Deliberate exposure to motor vehicle exhaust gas: the psychosocial profile of attempted suicide

Practical Capability Among Veterinarians: Preliminary Evidence of the Importance of Access to Lethal Medications in the Workplace

OBJECTIVE

Veterinarians die by suicide at elevated rates. Higher levels of capability for suicide among veterinarians, including access to lethal medications, may account for this discrepancy. This study aimed to determine the importance of accessibility of lethal medications in veterinary workplaces in the relationship between recent suicidal ideation and perceived likelihood of making a future suicide attempt.

METHOD

Participants identifying with one or more groups at high-risk for suicide (e.g., veterinarians, firearm owners) were recruited via social media to complete online self-report questionnaires examining demographic, work-related, and suicide-related risk factors. The sample of veterinarians (n = 310) was primarily female, White, and worked in small animal practices.

RESULTS

Method of lethal medication storage in the workplace moderated the relationship between past week ideation and perceived likelihood of a future suicide attempt such that the relationship became stronger among those storing medications unlocked during business hours and weaker among those storing medications locked during business hours.

CONCLUSION

Secure storage of lethal medications in the workplace may protect against suicide risk. Barriers to lethal medications, when not actively in use, may reduce both physical and cognitive accessibility. Future research should determine the impact of workplace lethal medication storage on suicidal behavior among veterinarians.HIGHLIGHTSLethal med storage moderates link between suicidal thoughts and belief suicide is likelyStoring unlocked may increase physical and cognitive accessibility of this methodWorking with vets to develop and implement means safety strategies will be important.

Suicide attempts presenting to the emergency department before and during the COVID-19 pandemic: a comparative study

Objective

To compare and analyze the differences in the sociodemographic and clinical characteristics of suicide attempters who visited an emergency department (ED) before and during the coronavirus disease (COVID-19) pandemic.

Methods

This single center, retrospective study was conducted by reviewing the medical records of patients in the “self-injury/suicide” category of the National Emergency Department Information System who visited an ED between January 2019 and December 2020. We obtained information on baseline characteristics, suicide attempt, and disposition. Data were analyzed using the chi-squared test.

Results

A total of 456 patients were included. The number of patients visiting the ED for suicide attempts increased by 18.2% (from 209 to 247 cases) during the COVID-19 pandemic, and the ratio of suicide attempters to the total number of ED visits increased by 48.8% (from 0.43% to 0.64%, P<0.001). There were significant differences in methods of suicide attempt, endotracheal intubation, ED disposition, and the presence of mental illness. Drug overdose (42.1% vs. 53.4%) and gas inhalation (5.7% vs. 8.5%) increased, and hanging decreased (6.0% vs. 2.0%) during the pandemic. Endotracheal intubation (13.9% vs. 5.7%) and intensive care unit admission (29.7% vs. 14.6%) decreased. More patients with the history of mental illness visited during the pandemic (54.0% vs. 70.1%).

Conclusion

Since the COVID-19 pandemic began, suicide attempts have increased in this single ED although the lethality of those attempts is low.

Finding Effective and Efficient Ways to Integrate Research Advances Into the Clinical Suicide Risk Assessment Interview

Research in clinical suicidology continues to rapidly expand, much of it with implications for day-to-day clinical practice. Clinicians routinely wrestle with how best to integrate recent advances into practice and how to do so in efficient and effective fashion. This article identifies five critical domains of recent research findings and offers examples of simple questions that can easily be integrated into a clinician's existing suicide risk assessment interview and related protocol helping inform the risk formulation process.

Linking Public Safety And Public Health Data For Firearm Suicide Prevention In Utah

In Utah, a state with a high rate of gun ownership, the shared concerns of diverse stakeholders generated bipartisan support for a state-funded study that tracked patterns of firearm suicide. The study linked sensitive public health and public safety data and identified opportunities for firearm suicide prevention. Findings reported to the state legislature included the proportion of suicide decedents who could have passed a background check for legal firearm possession at their time of death, had a permit to carry a concealed firearm, or had been seen in the hospital for a previous suicide attempt or self-harm. Within six months of the report's release, the legislature, health care and religious groups, and state agencies had launched diverse, major initiatives to reduce firearm suicide that were informed by the report's findings. We present the Utah experience as a case study in bringing diverse stakeholders-particularly gun owners-together to find common ground on firearm suicide prevention and in using linked data to support and guide their efforts.

Impact of confinement in vehicle trunks on decomposition and entomological colonization of carcasses

In order to investigate the impact of confinement in a car trunk on decomposition and insect colonization of carcasses, three freshly killed pig (Sus scrofa domesticus Erxleben) carcasses were placed individually in the trunks of older model cars and deployed in a forested area in the southwestern region of British Columbia, Canada, together with three freshly killed carcasses which were exposed in insect-accessible protective cages in the same forest. Decomposition rate and insect colonization of all carcasses were examined twice a week for four weeks. The exposed carcasses were colonized immediately by Calliphora latifrons Hough and Calliphora vomitoria (L.) followed by Lucilia illustris (Meigen), Phormia regina (Meigen) and Protophormia terraenovae (R.-D.) (Diptera: Calliphoridae). There was a delay of three to six days before the confined carcasses were colonized, first by P. regina, followed by Pr. terraenovae. These species represented the vast majority of blow fly species on the confined carcasses. Despite the delay in colonization, decomposition progressed much more rapidly in two of the confined carcasses in comparison with the exposed carcasses due to the greatly increased temperatures inside the vehicles, with the complete skeletonization of two of the confined carcasses ocurring between nine and 13 days after death. One confined carcass was an anomaly, attracting much fewer insects, supporting fewer larval calliphorids and decomposing much more slowly than other carcasses, despite similarly increased temperatures. It was later discovered that the vehicle in which this carcass was confined had a solid metal fire wall between the passenger area and the trunk, which served to reduce insect access and release of odors. These data may be extremely valuable when analyzing cadavers found inside vehicle trunks.

Use of lethal means restriction counseling for suicide prevention in pediatric primary care

Suicide is the second-leading cause of death for adolescents in the United States. Counseling patients and families on safe storage of firearms and medications is an effective method of suicide prevention. We sought to determine the self-reported frequency of lethal means restriction (LMR) counseling among primary care pediatric providers working with adolescents who are at risk for suicide as well as factors associated with consistently employing LMR counseling. An anonymous, self-report, electronic survey was conducted of primary care pediatricians in the Washington, DC metropolitan area of LMR counseling for suicide prevention. The survey was conducted over 10 weeks in autumn of 2017. Stepwise, multivariate logistic models were used to determine factors associated with firearm screening and LMR counseling for patients at risk for suicide. Response rate was 11% (n = 1546). Over a range of suicide risk scenarios, few respondents reported consistently screening for firearms (21.9%) or employing LMR counseling (19.4%). When adjusting for confounding, five or more years in practice was associated with higher odds of screening for firearms (aOR 4.6 [1.3-16]). Previous LMR training was strongly associated with consistent LMR counseling (aOR 8.3 [1.8-38.4]). While LMR counseling can reduce risk for completed suicide, most respondents do not consistently employ it. Those who have received training are more likely to counsel. Thus, LMR counseling should be a standard part of medical education for pediatricians.

Access to means of suicide, occupation and the risk of suicide: a national study over 12 years of coronial data

BACKGROUND

Availability of lethal means is a significant risk factor for suicide. This study investigated whether occupations with greater access to lethal means had higher suicide rates than those without access, and further, whether this relationship differed for females versus males.

METHODS

A retrospective mortality study was conducted across the Australian population over the period 2001 to 2012. Data from the Australian Bureau of Statistics, which collects Census information on occupation for the Australian population, and the National Coroners Information System, which records information on suicide deaths, were combined. Employed suicide records were coded by occupation and work-related access to lethal means. Descriptive analysis and negative binomial regression were used to assess the relationship between access to means and suicide.

RESULTS

Persons in occupations with access to firearms, medicines or drugs, and carbon monoxide more frequently used these methods to end their lives than those without access to means. Females employed in occupations with access to means had suicide rates that were 3.02 times greater (95% CI 2.60 to 3.50, p < 0.001) than those employed in occupations without access. Males in occupations with access had suicide rates that were 1.24 times greater than those without access (95% CI 1.16 to 1.33, p < 0.001).

CONCLUSION

Work-related access to means is a risk factor for suicide in the employed population, but is associated with a greater risk for females than males. The findings of this study suggest the importance of controlling access to lethal methods in occupations where these are readily available.

Neuroimaging, Cognitive, and Neurobehavioral Outcomes Following Carbon Monoxide Poisoning

Carbon monoxide is a colorless, odorless gas produced as a byproduct of combustion. Carbon monoxide is the leading cause of poisoning injury and death worldwide. Morbidity following CO poisoning includes neurologic sequelae, neuropathologic abnormalities on brain imaging, neurobehavioral changes, and cognitive impairments. It is estimated that as high as 50% of individuals with carbon monoxide poisoning will develop neurologic, neurobehavioral, or cognitive sequelae. Carbon monoxide related cognitive impairments included impaired memory, attention, executive function, motor, visual spatial, and slow mental processing speed. Given the high rate of brain related morbidity and the fact that the majority of carbon monoxide is avoidable, awareness and prevention of carbon monoxide poisoning is warranted.

Neuropsychological Evaluation of Children and Adolescents With Acute Carbon Monoxide Poisoning

OBJECTIVES

Carbon monoxide (CO) poisoning is a worldwide health problem. We have limited information regarding psychological adversities of CO poisoning in children and adolescents. The aim of this study was (1) to investigate the effects of severe CO poisoning on cognitive functions, mood, and behaviors in children and adolescents and (2) to identify factors related to occurrence of neuropsychological symptoms.

METHODS

This study included pediatric patients, who were evaluated after CO poisoning at the Department of Child and Adolescent Psychiatry between January 2012 and April 2013. The patients were evaluated at 2 time points. The first evaluation was done when they were discharged from emergency department, and the second evaluation was done 1 month after CO poisoning. Turkish versions of internationally recognized tests were used to evaluate anxiety, depressive symptoms, attention, visual-spatial skills, memory, and behaviors of patients.

RESULTS

Twenty-seven patients were analyzed. The mean age of the patients was 11.8 ± 2.7 years (range, 6-18 years). The mean carboxyhemoglobin level was 31.5% ± 7.8% (range, 19%-51%) dir. Delayed neurological sequel was observed in only 1 patient, who had headache and tinnitus. We found that carboxyhemoglobin level was not correlated with later neuropsychiatric test scores. However, we found a correlation between history of loss of consciousness and anxiety symptom level, hyperbaric oxygen (HBO) therapy session and behavioral problems, and time to HBO therapy and attention problems.

CONCLUSIONS

We suggest that CO exposure duration, history of loss of consciousness, time to HBO therapy, and the number of HBO therapy session affect neuropsychological symptom levels and occurrence of attention and behavioral problems.

Impulsive suicide attempts: a systematic literature review of definitions, characteristics and risk factors

BACKGROUND

Extensive research on impulsive suicide attempts, but lack of agreement on the use of this term indicates the need for a systematic literature review of the area. The aim of this review was to examine definitions and likely correlates of impulsive attempts.

METHODS

A search of Medline, Psychinfo, Scopus, Proquest and Web of Knowledge databases was conducted. Additional articles were identified using the cross-referencing function of Google Scholar.

RESULTS

179 relevant papers were identified. Four different groups of research criteria used to assess suicide attempt impulsivity emerged: (a) time-related criteria, (b) absence of proximal planning/preparations, (c) presence of suicide plan in lifetime/previous year, and (d) other. Subsequent analysis used these criteria to compare results from different studies on 20 most researched hypotheses. Conclusions regarding the characteristics of impulsive attempts are more consistent than those on the risk factors specific to such attempts. No risk factors were identified that uniformly related to suicide attempt impulsivity across all criteria groups, but relationships emerged between separate criteria and specific characteristics of suicide attempters.

LIMITATIONS

Only published articles were included. Large inconsistencies in methods of the studies included in this review prevented comparison of effect sizes.

CONCLUSIONS

The vast disparities in findings on risk factors for impulsive suicide attempts among different criteria groups suggest the need to address the methodological issues in defining suicide attempt impulsivity before further research into correlates of such attempts can effectively progress. Specific recommendations are offered for necessary research.

Reducing a suicidal person's access to lethal means of suicide: a research agenda

Reducing the availability of highly lethal and commonly used suicide methods has been associated with declines in suicide rates of as much as 30%-50% in other countries. The theory and evidence underlying means restriction is outlined. Most evidence of its efficacy comes from population-level interventions and natural experiments. In the U.S., where 51% of suicides are completed with firearms and household firearm ownership is common and likely to remain so, reducing a suicidal person's access to firearms will usually be accomplished not by fiat or other legislative initiative but rather by appealing to individual decision, for example, by counseling at-risk people and their families to temporarily store household firearms away from home or otherwise making household firearms inaccessible to the at-risk person until they have recovered. Providers, gatekeepers, and gun owner groups are important partners in this work. Research is needed in a number of areas: communications research to identify effective messages and messengers for "lethal means counseling," clinical trials to identify effective interventions, translational research to ensure broad uptake of these interventions across clinical and community settings, and foundational research to better understand method choice and substitution. Approaches to suicide methods other than firearms are discussed. Means restriction is one of the few empirically based strategies to substantially reduce the number of suicide deaths.

Neuropsychiatric disorders and risk factors in carbon monoxide intoxication

Neuropsychiatric sequelae may be observed in the late phases of carbon monoxide (CO) intoxication. Establishing a link between CO-related neuropsychiatric disorders and associated risk factors may decrease morbidity and mortality by means of appropriate treatment and counseling. The aim of the present study was to determine the relationship between neuropsychiatric outcomes of CO intoxication and demographic and clinical variables. Thirty patients who presented with CO intoxication and had no known neuropsychiatric disease, and 30 healthy controls were included. Physical examinations and laboratory tests were performed. Following the 1st therapy, they underwent mental and psychiatric tests 5 times (the time of discharge, during the 1st week, and during the 1st, 3rd, and 6th months). They underwent cerebral magnetic resonance imaging (MRI) at the end of the 1st month. They were evaluated by cognitive function tests at the 6th month. Lesions relevant to CO intoxication were detected in 46.7% of the patients via cranial computed tomography and in 13.3% via MRI. Evaluation of psychiatric tests revealed a clear decrease in cognitive functions, such as immediate memory, learning, reaching the criterion, spontaneous recall, attention, visual memory, and logical memory. It was found that the patients had anxiety within the 1st month, and the frequency of anxiety reached to the value of the control group by the end of the 6th month. In conclusion, we suggested that CO intoxication might lead to neuropsychiatric disorders. Our results emphasized that in addition to standard treatment, neuropsychiatric evaluation should also be performed in patients with CO intoxication.

The spectrum of adjustment disorders: too broad to be clinically helpful

The clinical value of the current Diagnostic and Statistical Manual of Mental Disorders diagnosis of adjustment disorder is controversial. The aim of this article is to review the literature on adjustment disorder and to present suggestions for the improvement of this diagnostic category in future classification systems. The literature utilized for this review was retrieved by MEDLINE (1967 until May 2009) and was supplemented by a manual search of the literature. The analysis of the literature indicates that the diagnosis of adjustment disorder is not characterized by consistent clinical description and prognosis, adequate differentiation from other disorders, or specific psychometric and neurobiologic features. The spectrum of affective disturbances entailed by the diagnosis of adjustment disorder appears to be too broad. A major problem seems to lie in the fact that it is an exclusion diagnosis that overlaps with subthreshold manifestations of mood and anxiety disorders. More precise characterizations of stress-related disturbances are available.

Motor Vehicle Exhaust Gas Suicide

Abstract. In many motorized countries, inhalation of carbon monoxide from motor vehicle exhaust gas (MVEG) has been one of the leading methods of suicide. In some countries it remains so (e.g., Australia 16.0% of suicides in 2005). Relative to other methods it is a planned method and one often used by middle-aged males. The study provides a review of countermeasures aimed at restricting this method of suicide. The prevention measures identified were catalytic converters (introduced to reduce carbon monoxide for environmental reasons); in-cabin sensors; exhaust pipe modification; automatic idling stops; and helpline signage at suicide “hotspots.” Catalytic converters are now in 90% of new vehicles worldwide and literature supports them being associated with a reduction in exhaust-gassing suicides. There remain, however, accounts of exhaust-gas fatalities in modern vehicles, whether accidentally or by suicide. These deaths and also crashes from fatigue could potentially be prevented by in-cabin multi-gas sensors, these having been developed to the prototype stage. Helpline signage at an exhaust-gassing suicide “hotspot” had some success in reducing suicides. The evidence on method substitution and whether a reduction in MVEG suicides causes a reduction in total suicides is inconsistent.

Affective outcome following carbon monoxide poisoning: a prospective longitudinal study

OBJECTIVE

To longitudinally assess the prevalence of depression and anxiety following carbon monoxide (CO) poisoning and to assess the contributions of mode of poisoning (accidental versus suicide attempt), cognitive sequelae, and oxygen dose (hyperbaric oxygen versus normobaric oxygen) to depression and anxiety.

BACKGROUND

CO is the most common cause of poisoning in the United States and may result in neuropathologic changes and cognitive and neurologic sequelae, yet little is known regarding affective outcomes.

METHOD

We prospectively assessed affect in 127 CO-poisoned patients. Self-report inventories of depression and anxiety were administered at 6 weeks and at 6 and 12 months post CO poisoning. The primary outcome was prevalence of depression and anxiety at 6 weeks. To determine the effect of mode of poisoning, cognitive sequelae, and oxygen dose, odds ratio estimates were calculated at all three times using logistic regression.

RESULTS

Depression and anxiety were present in 45% of patients at 6 weeks, 44% at 6 months, and 43% at 12 months. Patients with suicide attempt and cognitive sequelae had higher prevalence of depression and anxiety at 6 weeks. At 12 months, there were no differences in depression or anxiety regardless of mode of poisoning, presence of cognitive sequelae, or oxygen dose.

CONCLUSIONS

CO poisoning results in significant depression and anxiety that persist to at least 12 months. Patients with cognitive sequelae and suicide attempt had a higher rate of depression and anxiety at 6 weeks but not at 12 months. Clinicians need to be aware of affective morbidity following CO poisoning and remain vigilant about CO prevention.

Adjustment disorder and the course of the suicidal process in adolescents

BACKGROUND

Adjustment disorders are often associated with suicidal behaviour but there is little information regarding the nature of the relationship and the effect of adjustment disorders on the suicidal process. The authors' goal was to investigate the association of adjustment disorders (with depressed mood) and suicide in adolescents by means of a psychological autopsy study.

METHOD

Relatives and other informants of 19 suicide victims were interviewed by means of a semi-structured interview schedule. Differences in duration of the suicidal process between suicide victims diagnosed with adjustment disorder and suicide cases diagnosed with other psychiatric disorders were examined.

RESULTS

The suicidal process was significantly shorter in suicide victims diagnosed with adjustment disorder compared with suicide cases diagnosed with other disorders. No indications of a history of emotional or behavioural problems during early adolescence were found in suicide cases diagnosed with adjustment disorder.

LIMITATIONS

The study sample consists of a small sample size and retrospective interviews of relatives were used.

CONCLUSIONS

The suicidal process in suicide victims diagnosed with adjustment disorder appears to be short and rapidly evolving without any prior indications of emotional or behavioural problems. The importance of assessing the suicidal risk in patients diagnosed with adjustment disorder is underlined.

Do means matter?: Differences in characteristics of Finnish suicide completers using different methods

It is unclear whether suicides by different methods are distinguishable by their sociodemographic or clinical characteristics. We set out to investigate whether completed suicides by different methods show disparities in their sociodemographic and clinical characteristics. Within the National Suicide Prevention Project in Finland, all 1,397 suicides occurring April 1, 1987, through March 31, 1988, were investigated using the psychological autopsy method. Disparities were found in characteristics of suicide completers using different methods. Intoxication suicides were more often female and had a history of both previous attempts and psychiatric treatment, whereas suicides by shooting were the opposite in character. Victims using vehicle exhaust gas were most frequently younger males who had experienced a recent interpersonal loss or other adverse event and committed suicide while intoxicated with alcohol. Thus, typical characteristics associate with certain suicide methods, probably due to differences in availability and acceptability of the methods. Various restrictions on the availability of suicide methods are likely to exert their possible impact on somewhat different subpopulations at risk. In terms of suicide prevention, it seems reasonable to target availability restrictions for certain identifiable groups of potential suicide attempters. For instance, carefulness in the practice of prescribing of intoxicating substances to particular psychiatric patients seems justified.

The neuropsychiatry of carbon monoxide poisoning in attempted suicide: a prospective controlled study

OBJECTIVE

There are few prospective comprehensive controlled studies of the neuropsychiatric outcome in people who attempt suicide with carbon monoxide (CO). The present study aimed to evaluate this.

METHODS

A consecutive series of 41 adults (81% men) with CO exposure presenting over 3 years, and 20 matched controls, were evaluated with instruments to assess orientation, attention, concentration, speed of information processing, verbal memory, premorbid intellect, executive function (working memory, verbal fluency and set-switching), mood disorder, psychotic disorder, alcohol dependence and obsessive-compulsive disorder, levels of depression, hopelessness, suicide intent, anxiety, neurobehavioural function and social and interpersonal functioning. At 2 months follow-up, the neuropsychological battery was extended to include further tests of executive function (including problem-solving) and memory (including visual memory),

RESULTS

At initial assessment, control subjects showed similar levels of cognitive impairment as CO-exposed subjects (except in the case of four CO subjects with very severe impairment), but were more depressed. At 2-months follow-up, the trends were generally towards improvement in all subjects, with no between-group differences.

CONCLUSIONS

Indirect effects on cognitive state may be at least as great as direct CO neurotoxicity in suicide attempters. The study did not support CO exposure exacerbating mood disorder in this sample.

Methods of youth suicide in New Zealand: trends and implications for prevention

OBJECTIVE

One commonly suggested approach to reducing suicide is to restrict access to potentially lethal means of suicide. This paper summarises recent trends in methods of suicide among young people in New Zealand and examines the feasibility of suicide prevention through restricting access to methods of suicide.

METHOD

Data derived from official mortality statistics were used to examine trends, from 1977 to 1996, in methods of suicide among young people aged 15-24 years.

RESULTS

During the last two decades, male youth suicide rates in New Zealand doubled, from 20.3 per 100,000 in 1977 to 39.5 per 100,000 in 1996. This increase was accounted for, almost entirely, by increased use of hanging (71% of total increase) and vehicle exhaust gas (26% of total increase). Suicide rates among young females also increased, from 4 per 100,000 in 1977 to 14.3 per 100,000 in 1996. As for males, the increased female suicide rate was largely accounted for by increased rates of hanging and vehicle exhaust gas.

CONCLUSIONS

The marked increases in rates of youth suicide in New Zealand during the past two decades are accounted for, almost wholly, by increases in rates of suicide by hanging and, to a lesser extent, vehicle exhaust gas. In 1996 the majority (79.7%) of youth suicides were accounted for by these two methods: hanging (61.5%) and vehicle exhaust gas (18.2%). Both methods are widely available and difficult to restrict, implying that limiting access to means of suicide is a strategy which is unlikely to play a major role in reducing suicidal behaviour among young people in New Zealand.