworthy category includes individuals who have made serious suicide attempts, epidemiologically very similar to those completing suicide. This behavioral category is important, since interviewing survivors of a potentially lethal incident of self-harm enables a detailed investigation of the psychological process leading to the suicidal act.

AIM

To achieve a consensus definition and operational criteria of serious suicide attempts.

METHOD

We reviewed studies that included the term serious suicide attempt or related terms (e.g., highly lethal), with a focus on the variety of operational criteria employed across studies.

RESULTS

More than 60 papers addressing various types of serious suicide attempt were explored. We found a large variety of operational definitions, reflecting the lack of consensus regarding terminology and criteria related to the term.

CONCLUSION

We undertook the challenge of developing an integrative and comprehensive set of criteria of serious suicide attempt and suggest a definition comprising three key dimensions: medical lethality, potential lethality of the method used, and severity of the objective circumstances of the suicide intent. Clinicians and researchers are strongly encouraged to consider using the term serious suicide attempt with its attendant components.

Risk factors for suicide attempt among Israeli Defense Forces soldiers: A retrospective case-control study

BACKGROUND

A major risk factor for suicide is suicide attempts. The aim of the present study was to assess risk factors for nonfatal suicide attempts. Methods The study's cohort consisted of 246,814 soldiers who were divided into two groups: soldiers who made a suicide attempt (n=2310; 0.9%) and a control group of soldiers who did not (n=244,504; 99.1%). Socio-demographic and personal characteristics as well as psychiatric diagnoses were compared. Results The strongest risk factors for suicide attempt were serving less than 12 months (RR=7.09) and a history of unauthorized absence from service (RR=5.68). Moderate risk factors were low socioeconomic status (RR=2.17), psychiatric diagnoses at induction (RR=1.94), non-Jewish religion (RR=1.92), low intellectual rating score (RR=1.84), serving in non-combat unit (RR=1.72) and being born in the former Soviet Union (RR=1.61). A weak association was found between male gender and suicide attempt (RR=1.36). Soldiers who met more frequently with a primary care physician (PCP) had a higher risk for suicide attempt, as opposed to a mental health professional (MHCP), where frequent meetings were found to be a protective factor (P<0.0001). The psychiatric diagnoses associated with a suicide attempt were a cluster B personality disorder (RR=3.00), eating disorders (RR=2.78), mood disorders (RR=2.71) and adjustment disorders (RR=2.26).

LIMITATIONS

Mild suicidal behavior constitutes a much larger proportion than among civilians and may have secondary gain thus distorting the suicidal behavior data.

CONCLUSIONS

Training primary care physicians as gatekeepers and improved monitoring, may reduce the rate of suicide attempts.

Suicide Prevention

Suicide is a public health problem affecting people across the lifespan. It is currently the 10th leading cause of death, with rates having remained relatively flat for the past century. This article summarizes the problem of suicide and suicidal behavior along with suicide prevention efforts in the United States. Part 1 provides an overview of the epidemiology of suicide, including groups most at risk of suicide and suicidal behavior. Part 2 provides a review of common risk factors, organized by developmental life stage. A brief discussion of the lesser well-researched area of protective factors follows. Part 3 provides an overview of suicide prevention today, including the major types of prevention strategies, their successes, including means restriction, quality improvement in behavioral services, and comprehensive programs; and limitations to date, such as a lack of evidence for impact on actual deaths or behavior, small sample sizes, and low base rates. Finally, part 4 discusses challenges and future directions with an eye toward the great many opportunities that exist for prevention.

Prevalence of suicide ideation and attempts among Black Americans in later life

This article provides the first national estimates of the prevalence and correlates of nonfatal suicidal behavior among older Black Americans. There is a lack of national data on suicide ideation and attempts across ethnic classifications of Blacks in a nationally representative sample. Data are a subsample from the National Survey of American Life (NSAL), a national U.S. adult household probability sample of 5,191 Black Americans. The WHO Composite International Diagnostic Interview (CIDI) was used to assess older Blacks for nonfatal suicidal behavior and 14 DSM-IV disorders. Bivariate and multivariate logistic regression analyses were employed to delineate patterns and correlates of nonfatal suicidal behavior. The estimated lifetime prevalence of suicidal ideation and attempts among older Blacks in the United States was 6.1% and 2.1%, respectively. On an average it took 2.5 and 5.7 years respectively to go from ideation to attempts or from planning to attempts. Surprisingly, among older Black adults, men reported attempting suicide and seriously consider taking their own lives more than women. Older Blacks at higher risk for suicide attempts were middle aged, had poorer health, were anxious, and had multiple DSM-IV disorders. The results also show that approximately 1 in 4 attempters and 2 in 5 ideators have never sought treatment for their emotional or psychological problems. Preventative care, particularly screening in primary care settings, should consider these findings when treating older Black Americans for psychiatric-related risk.

Aggression-impulsivity, mental pain, and communication difficulties in medically serious and medically non-serious suicide attempters

BACKGROUND

Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt.

OBJECTIVES

To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters.

METHOD

The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression-impulsivity, mental pain, and communication difficulties.

RESULTS

The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p<.001 for all) and on anger-in, anger-out, violence, and impulsivity (p<.05 for all), with no significant difference between the two suicide attempter groups. Medically serious suicide attempters had significantly lower self-disclosure (p<.05) and more schizoid tendencies (p<.001) than the other three groups and significantly more feelings of loneliness than the medically non-serious suicide attempters and nonsuicidal psychiatric patients (p<.05). Analysis of aggression-impulsivity, mental pain, and communication variables with suicide lethality yielded significant correlations for self-disclosure, schizoid tendency, and loneliness. The interaction between mental pain and schizoid traits explained some of the variance in suicide lethality, over and above the contribution of each component alone.

CONCLUSIONS

Aggression-impulsivity and mental pain are risk factors for suicide attempts. However, only difficulties in communication differentiate medically serious from medically non-serious suicide attempters. The combination of unbearable mental pain and difficulties in communication has a magnifying effect on the risk of lethal suicidal behavior.

Serious suicidal behaviors: socio-demographic and clinical features in a multinational, multicenter sample

BACKGROUND

Declared suicidal intent and physical danger are both considered important components in defining suicidal behaviors (SB).

AIMS

1) To investigate characteristics of serious suicidal behaviors (SSB), defined by either suicidal intent or lethality; 2) To determine any difference in terms of socio-demographic, clinical and/or service usage variables between SSB and non-serious suicidal behaviors (NSSB).

METHODS

A total of 2631 contacts for SB were registered in the context of the MONSUE (Monitoring Suicidal Behavior in Europe) study project. Demographic and clinical information were registered. ICD-10 was used for classifying data about psychiatric diagnoses, methods used for SB and injuries reported. Clear intentionality, high-case fatality methods and serious injuries all defined SSB (n = 1169; 44.4%)

RESULTS

SSB were more often preceded by a contact with an inpatient (either psychiatric or somatic) rather than an outpatient service. Among those having a previous history of SB, SSB subjects had fewer contacts with health services before the previous attempt. The strongest predictors for SSB appeared to be older age and not professing a religion.

CONCLUSION

Many of the known factors contributing to the risk of completed suicide were also present for SSB. Our findings on service usage by suicide attempters show which aspects of mental health services should be strengthened in order to improve suicide prevention.

Mental pain, communication difficulties, and medically serious suicide attempts: a case-control study

Medical severe suicide attempts (MSSA) are epidemiologically very similar to individuals who complete suicide. Thus the investigation of individuals who have made MSSAs may add to our understanding of the risk factors for completed suicide. The aim of this study was to assess the role of mental pain and communication difficulties in MSSA. A total of 336 subjects were divided into 4 groups: 78 meeting criteria for MSSA compared with116 subjects who made a medically non-serious suicide attempt (MNSSA), 47 psychiatric controls with no history of suicidal behavior, and 95 healthy controls. Mental pain variants (e.g., hopelessness), facets of communication difficulties (e.g., self-disclosure), as well as socio-demographic and clinical characteristics were assessed. The MSSA had significantly higher communication difficulties than the other 3 groups. Moreover, the interaction between mental pain and communication difficulties explained some of the variance in suicide lethality, above and beyond the contribution of each component alone. This report underlines the importance of mental pain for suicide attempts in general while difficulties in communication abilities play a critical role in differentiating MSSA from MNSSA. The co-existence of unbearable mental pain with difficulties in communication significantly enhances the risk for more lethal forms of suicidal behavior.

A multidimensional risk factor model for suicide attempts in later life

BACKGROUND

Elderly suicide is a public health problem worldwide, and the risk factors are multidimensional. Chronic mental health problems, personality traits, stressful life events, comorbid medical conditions, social isolation, unemployment, and poverty are associated with higher risk for suicide in later life. There was a relative paucity of data on the neurobiological markers of elderly suicide.

OBJECTIVE

This study examines the conjoint roles of cerebrovascular risk factors (CVRFs) and other established biopsychosocial risk factors in older adults who had made a recent suicide attempt.

DESIGN

A cross-sectional, case-controlled study.

SETTING

A tertiary care setting in a public sector and a community setting.

SUBJECTS AND METHODS

Cases (N=77) were nondemented Chinese adults aged ≥65 years, enrolled in a regional psychogeriatric service following a suicide attempt; comparison subjects (N=99) were community-dwelling nondemented older adults with no lifetime history of suicide. Measures of sociodemographic profile, life events, suicidal behavior, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I psychopathology, personality traits, functional status, physical health, CVRFs, and executive cognitive functions were administered.

RESULTS

WEIGHTED SUM OF CVRF SCORE WAS SIGNIFICANTLY HIGHER IN OLDER WOMEN WHO HAD MADE A RECENT SUICIDE ATTEMPT (MEAN: 10.56; standard deviation [SD]: 5.46) than comparison subjects (mean: 7.24; SD: 4.04) (t=3.52, P=0.001; df=99). Logistic regression showed that CVRF score (Exp[B]: 1.289, P=0.033), DSM-IV depressive disorders (current) (Exp[B]: 348, P<0.001), number of life events in the past 12 weeks (Exp[B]: 10.4; P<0.001), and being married (Exp[B]: 12.2, P<0.048) significantly increased odds for suicide attempt status in older women (Nagelkerke R (2): 0.844). Association of CVRF score and suicide attempt status was not observed in older men for whom number of life events in the past 12 weeks (Exp[B]: 9.164; P<0.001), higher neuroticism (Exp[B]: 1.028; P=0.048), and impaired performance on a Modified Card Sorting Test (Exp[B]: 0.646; P=0.032) significantly increased odds for suicide attempt status in a logistic regression model (Nagelkerke R (2): 0.611).

CONCLUSION

Risk factors for cerebrovascular diseases may be associated with higher risk for attempted suicide in older women, but not in older men. Older men and women have distinct risk factor profiles that may inform targeted intervention and prevention strategies.

Attachment patterns in medically serious suicide attempts: the mediating role of self-disclosure and loneliness

Although the study of medically serious suicide behavior is an important strategy for understanding the nature of suicide, little is known about its underlying psychological mechanisms. This gap is addressed here by applying insights from attachment theory to severe suicidal behavior. The results show that both anxious and avoidant attachment patterns predict medical lethality. Path analysis indicated that interpersonal difficulties mediated the paths between insecure attachment patterns and lethality of suicide attempts. These results suggest that the psychological mechanisms of medically serious suicide behavior involve high levels of mental pain amplified by insecure attachment patterns and interpersonal difficulties. Implications for prevention and therapeutic intervention strategies are discussed.

Suicide clusters: a review of risk factors and mechanisms

Suicide clusters, although uncommon, cause great concern in the communities in which they occur. We searched the world literature on suicide clusters and describe the risk factors and proposed psychological mechanisms underlying the spatio-temporal clustering of suicides (point clusters). Potential risk factors include male gender, being an adolescent or young adult, drug or alcohol abuse, and past history of self-harm. However, the majority of studies lack methodological rigor. Many different psychological mechanisms are described, including contagion, imitation, suggestion, learning, and assortative relating, but supporting empirical evidence is generally lacking. More scientifically rigorous studies are needed to improve understanding of suicide clusters.

Medically serious versus non-serious suicide attempts: relationships of lethality and intent to clinical and interpersonal characteristics

BACKGROUND

The study of near-fatal suicide attempts may provide insight into the minds of suicidal subjects. The aim of the study was to investigate the relationship of intent and lethality in medically serious and medically non-serious suicide attempts and to examine relationship of specific psychological and clinical variables with the subjective and objective components of suicide intent.

METHODS

The study group included 102 participants, 35 consecutive subjects hospitalized for a medically serious suicide attempt and 67 subjects who presented to the same tertiary medical center after a medically non-serious suicide attempt. All were interviewed with the SCID-I and completed the Suicide Intent Scale (SIS), the Lethality Rating Scale, and instruments measuring mental pain and communication difficulties.

RESULTS

Patients who made medically serious suicide attempts had higher total SIS score and higher objective and subjective subscale scores. The objective component of the SIS was highly correlated with the lethality of the suicide attempt and communication difficulties; the subjective component was associated with mental pain variables. The interaction of mental pain and communication difficulties was predictive of the severity of the objective suicide intent.

LIMITATIONS

Relatively small number of patients with medically serious suicide attempt and the relatively large number of questionnaires which may to some extent have diminished informant reliability.

CONCLUSIONS

Suicidal individuals with depression and hopelessness who cannot signal their pain to others are at high risk of committing a medically serious suicide attempts.

Controlling access to suicide means

Background: Restricting access to common means of suicide, such as firearms, toxic gas, pesticides and other, has been shown to be effective in reducing rates of death in suicide. In the present review we aimed to summarize the empirical and clinical literature on controlling the access to means of suicide. Methods: This review made use of both MEDLINE, ISI Web of Science and the Cochrane library databases, identifying all English articles with the keywords “suicide means”, “suicide method”, “suicide prediction” or “suicide prevention” and other relevant keywords. Results: A number of factors may influence an individual’s decision regarding method in a suicide act, but there is substantial support that easy access influences the choice of method. In many countries, restrictions of access to common means of suicide has lead to lower overall suicide rates, particularly regarding suicide by firearms in USA, detoxification of domestic and motor vehicle gas in England and other countries, toxic pesticides in rural areas, barriers at jumping sites and hanging, by introducing “safe rooms” in prisons and hospitals. Moreover, decline in prescription of barbiturates and tricyclic antidepressants (TCAs), as well as limitation of drugs pack size for paracetamol and salicylate has reduced suicides by overdose, while increased prescription of SSRIs seems to have lowered suicidal rates. Conclusions: Restriction to means of suicide may be particularly effective in contexts where the method is popular, highly lethal, widely available, and/or not easily substituted by other similar methods. However, since there is some risk of means substitution, restriction of access should be implemented in conjunction with other suicide prevention strategies.

Suicide by firearms on the island of Crete: a 9-year record

BACKGROUND

Whereas firearm suicide mortality has been a longstanding public concern worldwide, in Greece no systematic analysis has been reported so far despite the recent evidence of a rising rate of gun ownership.

AIMS

To estimate the proportion of firearm suicides on the island of Crete, Southern Greece, well-known for its widespread gun ownership; to describe the victims' sociodemographic profile and firearm-related suicide variables; and to assess the severity of suicidal intention in the group.

METHODS

Records of suicides between 1999 and 2007 were reviewed and information was extracted into a computerized database. A rating of the circumstances section of the Beck's Suicide Intent Scale (SIS) for each case was also performed.

RESULTS

The firearm suicide rate was 1.3 per 100,000, with males constituting the vast majority. These men were more likely to be less than 55 years of age, to have lived in the western part of the island, to have some degree of planning prior to the suicidal act, and to have used a shotgun, but less likely to have left a note.

CONCLUSIONS

As an important first step toward implementing preventive initiatives the authors stress the need for a thorough look at the sociocultural factors associated with firearms in the region.

Do local landmark bridges increase the suicide rate? An alternative test of the likely effect of means restriction at suicide-jumping sites

A number of recent studies have examined the effect of installing physical barriers or otherwise restricting access to public sites that are frequently used for suicides by jumping. While these studies demonstrate that barriers lead to a reduction in the number of suicides by jumping at the site where they are installed, thus far no study has found a statistically significant reduction in the local suicide rate attributable to a barrier. All previous studies are case studies of particular sites, and thus have limited statistical power and ability to control for confounding factors, which may obscure the true relationship between barriers and the suicide rate. This study addresses these concerns by examining the relationship between large, well-known bridges ("local landmark" bridges) of the type that are often used as suicide-jumping sites and the local suicide rate, an approach that yields many more cases for analysis. If barriers at suicide-jumping sites decrease the local suicide rate, then this implies that the presence of an unsecured suicide-jumping site will lead to a higher local suicide rate in comparison to areas without such a site. The relationship between suicides and local landmark bridges is examined across 3116 US counties or county equivalents with negative binomial regression models. I found that while exposure to local landmark bridges was associated with an increased number of suicides by jumping, no positive relationship between these bridges and the overall number of suicides was detected. It may be impossible to conclusively determine if barriers at suicide-jumping sites reduce the local suicide rate with currently available data. However, the method introduced in this paper offers the possibility that better data, or an improved understanding of which potential jumping sites attract suicidal individuals, may eventually allow researchers to determine if means restriction at suicide-jumping sites reduces total suicides.

Mental pain and its communication in medically serious suicide attempts: an "impossible situation"

BACKGROUND

The study of near-fatal suicide attempters may provide insight into the minds of suicidal subjects. Our aim is to test the hypothesis that mental pain is a general risk factor for suicidal behavior and communication difficulties are a particular risk factor for medically serious suicidal behavior.

METHODS

Thirty five subjects who made medically serious suicide attempts were compared with 67 medically not serious suicide attempters and 71 healthy controls. All were interviewed with the SCID-I and completed questionnaires covering mental pain, communication difficulties and seriousness of suicide attempt.

RESULT

Variables from the mental pain domain (e.g. depression) predicted the presence of suicidal behavior, and variables from the communication difficulties domain (e.g., self-disclosure) predicted the lethality and seriousness of the suicide attempts.

LIMITATIONS

Relatively small number of patients with medically serious suicide attempt and the relatively large number of questionnaires which may to some extent have diminished informant reliability.

CONCLUSIONS

Problems with sharing of feelings with others are an important risk factor for near-lethal suicide, over and above the contribution of psychiatric illness and mental pain, including depression and hopelessness.

Age-sex differences in medicinal self-poisonings: a population-based study of deliberate intent and medical severity

BACKGROUND

Deliberate self-harm (DSH) is related to suicide and DSH repetition is common. DSH hospital presentations are often self-poisonings with medicinal agents. While older age and male sex are known risk factors for suicide, it is unclear how these factors are related to the nature and severity of medicinal self-poisoning (SP). Such knowledge can guide prevention strategies emphasizing detecting and treating mental illness and controlling access to means.

METHODS

Medicinal SP presentations by 18,383 residents of Ontario, Canada, aged 12 years and older, who presented to a hospital emergency department in that province between April 1, 2001-March 31, 2002 were characterized by the agents taken, identification of deliberate intent and medical severity.

RESULTS

We found distinct age-sex differences in the nature and severity of medicinal SP. In youths, aged 12-17, about 40% of presentations involved analgesics, typically not prescribed and most often the acetaminophen agent-group. Females aged 12-64 were identified as deliberate more often than their male counterparts and this pattern occurred in most agent-groups, even among those who took antidepressants. The acetaminophen agent-group was most consistently associated with medical severity and this effect was strongest among female youths. Although medicinal SP was less frequent in the elderly, these presentations tended to be more medically serious and less often identified deliberate.

CONCLUSIONS

The high proportion of medicinal SP in youths involving agents typically not prescribed and the medical severity of the acetaminophen agent-group underscore how prevention strategies must extend beyond controlling access to antidepressants. Despite a higher risk for suicide, males and the elderly may not have their deliberate intent detected and therefore, may not receive appropriate treatment. The emergency department can serve as important link to mental health care and usage patterns can provide feedback about the need for system-level enhancements and DSH surveillance.

Trait aggression in suicide attempters: a pilot study

Suicide attempt is a potent risk factor of subsequent suicide. Understanding the characteristics of suicide attempters is important for preventing suicide. The authors investigated aggression in medically serious suicide attempters at an emergency department. Trait aggression was evaluated in 55 suicide attempters and 71 healthy individuals as a control group using the Japanese version of the Buss-Perry Aggression Questionnaire (BAQ). Total BAQ scores (t = 2.782, P = 0.006) and the hostility scores (t = 3.735, P < 0.001) were significantly higher in the suicide attempters than the controls. It suggested that to focus on aggression and its management is one of the key components for preventing suicide.

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

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

Psychiatric assessment of suicide attempters in Japan: a pilot study at a critical emergency unit in an urban area

BACKGROUND

The incidence of suicide has increased markedly in Japan since 1998. As psychological autopsy is not generally accepted in Japan, surveys of suicide attempts, an established risk factor of suicide, are highly regarded. We have carried out this study to gain insight into the psychiatric aspects of those attempting suicide in Japan.

METHODS

Three hundred and twenty consecutive cases of attempted suicide who were admitted to an urban emergency department were interviewed, with the focus on psychosocial background and DSM-IV diagnosis. Moreover, they were divided into two groups according to the method of attempted suicide in terms of lethality, and the two groups were compared.

RESULTS

Ninety-five percent of patients received a psychiatric diagnosis: 81% of subjects met the criteria for an axis I disorder. The most frequent diagnosis was mood disorder. The mean age was higher and living alone more common in the high-lethality group. Middle-aged men tended to have a higher prevalence of mood disorders.

CONCLUSION

This is the first large-scale study of cases of attempted suicide since the dramatic increase in suicides began in Japan. The identification and introduction of treatments for psychiatric disorders at emergency departments has been indicated to be important in suicide prevention.

Familial pathways to early-onset suicidal behavior: familial and individual antecedents of suicidal behavior

OBJECTIVE

The authors sought to identify clinical predictors of new-onset suicidal behavior in children of parents with a history of mood disorder and suicidal behavior.

METHOD

In a prospective study of offspring of parents with mood disorders, 365 offspring (average age, 20 years) of 203 parents were followed for up to 6 years. Offspring with incident suicide attempts or emergency referrals for suicidal ideation or behavior ("incident events") were compared with offspring without such events on demographic and clinical characteristics. Multivariate analyses were conducted to examine predictors of incident events and predictors of time to incident event.

RESULTS

Offspring of probands who had made suicide attempts, compared with offspring of parents with mood disorders who had not made attempts, had a higher rate of incident suicide attempts (4.1% versus 0.6%, relative risk=6.5) as well as overall suicidal events (8.3% versus 1.9%, relative risk=4.4). Mood disorder and self-reported impulsive aggression in offspring and a history of sexual abuse and self-reported depression in parents predicted earlier time to, and greater hazard of, an incident suicidal event.

CONCLUSIONS

In offspring of parents with mood disorders, precursors of early-onset suicidal behavior include mood disorder and impulsive aggression as well as parental history of suicide attempt, sexual abuse, and self-reported depression. These results suggest that efforts to prevent the familial transmission of early-onset suicidal behavior by targeting these domains could reduce the morbidity of suicidal behavior in high-risk youths.

Prevalence of and risk factors for lifetime suicide attempts among blacks in the United States

CONTEXT

Lack of data on the lifetime prevalence and age at onset of suicide ideation, plans, and attempts among blacks in the United States limits the creation and evaluation of interventions to reduce suicide among black Americans.

OBJECTIVE

To examine the prevalence and correlates of suicide ideation, planning, and attempts across 2 ethnic classifications of blacks in a nationally representative sample.

DESIGN, SETTING, AND PARTICIPANTS

Data are from the National Survey of American Life, a national household probability sample of 5181 black respondents aged 18 years and older, conducted between February 2001 and June 2003, using a slightly modified adaptation of the World Health Organization World Mental Health version of the Composite International Diagnostic Interview. Bivariate and survival analyses were used to delineate patterns and correlates of nonfatal suicidal behavior.

MAIN OUTCOME MEASURES

Self-reports of lifetime suicide ideation, planning, and attempts.

RESULTS

Survey respondents, categorized as African Americans and Caribbean Americans, reported lifetime prevalence of 11.7% for suicide ideation and 4.1% for attempts. Among the respondents who reported ideation, 34.6% transitioned to making a plan and only 21% made an unplanned attempt. Among 4 ethnic-sex groups, the 7.5% lifetime prevalence for attempts among Caribbean black men was the highest among black Americans. The greatest risk of progressing to suicide planning or attempt among ideators occurred within the first year after ideation onset. Blacks at higher risk for suicide attempts were in younger birth cohorts, less educated, Midwest residents, and had 1 or more Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition disorders.

CONCLUSIONS

This study documents the burden of nonfatal suicidality among US blacks, notably Caribbean black men, and individuals making planned attempts. Advancing research on the transition from suicide planning to attempt is vital to the efficacy of health care professionals' ability to screen blacks at risk for suicide.

Suicide Intent and Accurate Expectations of Lethality: Predictors of Medical Lethality of Suicide Attempts

The degree of intent to commit suicide and the severity of self-injury were examined in individuals (N = 180) who had recently attempted suicide. Although a minimal association was found between the degree of suicide intent and the degree of lethality of the attempt, the accuracy of expectations about the likelihood of dying was found to moderate the relationship between suicide intent and lethality. Specifically, higher levels of suicide intent were associated with more lethal attempts but only for those individuals who had more accurate expectations about the likelihood of dying from their attempts.