Explaining the gender difference in self-reported suicide attempts: a nationally representative study of Norwegian adolescents

Clinical and personality profile of depressed suicide attempters: A preliminary study at the open-door policy Mood Disorder Unit of San Raffaele Hospital

Suicidal behavior is a complex phenomenon with high rates among psychiatric inpatients. Mood disorders and personality dysfunctions represent relevant risk factors for suicides attempts and suicidal ideation. Our study aims to investigate the role of the co-occurrence of clinical variables (duration of depressive state, previous suicide attempts), socio-demographic variables (gender, employment and civil status) and narcissistic personality features in the suicide risk of admitted psychiatric patients affected by a mood disorder. The sample was composed of 93 patients consecutively admitted in an open ward psychiatric Unit. Forty-eight participants had a positive history of previous suicide attempts: the suicide attempters (SA) were mostly female, unemployed and married. The SA group were observed to have suffered from a depressive episode with a longer duration; moreover in the SA group, the presence of active suicidal ideation was significantly related to a higher number of previous suicide attempts. In the whole sample, suicidal ideation was significantly related to narcissistic vulnerability personality features. Using a multidimensional approach, the present study allows a preliminary profiling of patients at risk for suicidal behavior during hospitalization.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.

Internalizing and externalizing symptoms and suicidal behaviour in young people: a systematic review and meta-analysis of longitudinal studies

OBJECTIVE

To assess internalizing and externalizing symptoms as risk factors for suicidal behaviour and suicide among adolescents and young adults.

METHOD

We conducted a systematic review of articles published until January 2017. We identified 26 883 potential papers; 1701 full-text articles were assessed for eligibility, of which 1479 were excluded because of methodological reasons. Diverse meta-analyses were performed for each group of symptoms. Odds ratios (ORs) and 95% confidence intervals (95% CI) or beta coefficients for categorical variables, and effect size (ES) were calculated for continuous variables.

RESULTS

Finally, 41 studies were included, involving participants aged 12-26 years for a systematic review, and 24 articles were included for meta-analysis. The meta-analysis showed that youths with any internalizing (ES = 0.93) or externalizing symptoms (ES = 0.76 and OR = 2.59) were more likely to attempt suicide in future. This effect was also seen in depression symptoms (OR = 6.58 and ES = 1.00), legal problems (OR = 3.36), and anxiety (ES = 0.65).

CONCLUSION

Reported internalizing and externalizing symptoms are predictors of suicide behaviour in young people; therefore, the detection and management of these symptoms in young populations could be a crucial strategy for preventing suicidality in this group.

Suicide contagion, gender, and suicide attempts among adolescents

Exposure to suicidal behavior (ESB) through social networks is often associated with an increased risk of suicidality, but empirical research-largely limited to the Western populations-has produced mixed results. Using survey data, we examined (a) the association between ESB and suicide attempt, and (b) the exacerbating role of ESB on gender differences in suicide attempt risk among Turkish adolescents (N = 2035). ESB was significantly associated with increased risk of suicide attempt, and it contributed to the higher attempt risk among girls. Suicidal behaviors spread through social networks via ESB, and suicide contagion exacerbates the existing gender differences.

The Longitudinal Association of Being Bullied and Gender with Suicide Ideations, Self-Harm, and Suicide Attempts from Adolescence to Young Adulthood: A Cohort Study

Longitudinal associations between being bullied during adolescence and suicide ideations, self-harm, and suicide attempts into young adulthood were examined. A large representative sample was examined in 1998 (N = 2,464, MA 13.7), 1999/2000, and 2012 to reassess the outcome measures. At all ages, bullied participants showed more suicide ideation, self-harm, and suicide attempts, regardless of gender. Bullied females showed a decrease in suicide ideation from adolescence to adulthood, while bullied males showed an increase in suicide attempts in the same time period. Being bullied in adolescence strongly predicts suicidal behavior and self-harm. Preventive efforts might reduce the risk of later suicidality.

Prospective Associations of Coping Styles With Depression and Suicide Risk Among Psychiatric Emergency Patients

Suicide is the second leading cause of death for those ages 13-25 in the United States. Coping is a mediator between stressful life events and adverse outcomes, and coping skills have been incorporated into interventions (e.g., cognitive-behavioral therapy, dialectical behavior therapy, safety-planning interventions) for suicidal populations. However, longitudinal research has not directly examined the prospective associations between multiple coping styles and suicide-related outcomes in high-risk samples. This study identified cross-sectional and 4-month longitudinal associations of coping styles with suicide risk factors (i.e., depression, suicidal ideation, suicidal behavior) in a sample of 286 adolescent and young adult psychiatric emergency patients. Positive reframing was the coping style most consistently associated with positive outcomes, whereas self-blame and disengagement were consistently associated with negative outcomes. Active coping protected against suicidal behavior for males, but not for females. This was the first study to examine longitudinal relationships between coping and suicide-related outcomes in a high-risk clinical sample. Findings suggest that clinical interventions with suicidal adolescents and young adults may benefit from a specific focus on increasing positive reframing and reducing self-blame.

Self-injury and suicide behavior among young people with perceived parental alcohol problems in Denmark: a school-based survey

The aim of this study was to test the hypothesis that young people who perceive their parents to have alcohol problems are more likely to self-injure, have suicide ideation, and to attempt suicide than young people without parental alcohol problems. We also tested whether the association between parental alcohol problems and self-injury, suicide ideation, and suicide attempt among young people differed depending on the gender of the child and the parent. Data came from the Danish National Youth Study 2014, a web-based national survey. A total of 75,853 high school and vocational school students participated. Self-injury, suicidal ideation, and suicide attempts were outcomes and the main exposure variables were perceived parental alcohol problems, gender of the parent with alcohol problems, cohabitation with a parent with alcohol problems, and severity of the parents' alcohol problems. Young people with parental alcohol problems had higher odds of self-injury [boys: OR = 1.59 (95% CI 1.40-1.82); girls: OR = 1.84 (95% CI 1.69-1.99)], suicidal ideation [boys: OR = 1.81 (95% CI 1.59-2.06); girls: OR 1.74 (95% CI 1.59-1.89)], and suicide attempt [boys: OR = 2.10 (95% CI 1.63-2.71); girls: OR = 2.09 (95% CI 1.80-2.42)] compared to young people without parental alcohol problems. Girls with parental alcohol problems had higher odds of self-injury than boys with parental alcohol problems, whereas no gender differences were found for suicidal ideation and suicide attempts. Also no differences were found depending on the gender of the parent with alcohol problems. This study shows that young people with parental alcohol problems have higher odds of self-injury, suicide ideation, and suicide attempts.

Gender differences in exposure and vulnerability to psychosocial and behavioral factors of suicide attempt among Korean adolescents

INTRODUCTION

This study examined gender differences in suicide attempts and their association with exposure and vulnerability to psychosocial, behavioral, and structural factors among Korean adolescents.

METHODS

Data of 74 854 adolescents, taken from the 2010 Korea Youth Risk Behavior Survey, were used. Logistic regression analysis was used to assess the contribution of differential exposure to psychosocial, behavioral, and structural factors for gender differences of suicidal attempt.

RESULTS

Gender differences were observed in the degree of exposure to the various factors. Females were more likely to report psychosocial problems, whereas males were more likely to report experience of smoking and drinking alcohol and to engage in vigorous physical activity. Stress and unhappiness were significantly associated with suicide attempts in both males and females, and gender differences in these variables were nonsignificant. Depressive symptoms were associated with a higher risk of suicide attempts, and this relationship was significantly stronger for males. The effects of cigarette smoking and risky drinking were significantly stronger in females.

DISCUSSION

Greater exposure to perceived stress, feelings of unhappiness, depression, and higher vulnerability of smoking and heavy drinking accounted for higher suicide attempts of female adolescents. Higher exposure to health-related behaviors and greater vulnerability to depressive symptoms in male were also noted. In conclusion, differences in exposure and vulnerability to psychosocial and behavioral factors may partly explain gender differences in suicide attempts among Korean adolescents.

Hopelessness and Loneliness Among Suicide Attempters in School-Based Samples of Taiwanese, Philippine and Thai Adolescents

The aim of this study was to assess the level of suicide attempts in three school-based samples of Southeast Asian adolescents (Taipei, Taiwan; the Philippines; Chiang Mai, Thailand) and determine whether adolescent suicide attempters score higher on measures of hopelessness and loneliness relative to nonattempters. It was hypothesized that hopelessness and loneliness would be related to suicide attempts, and that hopelessness would continue to be associated with suicide attempts when controlling for loneliness. The prevalence of suicide attempts across the three samples of Asian youth were not consistent with Taiwanese girls and boys as the most likely to have ever attempted suicide. As expected, results showed that suicide attempters (in past 12 months and ever) scored higher on hopelessness and loneliness than nonattempters across all three samples and for both genders. However, the statistical control of loneliness demonstrably weakened the association between suicide attempt behaviour and hopelessness across the samples and for both genders, and resulted in nonsignificant ANCOVA tests for some of the sample-gender groups. These results attest to the need for more research investigating connections between youth suicide attempts, hopelessness and loneliness in adolescent populations. Loneliness should be included as a potential determinant of youth suicidal behaviour in future research.

Prevalence and influence factors of suicidal ideation among females and males in Northwestern urban China: a population-based epidemiological study

Background

Suicide is an urgent public health challenge for China. This study aims to examine the prevalence, influence factors, and gender differences of suicidal ideation among general population in Northwestern Urban China.

Methods

Data used in this study were derived from the third wave of a cohort study of a randomized community sample with 4291 participants (≥20 years) in 2008 in Lanzhou City and Baiyin City, Gansu Province. Data were collected via face-to-face interview by the trained interviewers. Descriptive analyses, chi-square tests and multivariate logistic regressions were performed by using Stata 12.0, as needed.

Results

The prevalence of 12-month suicidal ideation was 4.29 %, there was no significant difference between males and females [5.04 % vs 3.62 %, Adjusted Odds Ratio (AOR) = 0.83, p = 0.351]. Several risk factors for suicidal ideation were confirmed, including being unmarried (AOR = 1.55, p = 0.030), having depression symptoms (AOR = 2.33, p < 0.001), having other insurance (AOR = 1.83, p = 0.01) or no insurance (AOR = 1.73, p = 0.024). In addition, several influence factors were significantly different in males and females, such as being currently married (unmarried vs married, AOR = 1.84, p = 0.027, for females; no difference for males), feeling hopeless (hopless vs hopeful, AOR = 1.92, p = 0.06, for females; no difference for males), having other insurances (having other insurances vs having basic employee medical insurance, AOR = 1.92, p = 0.044, for males; no difference for females), having debts (having debts vs no debts, AOR = 2.69, p = 0.001, for males; no difference for females), currently smoking (smoking vs nonsmoking, AOR = 3.01, p = 0.019 for females, no difference for males), and currently drinking (drinking vs nondrinking, AOR = 2.01, p = 0.022, for males; no difference for females).

Discussion and conclusion

These findings suggested that comprehensive suicide prevention strategies should be developed or strengthened in order to prevent suicide ideation in China, and the gender-specific differences need to be explored through further researches.

Shame and Gender Differences in Paths to Youth Suicide: Parents' Perspective

Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. We constructed a generic conceptual model of the processes underlying youth suicide, grounded in 78 interviews with parents in 52 consecutive cases of suicide (19 women, 33 men) identified at forensic medical autopsy and compared by sex. We found different forms of shame hidden behind gender-specific masks, as well as gender differences in their paths to suicide. Several interacting factors formed negative feedback loops. Finding no way out, the young persons looked for an "emergency exit." Signs and preparations could be observed at different times but recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. We discuss parents' experiences from the theoretical perspective on gender identity and developmental breakdown. Giving voice to the parents' tacit knowledge can contribute to better prevention and treatment.

Prevalence of suicide attempts among Chinese adolescents: A meta-analysis of cross-sectional studies

OBJECTIVE

According to World Health Organization, for every committed suicide there were 20 suicide attempts at least. In the last decade, despite the increasing awareness on suicide attempts among adolescents in China, there has been no comprehensive system reporting vital statistics. Consequently, the prevalence of suicide attempts reported in some studies ranged variedly. Therefore, the purpose of this study was to provide the first meta-analysis of cross-sectional studies of suicide attempts to fill this gap.

METHODS

Two reviewers independently screened potentially relevant cross-sectional studies of suicide attempts through PubMed-Medline, Embase, Wanfang Data, Chongqing VIP and Chinese National Knowledge Infrastructure databases using the core terms 'suicid*'/'suicide attempt*'/'attempted suicide' and 'adolescen*'/'youth'/'child*'/'student*' and 'China'/'Chinese' in the article titles, abstracts and keywords. Chi-square based Q test and I(2) statistic assessed the heterogeneity. Forest plot was used to display results graphically. Potential publication bias was assessed by the funnel plot, Begg's and Egger's test.

RESULTS

In total, 43 studies with 200,124 participants met the eligibility criteria. The pooled prevalence of suicide attempts among Chinese adolescents was 2.94% (95% CI: 2.53%-3.41%). Substantial heterogeneity in prevalence estimates was revealed. Subgroup analyses showed that the prevalence for males was 2.50% (95% CI: 2.08%-3.01%), and for females was 3.17% (95% CI: 2.56%-3.91%).

CONCLUSIONS

In sum, abstracting across the literatures, the prevalence of suicide attempts among Chinese adolescents was moderate compared with other countries around the world. Necessary measures should be set out prevent them in the future.

Cognitive correlates of serious suicidal ideation in a community sample of adolescents

BACKGROUND

Studies indicate that a dysfunctional attributional style, problem-solving deficits and hopelessness place youths at risk of developing suicidal thoughts and engaging in suicidal behaviour. However, in the realm of suicidality in adolescent, no study has examined the linkages between these three cognitive variables and suicidal ideation in non-clinical samples while taking into account the moderating role of gender on the relationships and controlling for depression.

METHODS

In this community study of 712 adolescents 14-18 years of age, through a multivariate approach, the interaction between the cognitive variables, depression and gender was examined with depression controlled in the analyses.

RESULTS

Problem-solving deficits and hopelessness proved predictive of such ideation whether or not depressive symptoms were controlled in the analyses. Negative problem orientation/avoidant style was more predictive of ideation in boys than in girls. On the other hand, hopelessness was more predictive for girls than boys.

LIMITATIONS

Results were based on a convenience community sample of adolescents and a cross-sectional survey.

CONCLUSIONS

Results suggest that a unique explanatory model of the suicide process in adolescence that fails to take account of gender would be ill informed. Suicide prevention strategies should be differentiated according to gender with a stronger emphasis in hopelessness in female adolescents, and problem-solving deficits in male adolescents.

Multi-country, cross-national comparison of youth suicide ideation: Findings from Global School-based Health Surveys

This study describes the prevalence of suicide ideation in 109 Global School-based Health Surveys (GSHS) conducted from 2003–2010 representing 49 different countries and 266,694 school-attending students aged 13–15 years primarily living in developing areas of the World. Prevalence of suicide ideation varied widely among and between countries, regions, and by gender, with an overall mean prevalence of suicide ideation of 15.3%. When grouped by region, Africa had the highest percentage of participants reporting suicide ideation (19.8%). The wide variability in the prevalence of suicide ideation found in this study confirms that school psychologists and counselors must be prepared to deal with the unique needs and characteristics of the specific populations of youth they serve, as the needs are likely to vary substantially from locality to locality, and country to country.

A longitudinal evaluation of religiosity and psychosocial determinants of suicidal behaviors among a population-based sample in the United States

BACKGROUND

Relationships among religiosity and other psychosocial factors in determining suicidal behaviors in adolescence and in emerging adulthood have been inconclusive. We sought to investigate prospective relationships among religiosity, psychosocial factors and suicidal behaviors using a nationally representative sample of adolescents emerging into adulthood.

METHOD

Analysis was based on 9412 respondents from four waves of National Longitudinal Study of Adolescent Health. A Generalized Estimating Equation (GEE) procedure was used to fit a series of models on the response variable (suicidal behaviors) and a set of psychosocial and religiosity predictors taking into account the correlated structure of the datasets.

RESULTS

Analyses showed that adolescent suicidality and religious activity participation showed significant declines over time. Using multinomial logistic regression we found that females showed statistically significant risks of suicidal behaviors, but this effect declined in adulthood. In adjusted models, baseline attendance of a church weekly was associated with 42% reduction (95% Confidence Interval: 0.35-0.98) of suicide ideation in Wave III. Across all waves, low support from fathers (compared with mothers) consistently explained variability in suicidal behaviors among genders emerging into adulthood.

LIMITATIONS

Accurate measurement of religiosity is psychometrically challenging.

CONCLUSIONS

The findings of the study indicate that religious activity participation is associated with reduced suicidal behaviors among adolescents but this effect declines during emerging adulthood. Psychosocial supports particularly from fathers' have an enduring impact on reduced suicidal behaviors among adolescents and emerging adults. Prevention, identification and evaluation of disorders of suicidality need a careful assessment of underlying mental pain (psyache) to reduce the likelihood of aggravated suicide.

Gender differentiation in methods of suicide attempts

Background

Suicide is an important public health problem worldwide, especially due to an increasing rate of suicides committed by violent methods. This study compared and assessed the methods used in suicide attempts (but no completed suicides) as undertaken by men and women and investigated the possible role of gender in the selection of suicide method.

Material/Methods

The study was conducted among persons who attempted suicide by various methods and were admitted to hospital. The study population comprised 147 participants (33 males and 114 females) aged between 14 and 33 years.

Results

The most prevalent methods of suicide attempts were pharmacological drugs abuse (42.31%) and exsanguination (25.64%), and the least frequent were poisoning and throwing oneself under a moving car (1.28%). The findings revealed that the female subjects tended to choose pharmacological drugs overdose and exsanguination as the suicide method, while males more frequently used hanging and asphyxia. Females also used a greater number of different suicide methods.

Conclusions

The study results indicate that women as a group more frequently attempted suicide rather than actually committing it, whereas men were more likely to complete suicides and choose more violent suicide methods; thus, women are the “attempters” and “survivors” of suicide attempts. The study findings may have implications for therapy and prevention of suicide, and suggest that psychotherapeutic activities should be tailored to the psychological and personality traits associated with gender identity.

Suicide attempts: prevention of repetition

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Adolescent suicide attempts in Bærum, Norway, 1984-2006

BACKGROUND

There are presently few international studies that examine adolescents' own experience of both triggering and the underlying reasons behind their suicide attempts.

AIMS

To present the rates, triggering factors, and underlying reasons for such behavior.

METHODS

The 23-year (1984-2006) surveillance study reported includes all general hospital-treated suicide attempters aged between 13 and 19 years (n = 254) living in the municipality of Bærum, a suburb on the outskirts of Oslo, Norway.

RESULTS

Suicide attempt rates for both sexes decreased during the period of study. The female suicide attempt rate was on average 3.5 times higher than the male rate. An average of 8.2% of the suicide attempters made a repeat attempt within the following year. Overall, the most commonly reported trigger was a relational conflict (50.2%), and the most commonly reported underlying reason was a dysfunctional family situation (43.6%), followed by mental health problems (22.8%). The main gender difference for both triggers and underlying reasons was that relational conflicts were reported significantly more often by girls than by boys as triggers (55.0% versus 32.7%), and dysfunctional family issues were reported significantly more often by girls than by boys (47.1% versus 30.8%) as underlying reasons for the attempt. Mental health problems were reported less frequently as an underlying reason by girls than boys (21.2% versus 28.8%).

CONCLUSIONS

A family-oriented intervention embracing the extended family system seems warranted in a majority of the cases in our study.

Increasing self-reported suicide attempts by adolescents in Greece between 1984 and 2007

PURPOSE

This study examines trends in self-reported suicide attempts by Greek adolescents.

METHODS

Data were obtained from five nationwide school probability surveys, each of approximately 8,000-10,000 adolescents aged 14-18 years, carried out from 1984 to 2007. Students answered an anonymous questionnaire in their classrooms supervised by research assistants. Logistic regression analysis used as dependent variable any self-reported suicide attempts and as independent variables basic sociodemographic information and the year of the survey.

RESULTS

Self-reported suicide attempts doubled in prevalence from 7.0% in 1984 to 13.4% in 2007. Female gender (odds ratio OR 2.49, 95% confidence interval CI 2.30-2.71), living in a single parent family (OR 1.91, CI 1.73-2.11), lower paternal education (OR 1.20, CI 1.10-1.31) and living in a major city (OR 1.17, CI 1.08-1.27 for Greater Athens and OR 1.13, CI 1.00-1.28 for Thessaloniki) were significantly associated with suicide attempts. A larger increase among males, from 2.4 to 8.4%, compared to females (11.5 to 17.9%) contributed to a decrease in gender differences.

CONCLUSIONS

Changes in Greek society during the last 30 years, including loosening of family ties, increased drug use and stress because of the demands of school work, are hypothesised to have had an impact on the increasing trend in suicide attempts among adolescents.

Suicidality among Norwegian youth: review of research on risk factors and interventions

BACKGROUND AND AIM

Published research on suicidality among Norwegian youth and publications describing interventions were summarized in order to access the current status of knowledge building via empirical research.

METHOD

A systematic Medline search identified 29 studies on risk factors on the entire spectrum of suicidal phenomena from self-harm without suicidal ideation to completed suicide with the mean age at/under 25 years. A specialist Norwegian journal, Suicidologi, was searched for additional matter, especially interventions.

RESULT

Most studies focussed on psychological and psychiatric risk factors of attempted suicide. Other suicidal phenomena, psychosocial and societal risk factors, and impact of interventions were hardly studied. Depression, previous suicidal behaviour, alcohol use and non-intact parental unit were consistent significant risk factors found in suicide and attempted suicide studies.

CONCLUSION

Supporting non-intact parental units and the maintenance of intact parental units along with early detection and management of suicide attempts, depression and alcohol use should be targeted as suicide prevention interventions among adolescents.

[Smoking and nicotine dependence]

BACKGROUND

The prevalence of smoking is decreasing. At the same time, studies suggest that the relative proportion of nicotine dependent smokers is increasing. This may leave us with a smaller, but more problematic group of smokers. Few studies have investigated nicotine dependence in Norway.

MATERIAL AND METHODS

Data were collected in the Young in Norway Longitudinal Study, where 2,890 respondents were followed up from their early teens until their late 20s. Information was collected on smoking habits, nicotine dependence, education, various indicators of social marginalization, anxiety, depression, suicidal behaviour, alcohol problems and use of drugs.

RESULTS

At the age of 28 years, 12 % (n = 357) were classified as non-dependent daily smokers, whereas 5 % (n = 148) fulfilled criteria for "weak" and 3 % (n = 93) for "strong" nicotine dependence. 74 % of those who were in the "strong" dependent group at age 22 were still daily smokers at age 28; versus 50 % of non-dependent smokers. Nicotine dependence was associated with weak social resources, reduced mental health, alcohol problems and use of illegal drugs.

INTERPRETATION

Daily smokers are more or less nicotine dependent. Smokers with a strong dependency have more stable smoking habits, weaker social resources and more problems with mental health, alcohol and drug use than others. Nicotine dependence represents a larger health political challenge for the authorities than previously recognised.

Smoking, nicotine dependence and mental health among young adults: a 13-year population-based longitudinal study

AIMS

To investigate prospectively the associations between daily smoking and nicotine dependence and anxiety, depression and suicide attempts.

METHODS

Data were from the Young in Norway Longitudinal Study. A population-based sample (n = 1501) was followed for 13 years from ages 13-27 years. Data were gathered on smoking patterns and nicotine dependence; and depression, anxiety and parasuicide. Extensive information on socio-demographic factors, parental and family conditions, parental rearing practices, educational career, conduct problems, alcohol problems and use of illegal substances was also collected.

RESULTS

Young adults who were nicotine-dependent had clearly elevated rates of anxiety, depression and parasuicide. These rates declined after controlling for a previous history of mental health problems and potential confounding factors. After adjustment, nicotine dependence was still associated with anxiety, depression and parasuicide. There was also a significant association with later depression in the group of non-dependent daily smokers. Measures of reduced mental health did not predict later smoking initiation or the development of nicotine dependence.

CONCLUSIONS

Mental health was reduced more seriously in nicotine-dependent smokers than in non-dependent smokers. These findings are consistent with the hypothesis that smoking, in particular nicotine dependence, influences mental health.

Predictors of non-suicidal self-injury versus attempted suicide: similar or different?

A nationally representative sample of Norwegian high school students (ages 14 to 19, N = 2,924) completed self-reports in school about non-suicidal self-injury (NSSI), suicide attempt (SA), and risk and protective factors. They were re-examined 5 years later. In all 2.2% reported NSSI with no SA during the follow-up period and 3.2% reported SA. Several risk and protective factors were common to NSSI and SA: previous SA, young age, debut of sexual intercourse before the age of 15, and non-heterosexual sexual interest. However, other risk and protective factors were unique to NSSI or SA: Previous NSSI increased the risk for future NSSI whereas satisfaction with social support protected against later NSSI. Suicidal ideation increased the risk for SA whereas attachment to parents protected against it. NSSI did not increase the risk of future SA. NSSI and SA may be thus conceived of as only partly overlapping phenomena, and not necessarily just representing different degrees of suicidality.

Preventing youth suicide: issues for law enforcement personnel

Suicide is a leading cause of death for adolescents. A number of problem behaviors associated with youth suicide fall into the purview of law enforcement personnel, and they are therefore in a position to detect risk and prevent suicidal behaviors. Eight hundred one youth identified as having school difficulty, a group at increased risk for both suicide and legal problems, participated in a paper and pencil survey followed by an interview focusing on suicide risk and protective factors. Linear regression was used to examine the ability of factors within each risk and protective factor dimension to predict current suicide risk. The study goal was to determine the most relevant factors influencing suicide risk in each domain examined. Findings are discussed in terms of implications for assessment and policy for law enforcement personnel.

Gender-specific association between iron status and the history of attempted suicide: implications for gender paradox of suicide behaviors

PURPOSE

Iron deficiency (ID) has been linked with high impulsivity, and an increased risk of ID was reported among suicide attempters. We hypothesized that poor iron status might be prevalent among suicide attempters, who have high impulsivity.

METHODS

As a part of the third National Health and Nutrition Examination Survey (1988-1994), a set of iron indices were measured in 2598 men and 2975 women aged 17-39 years, who completed a mental disorder diagnostic interview.

RESULTS

Using non-attempters as reference within each gender, we observed a gender-dependent association between poor iron status and the history of attempted suicide. For male attempters (n=74), the prevalence ratios (PR) of abnormal serum ferritin, serum iron and protoporphyrin were 18.3 (95%CI=3.3-101.7), 3.2 (1.1-9.4) and 5.4(1.8-15.6). In contrast, the PR of abnormal serum ferritin for female attempters (n=217) was 0.3 (0.1-0.6). The hematological indices did not differ significantly between attempters and non-attempters among either men or women. Compared with non-attempters, male attempters were prone to a higher odds [17.5 (4.2-72.4)] while female attempters to a lower odds [0.6 (0.3-1.1)] of ID.

CONCLUSION

These data suggest new opportunities for exploring biological bases of gender paradox of suicidal behaviors and a novel way to enhance therapeutic and preventive interventions against suicide.

Suicide risk and protective factors among youth experiencing school difficulties

Youth who experience difficulty in school are at risk for suicide, yet there is little published information specific to risk and protective factors among this group. The purpose of this study was to conduct an in-depth examination of risk and protective factors associated with suicidal behaviour among youth who were experiencing problems in school and to compare these factors between suicide risk and non-suicide risk subgroups. Participants were 730 high school students in the Northwest and Southwest regions of the United States, aged 14-21 years. All participants were known to be experiencing difficulty with grades and/or attendance. Students completed a paper-and-pencil questionnaire and a one-on-one interview, which assessed suicidal behaviours as well as risk factors (e.g. drug involvement, emotional distress, stress), and protective factors (e.g. self-esteem, coping, support). Analysis of covariance tests, controlling for age and sex, were conducted to examine differences between the suicide risk and non-suicide risk groups on each risk and protective factor. The suicide risk subgroup reported higher levels of all risk factors, except alcohol and marijuana use, and lower levels of protective factors. While the groups did not differ on frequency of alcohol or marijuana use, they did differ on other illicit drug use and consequences of alcohol and other illicit drug use. Recommendations for nurses practising in school settings are discussed.

Nonfatal suicide-related behavior among inmates: testing for gender and type differences

Suicide-related behavior (SRB) is significantly more prevalent among female (40.8%) than among male (28%) inmates, although suicide risk is higher among the latter. When instrumental behavior (IB) is excluded and only suicidal acts (SA) considered, rates for the two groups are more comparable (11.9% and 16%, respectively). Compared with other female inmates, the SRB group is more suicidal, hostile, and impulsive and more likely to have been previously victimized and to be diagnosed with Axis I and II disorders. Women with IB are not significantly different from those with SA, except that their behavior provides significantly greater tension release.

Suicide attempts among indigenous Sami adolescents and majority peers in Arctic Norway: prevalence and associated risk factors

The prevalence of suicide attempts and associated risk factors such as sociodemographic conditions, emotional/behavioural problems and parent-child relationships were examined among 591 indigenous Sami and 2100 majority adolescents in Arctic Norway. There were no significant ethnic differences in prevalence of suicide attempts. In both ethnic groups, suicidal ideation, anxious/depressed problems and eating behaviour problems were associated with suicide attempts. Cross-cultural differences in risk factors associated with suicide attempts existed. For Sami adolescents, factors diverging from the traditional cultural norms were associated with suicide attempts, such as alcohol intoxication, single-parent home and paternal overprotection (p</=.05). Vocational studies, not living together with parents, current smoking and experienced sexual intercourse were ethnic specific risk factors associated with suicide attempts among majority peers (p</=.05). Clinicians should take into account that risk factors can differ between ethnic groups and should be sensitive to culturally divergent behaviour.

Gender and Cultural Patterns of Suicidal Behavior

Patterns of suicidal behavior vary among cultures and along gender. Young Hindustani immigrant women attempt suicide four times more often than young Dutch women. This article explores multi-disciplinary explanations for suicidal behavior in this group. The interconnection of Durkheimian concepts of social integration and regulation with ecological insights into family relations and psychological and psychiatric theories on individual distress are relevant. It is suggested that young Hindustani women who display suicidal behavior possess certain personality and cognitive constellations that are interlocked with specific parenting styles in stressful family environments. These families are embedded in a context of moral transformations resulting from migration to a Western culture and may be facing difficulties accompanying the transitional processes encountered in the West, particularly those regarding gender roles. Durkheimian fatalistic and anomic suicides elucidate this. The Hindustani women who appear most at risk are those facing contradictory norms and overregulation, which prevent them from developing autonomy.

Gender in suicide attempt rates and childhood sexual abuse rates: is there an interaction?

Two competing explanations for higher rates of attempted suicide in women than men were compared. Because childhood sexual abuse is more prevalent in girls than boys, one explanation of higher rates of suicide attempts in women is that it is a direct result of the higher incidence of sexual abuse in girls. Alternatively, higher rates of suicide attempts might result from gender differences in the impact of childhood sexual abuse on suicidal behavior. To compare these theories, data from 1,889 abstinent, substance-dependent patients who completed the Childhood Trauma Questionnaire (CTQ) and who were interviewed about suicide attempts was examined. Scores on each scale of the CTQ were examined as a function of gender and attempter status. Results showed higher rates of suicide attempts in women than in men, higher CTQ scores in women than men, and a higher CTQ score in attempters than nonattempters. However, logistic regression indicated that gender and abuse did not interact to determine attempter status. Thus, the data support the first hypothesis that the greater frequency of suicide attempts in women may be partly attributed to the higher prevalence of childhood sexual abuse in girls. The generalizability of these results to the general population and to other diagnostic groups requires further study.

Predictors of suicidal ideation among high school students by gender in South Korea

The purpose of this study was to examine the evidence to determine if there are gender differences in suicidal ideation of adolescents. This study examined the main effect of risk factors from 5 domains and protective factors from 1 domain in relation to suicidal ideation by gender and identified the most important predictors of suicidal ideation for males (N = 654) and females (N = 658). This study was a cross-sectional survey, and data were collected through self-report questionnaires. In the univariate analysis, especially, risk factors from behavioral variables and psychosocial-environmental variables appeared to be gender skewed. For males, all behavioral variables were predictive of suicidal ideation. For the females, unlike the males, Wang-tta or victim of bullying behavior and sexual orientation as behavioral variables were predictive of suicidal ideation. For males, parental divorce and parental alcohol abuse as psychosocial-environmental variables were predictive of suicidal ideation. For the females, again unlike for the males, all the psychosocial-environmental variables were not predictive of suicidal ideation. The most important predictors of suicidal ideation for males as a result of the multivariate analysis were history of suicidal attempt, depression, hostility, smoking, parental alcohol abuse, communication with friends, and self-esteem. The most important predictors of suicidal ideation for females as a result of the multivariate analysis were depression, hostility, sexual orientation, and self-esteem. These results would indicate that an effective suicide screening and prevention program for adolescents should consider gender differences.

Suicide attempts in israel: age by gender analysis of a national emergency departments database

An analysis of all emergency department admissions in Israel classified as an attempted suicide in the years 1996-2002 was done to examine attempted suicide rates by age and gender with particular attention to adolescents and young adults. Gender differences in attempted suicide rates were significant only during adolescence and young adulthood, ages 13 to 26. The highest rate for females was 3 years earlier than the highest rate for males. The results lead to the conclusion that women do not attempt suicide more than men, except for 13-26 year olds.

Self-harm

The term self-harm is commonly used to describe a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning, and superficial cutting in response to intolerable tension. As with suicide, rates of self-harm vary greatly between countries. 5-9% of adolescents in western countries report having self-harmed within the previous year. Risk factors include socioeconomic disadvantage, and psychiatric illness--particularly depression, substance abuse, and anxiety disorders. Cultural aspects of some societies may protect against suicide and self-harm and explain some of the international variation in rates of these events. Risk of repetition of self-harm and of later suicide is high. More than 5% of people who have been seen at a hospital after self-harm will have committed suicide within 9 years. Assessment after self-harm includes careful consideration of the patient's intent and beliefs about the lethality of the method used. Strong suicidal intent, high lethality, precautions against being discovered, and psychiatric illness are indicators of high suicide risk. Management after self-harm includes forming a trusting relationship with the patient, jointly identifying problems, ensuring support is available in a crisis, and treating psychiatric illness vigorously. Family and friends may also provide support. Large-scale studies of treatments for specific subgroups of people who self-harm might help to identify more effective treatments than are currently available. Although risk factors for self-harm are well established, aspects that protect people from engaging in self-harm need to be further explored.

Correlates and predictors of self-reported suicide attempts among incarcerated youths

The correlates and predictors of suicidal behaviors among 900 young offenders in detention centers in South Australia are investigated. That young offenders are a high-risk population is confirmed, with a quarter of the youths reporting recent suicidal ideation and more than a quarter reporting having made a suicide attempt. Past suicide attempts are significantly predictive of future suicide attempts. Other variables both concurrently and prospectively associated with suicidal behaviors (even after controlling for prior suicide attempt status) are substance use, prolonged dysphoric mood, attention deficit hyperactivity disorder signs, and having a bad temper. These variables not only have predictive value but should also be considered as appropriate targets when intervening to reduce suicide risk. It is suggested that impulsiveness is an underlying common factor.

Parasuicide in a low-income country: results from three-year hospital surveillance in Nicaragua

AIMS

A study was undertaken to assess the incidence of parasuicide in Nicaragua, to identify groups at risk, and to describe the characteristics of parasuicides, such as methods used and seasonal and diurnal patterns.

METHOD

All hospital-admitted parasuicide cases in the area of Leon, Nicaragua, were assessed over a three-year period using standardized instruments.

RESULTS

Two hundred and thirty-three parasuicide cases were identified in the catchment area giving a parasuicide rate of 66.3/100,000 inhabitants per year based on the population 10 years and older. Corresponding figure for 15 years and older was 71.3. A majority were females (68.8%), who were significantly younger than the males (mean 20.8 years vs. mean 24.6 years). The highest rates were found in the age group 15-19 years with a female rate three times higher than the male rate (302.9 vs. 98.9). Pesticides, a highly lethal substance, were used as method in 19.1% of the attempts. Consistent seasonal variation with peaks in May-June and September-October were found over the years. Among parasuicide cases, 46.5% had been in contact with the healthcare system within 6 months before attempting suicide.

CONCLUSIONS

Parasuicides represent a significant health problem among young people in Nicaragua. Preventive efforts should be directed especially towards the life situation for young girls, limitation of availability of suicide means, increased awareness in schools concerning suicidal problems, as well as improved management of patients with mental health problems within primary healthcare.

Intoxicants and suicidal behaviour among adolescents: changes in levels and associations from 1992 to 2002

AIMS

To assess whether a substantial increase in substance use over a 10-year period has had an impact on the level of, or associations with, non-fatal suicidal behaviour among Norwegian teenagers.

DESIGN, SETTING AND PARTICIPANTS

Two cross-sectional school surveys applying identical procedures and measures in 1992 and 2002, using national samples comprising 11 000 and 12 000 13-19-year-old students.

FINDINGS

A significant proportion of the increase in the prevalence of attempted suicide among girls could be attributed to the increase in substance use, taking into account other risk and protective factors. Among boys no net increase in the prevalence of attempted suicide was observed, and the impact of substance use on suicidal behaviour was lower in 2002 than in 1992. Yet, it also appeared that unobserved protective factors may have countered the impact of increased substance use among boys. For both genders a larger fraction of attempted suicides was attributable to alcohol intoxication than to use of any other substance.

CONCLUSIONS

A significant increase in use of alcohol and drugs may not necessarily be reflected in changes in the level of suicidal behaviour. Further studies applying other data sources and designs are warranted to supplement and validate the present findings.

Impact of gender and parents' marital status on adolescents' suicidal ideation

This study investigated the effect of gender and parents' marital status on adolescents' suicidal ideation in a sample of Grade 8 and Grade 9 students (mean age = 14.12 years) in Singapore. Two hundred and seventy-one (149 boys and 122 girls) students completed the junior high school version of the Suicidal Ideation Questionnaire (SIQ-JR) and a short demographic questionnaire. Consistent with our hypothesis, the 2 (Gender) x 2 (Parents' marital status) ANOVA yielded a statistically significant interaction effect as expected. Specifically, tests of simple effects reveal that adolescent boys from single-parent families were found to be significantly higher on suicidal ideation compared with adolescent boys from two-parent families. This difference was not found among adolescent girls--adolescent girls from single-parent and two-parent families did not differ significantly on suicidal ideation. Being a boy in a single-parent home environment may increase one's risk for endorsing clinically significant suicidal ideation.

Suicidal ideation and attempts in Norwegian police

Studies on suicide among police show inconsistent results, thereby contributing to considerable speculation regarding why police officers commit suicide. The present paper is the first nationwide study on suicidal ideation and attempts among police. 3,272 Norwegian police completed Paykel's Suicidal Feelings in the General Population questionnaire. Lifetime prevalence of specific questionnaire items ranged from 24% for the feeling that life was not worth living, 6.4% for having seriously considered suicide, and 0.7% for attempted suicide. Independent predictors of serious suicidal ideation were marital status, subjective health complaints, reality weakness, anxiety, and depression. Serious suicidal ideation was mainly attributed to personal and family problems.