Availability of mental health service providers and suicide rates in Slovenia: a nationwide ecological study

The relationship between a comprehensive index of prosperity and suicide rates in former Soviet countries, including a comparison with European and Asian countries: Discussion from a new perspective

Investigations of suicide in countries of the former Soviet Union, which broke into 15 different countries in the early 1990s, require examinations of a combination of economic, social, and health factors. It is important to address these factors individually and to examine the various composite indicators for each. Moreover, it would be worthwhile to explore the potential applicability of a comprehensive worldwide index. We analyzed data from nine of the former Soviet countries for which both the annual suicide rate and the Global Competitiveness Index (GCI) were available for the years 2006-2017. We determined the precise relationships between the suicide rate and the GCI during this period in these nine countries as well as in nine countries with high suicide rates in Europe and Asia. The results indicated the following: (i) In six of the nine former Soviet countries with complete data, the suicide rate showed a relationship with the GCI. Notably, this relationship was inverse in all but one country. (ii) Among the nine European and Asian countries with high suicide rates, three exhibited a correlation between the suicide rate and the GCI. Measures to prevent suicide should be devised especially in countries of the former Soviet Union through collaboration among multiple fields and organizations, as necessary, with particular attention paid to countries with worse or worsening GCI values.

Psychiatrist density and risk of suicide: a multilevel case-control study based on a national sample in Taiwan

AIM

No previous studies, to our knowledge, have investigated the association between psychiatrist density and suicide, accounting for individual- and area-level characteristics.

METHODS

We investigated all suicide cases in 2007-2017 identified from the national cause-of-death data files, with each suicide case matched to 10 controls by age and sex and each suicide case/control assigned to one of the 355 townships across Taiwan. Our primary outcome was the odds ratio (OR) of suicide and its 95% confidence interval (CI) estimated via multilevel models, which included both individual- and area-level characteristics. Townships with no psychiatrists were compared with the quartiles of townships with psychiatrists (density per 100,000 population): quartile 1 (Q1) (0.01-3.02); quartile 2 (Q2) (3.02-7.20); quartile 3 (Q3) (7.20-13.82); and quartile 4 (Q4) (>13.82).

RESULTS

A total of 40,930 suicide cases and 409,300 age- and sex-matched controls were included. We found that increased psychiatrist density was associated with decreased suicide risk (Q1: adjusted OR [aOR], 0.95 [95% CI, 0.90-1.01]; Q2: aOR, 0.90 [95% CI, 0.85-0.96]; Q3: aOR, 0.89 [95% CI, 0.83-0.94]; Q4: aOR, 0.89 [95% CI, 0.83-0.95]) after adjusting for individual-level characteristics (employment state, monthly income, physical comorbidities, and the diagnosis of psychiatric disorders) and area socioeconomic characteristics.

CONCLUSIONS

The psychiatrist density-suicide association suggests an effect of increased availability of psychiatric services on preventing suicide. Suicide prevention strategies could usefully focus on enhancing local access to psychiatric services.

Association between mental health workforce supply and clusters of high and low rates of youth suicide: An Australian study using suicide mortality data from 2016 to 2020

OBJECTIVE

To examine the association between mental health workforce supply and spatial clusters of high versus low incidence of youth suicide.

METHODS

A cross-sectional analysis of spatial suicide clusters in young Australians (aged 10-25) from 2016 to 2020 was conducted using the scan statistic and suicide data from the National Coronial Information System. Mental health workforce was extracted from the 2020 National Health Workforce Dataset by local government areas. The Geographic Index of Relative Supply was used to estimate low and moderate-to-high mental health workforce supply for clusters characterised by a high and low incidence of suicide (termed suicide hotspots and coldspots, respectively). Univariate and multivariate logistic regression was used to determine the association between suicide clusters and a range of sociodemographic characteristics including mental health workforce supply.

RESULTS

Eight suicide hotspots and two suicide coldspots were identified. The multivariate analysis showed low mental health workforce supply was associated with increased odds of being involved in a suicide hotspot (adjusted odds ratio = 8.29; 95% confidence interval = 5.20-13.60), followed by residential remoteness (adjusted odds ratio = 2.85; 95% confidence interval = 1.68-4.89), and illicit drug consumption (adjusted odds ratio = 1.97; 1.24-3.11). Both coldspot clusters occurred in areas with moderate-to-high mental health workforce supply.

CONCLUSION

Findings highlight the potential risk and protective roles that mental health workforce supply may play in the spatial distributions of youth suicide clusters. These findings have important implications for the provision of postvention and the prevention of suicide clusters.

Suicide versus homicide firearm injury patterns on trauma systems in a study of the National Trauma Data Bank (NTDB)

Firearm related mortality in the USA surpassed all other developed countries. This study hypothesizes that injury patterns, weapon type, and mortality differ between suicide groups as opposed to homicide. The American College of Surgeons National Trauma Database was queried from January 2017 to December 2019. All firearm related injuries were included, and weapon type was abstracted. Differences between homicide and suicide groups by sex, age, race, and injury severity were compared using a Mann–Whitney test for numerical data and Fisher’s exact test for categorical data. The association between weapon type and mortality relative to suicide as opposed to homicide was assessed in Fisher’s exact tests. Significance was defined as p < 0.05. There were 100,031 homicide and 11,714 suicide subjects that met inclusion criteria. Homicides were mostly assault victims (97.6%), male (88%), African–American (62%), had less severe injury (mean (ISS) 12.07) and a median age of 20 years old (IQR: 14, 30, p < 0.01). Suicides were mostly male (83%), white (79%), had more severe injury (mean ISS 20.73), and a median age of 36 years old (IQR: 19, 54, p < 0.01). Suicide group had higher odds of head/neck (OR = 13.6) or face (OR = 5.7) injuries, with lower odds of injury to chest (OR = 0.55), abdominal or pelvic contents (OR = 0.25), extremities or pelvic girdle (OR = 0.15), or superficial soft tissue (OR = 0.32). Mortality rate was higher for suicide group (44.8%; 95% confidence interval (CI) 43.9%, 45.7%) compared to the homicide group (11.5%; 95% CI 11.3%, 11.7%). Suicide had higher mortality, more severe injuries, and more head/neck/facial injuries than homicide. Majority of suicides were with handguns.

Long-Term Rehabilitation Utilization Pattern Among Stroke Patients Under the National Health Insurance Program

OBJECTIVE

The aim of this study was to understand the frequency of patients receiving rehabilitation services at various periods after stroke and the possible medical barriers to receiving rehabilitation.

DESIGN

A retrospective cohort study was conducted using a nationally representative sample in Taiwan. A total of 14,600 stroke patients between 2005 and 2011 were included. Utilization of physical therapy or occupational therapy at different periods after stroke onset was the outcome variable. Individual and geographic characteristics were investigated to determine their effect on patients' probability of receiving rehabilitation.

RESULTS

More severe stroke or more comorbid diseases increased the odds of receiving physical therapy and occupational therapy; older age was associated with decreased odds. Notably, sex and stroke type influenced the odds of rehabilitation only in the early period. Copayment exemption lowered the odds of rehabilitation in the first 6 mos but increased the odds in later periods. Rural and suburban patients had significantly lower odds of receiving physical therapy and occupational therapy, as did patients living in areas with fewer rehabilitation therapists.

CONCLUSIONS

Besides personal factors, geographic factors such as urban-rural gaps and number of therapists were significantly associated with the utilization of post-stroke rehabilitation care. Furthermore, the influence of certain factors, such as sex, stroke type, and copayment exemption type, changed over time.

Characteristics of Korean students advised to seek psychiatric treatment before death by suicide

INTRODUCTION

Suicide is the leading cause of death among adolescents in Korea. Psychiatric disorders are well-known risk factors for suicide, but the proportion of children and adolescents who died by suicide and who had received psychiatric treatment is low. This study aims to examine how many school students who died by suicide were advised by their school to seek psychiatric treatment before their death and to characterize their clinical characteristics.

METHODS

We analyzed data collected by the Ministry of Education of Korea for all students who died by suicide between 2016 and 2020. Students were grouped according to whether or not they were advised to seek psychiatric treatment by their school-based on mental health screening and teachers' judgments. Sociodemographic characteristics (sex, educational stage, family structure, and socioeconomic status), suicide-related characteristics (place of suicide, suicide method, suicide note, previous self-harm, and previous suicide attempt), emotional and behavioral status, school life and personal, and family problems were compared between the two groups.

RESULTS

Analysis was conducted for 544 students, 110 (20.2%) of whom were advised to seek psychiatric treatment by their school before their death. This group had a higher proportion of girls; poorer attendance; higher frequency of depression, anxiety, impulsivity, and social problems; personal problems (appearance, friend-related, and mental and physical health problems); family problems (mental health problems of family, bad relationship with parents, and conflict of parents); and higher incidence of self-harm or suicide attempts (P < 0.001) than the other group.

CONCLUSION

Teachers seem to advise psychiatric treatment when mental health problems are revealed at school. It showed distinctive clinical characteristics between the two groups. Preventing suicide among students requires the attention and effort not only of schools, but also of families, communities, and mental health professionals.

Macro-level mental health system indicators and cross-national suicide rates

Background

The relationship between macro-level mental health system indicators and population suicide rates is an area of contention in the literature, necessitating an analysis of current cross-national data to document any new trend in the relationship.

Objective

This study investigated whether mental health system indicators are associated with national suicide rates.

Method

Using an ecological study design and multivariate non-parametric robust regression models, data on suicide rates and mental health system indicators of 191 countries retrieved from WHOs 2017 Mental Health Atlas were compared.

Results

Findings revealed that the average suicide mortality rate was significantly higher in high- income countries, relative to low-income countries. High-income countries are significantly more likely to have high number of mental health professionals, mental health policies and legislation, independent mental health authority and suicide prevention programs. These mental health system indicators demonstrated significant and positive association with suicide, suggesting that countries scoring high on these factors have higher odds of being categorized as high suicide risk countries.

Conclusion

The findings have several implications for policy and practice, including the need to make existing mental health systems very responsive to suicide prevention.

Association of Selected Area-Level Indicators With Suicide Mortality in Slovenian Municipalities

Background: With an average suicide rate of 20 per 100,000 in the last decade, Slovenia is above the EU average. There are considerable regional differences in suicide mortality within the country. Aim: We aimed to investigate the relationship between selected indicators at area level and the suicide rate in Slovenian municipalities. Method: Sociodemographic, socioeconomic, and (mental) health data in the years 2012-2016 were analyzed for 212 municipalities. Robust correlation and regression analyses were performed to determine the relationship between different variables and the suicide rate. Results: The suicide rate was positively associated with the percentage of male inhabitants, the high social cohesion in the neighborhood, and the number of sick leave days per capita. It was negatively related to the net income per capita, the marriage rate, the divorce rate, and the availability of professional mental healthcare services. Limitations: The small suicide frequencies within municipalities constitute a limitation of the study. Conclusion: Factors at local, municipal level can be linked to the risk of suicide. In Slovenia, neighborhood cohesion is one of the factors that should be considered when designing suicide prevention measures in a community.

The geography of suicide in older adults in Hong Kong: An ecological study

OBJECTIVES

The geography of suicide has been widely explored among the general population. However, little is known of the geographic variations in suicides among the older adults and their spatial correlates. This study aims to explore the spatial variations in the elderly suicide rates and their correlates in Hong Kong.

METHODS

Bayesian hierarchical models have been used to estimate smoothed standardized mortality ratios (2006-2015) on suicide in people aged 65 years or older in each geographic unit in Hong Kong. Their associations with the Social Vulnerability Index and the accessibility of eight types of services (ie, recreational services, rehabilitation services, food services, daily necessity services, community services, and transportation services) were further analyzed.

RESULTS

The results suggested that compared with the simple "inner-city high suicide rate and suburban low" pattern in the Western studies and the "central low suicide rate and peripheral high" pattern in the Asian studies, the spatial variations of elderly suicides in Hong Kong exhibit a much more complicated pattern. In Hong Kong, higher elderly suicide clusters were found in both the lower-density areas located in the New Territories and in some inner-city areas. The spatial variations of suicide in the older adults cannot be explained by the Social Vulnerability Index. Instead, service provision such as recreational services, daily necessity resources, and community centers played a more significant role in affecting suicides in the older adults.

CONCLUSIONS

Strengthening public services, providing more public spaces and activities, and making good use of the community resources might be key and efficient strategies in elderly suicide prevention in Hong Kong. Key points The spatial variations of elderly suicides in Hong Kong show a much more complicated pattern compared with the simple "inner-city high suicide rate and suburban low" pattern in the Western countries and the "central low suicide rate and peripheral high" pattern in some of the Asian countries. In Hong Kong, suicide rates in the city centers were not higher than the average in the city. Clusters of higher suicide rates were mainly found in the New Territories, which is somewhat disconnected from the city and, in some inner-city neighborhoods, with high-density population. The spatial variations of suicide in the older adults in Hong Kong cannot be explained by the neighborhood Social Vulnerability Index as in the existing literature. Neighborhood service provision such as recreational services, daily necessity resources, and community centers played a significant role in affecting suicides in the older adults in Hong Kong.

Suicides in Greece before and during the period of austerity by sex and age group: Relationship to unemployment and economic variables

BACKGROUND

There is disagreement on the specific mechanism through which the economic recession increased suicides in Greece. Unemployment is considered by many authors to be the determining factor but the data are inconclusive and often negative, especially concerning the temporal relationship between onset of increase in unemployment and increase in suicides AIMS: The aim of this paper was to clarify the specific role of unemployment as well as of other socioeconomic variables on specific age-by-gender groups concerning the increase in suicides.

METHODS

Data of the Hellenic Statistical Authority ELSTAT (www.

STATISTICS

gr) were analyzed with Linear Regression Analysis and Bonferroni correction for multiple testing RESULTS: Unemployment correlates with suicide rates only in males aged 20-24, 50-54 and 60-64 years (p < 0.001). Unemployment could held responsible for an additional 148 male deaths during the period 2009-2015, which accounts for 5.3% of the total (29 additional deaths per year). The changes in all the socioeconomic conditions could held responsible for 317 cases of suicide or 9.4% of total CONCLUSIONS: The results of the current study suggest that there was a 33% increase in deaths by suicide in Greece during the early years of recession (2009-2015); one third could be directly attributed to unemployment, one third to other consequences of recession while another third is of unknown origin. The effect of unemployment is specifically restricted to males at the beginning of their working career (20-24 years old) and to middle aged (45-49 and 55-59 years old).

The impact of strengthening mental health services to prevent suicidal behaviour

OBJECTIVE

Successive suicide prevention frameworks and action plans in Australia and internationally have called for improvements to mental health services and enhancement of workforce capacity. However, there is debate regarding the priorities for resource allocation and the optimal combination of mental health services to best prevent suicidal behaviour. This study investigates the potential impacts of service capacity improvements on the incidence of suicidal behaviour in the Australian context.

METHODS

A system dynamics model was developed to investigate the optimal combination of (1) secondary (acute) mental health service capacity, (2) non-secondary (non-acute) mental health service capacity and (3) resources to re-engage those lost to services on the incidence of suicidal behaviour over the period 2018-2028 for the Greater Western Sydney (Australia) population catchment. The model captured population and behavioural dynamics and mental health service referral pathways and was validated using population survey and administrative data, evidence syntheses and an expert stakeholder group.

RESULTS

Findings suggest that 28% of attempted suicide and 29% of suicides could be averted over the forecast period based on a combination of increases in (1) hospital staffing (with training in trauma-informed care), (2) non-secondary health service capacity, (3) expansion of mental health assessment capacity and (4) re-engagement of at least 45% of individuals lost to services. Reduction in the number of available psychiatric beds by 15% had no substantial impact on the incidence of attempted suicide and suicide over the forecast period.

CONCLUSION

This study suggests that more than one-quarter of suicides and attempted suicides in the Greater Western Sydney population catchment could potentially be averted with a combination of increases to hospital staffing and non-secondary (non-acute) mental health care. Reductions in tertiary care services (e.g. psychiatric hospital beds) in combination with these increases would not adversely affect subsequent incidence of suicidal behaviour.

Epidemiology of Suicide and the Psychiatric Perspective

Suicide is a worldwide phenomenon. This review is based on a literature search of the World Health Organization (WHO) databases and PubMed. According to the WHO, in 2015, about 800,000 suicides were documented worldwide, and globally 78% of all completed suicides occur in low- and middle-income countries. Overall, suicides account for 1.4% of premature deaths worldwide. Differences arise between regions and countries with respect to the age, gender, and socioeconomic status of the individual and the respective country, method of suicide, and access to health care. During the second and third decades of life, suicide is the second leading cause of death. Completed suicides are three times more common in males than females; for suicide attempts, an inverse ratio can be found. Suicide attempts are up to 30 times more common compared to suicides; they are however important predictors of repeated attempts as well as completed suicides. Overall, suicide rates vary among the sexes and across lifetimes, whereas methods differ according to countries. The most commonly used methods are hanging, self-poisoning with pesticides, and use of firearms. The majority of suicides worldwide are related to psychiatric diseases. Among those, depression, substance use, and psychosis constitute the most relevant risk factors, but also anxiety, personality-, eating- and trauma-related disorders as well as organic mental disorders significantly add to unnatural causes of death compared to the general population. Overall, the matter at hand is relatively complex and a significant amount of underreporting is likely to be present. Nevertheless, suicides can, at least partially, be prevented by restricting access to means of suicide, by training primary care physicians and health workers to identify people at risk as well as to assess and manage respective crises, provide adequate follow-up care and address the way this is reported by the media. Suicidality represents a major societal and health care problem; it thus should be given a high priority in many realms.

Attitudes within the general population towards seeking professional help in cases of mental distress

BACKGROUND

Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes.

AIM

To examine attitudes within the general population towards seeking professional help in times of mental distress.

METHODS

A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour.

RESULTS

More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes.

CONCLUSION

Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.

Antidepressant sales and regional variations of suicide mortality in Germany

Suicides account for over one million deaths per year worldwide with depression among the most important risk factors. Epidemiological research into the relationship between antidepressant utilization and suicide mortality has shown heterogeneous and contradictory results. Different methodological approaches and limitations could at least partially explain varying results. This is the first study assessing the association of suicide mortality and antidepressant sales across Germany using complex statistical approaches in order to control for possible confounding factors including spatial dependency of data. German suicide counts were analyzed on a district level (n = 402) utilizing ecological Poisson regressions within a hierarchical Bayesian framework. Due to significant spatial effects between adjacent districts spatial models were calculated in addition to a baseline non-spatial model. Models were adjusted for several confounders including socioeconomic variables, quality of psychosocial care, and depression prevalence. Separate analyses were performed for Eastern and Western Germany and for different classes of antidepressants (SSRIs and TCAs). Overall antidepressant sales were significantly negatively associated with suicide mortality in the non-spatial baseline model, while after adjusting for spatially structured and unstructured effects the association turned out to be insignificant. In sub-analyses, analogue results were found for SSRIs and TCAs separately. Suicide risk shows a distinct heterogeneous pattern with a pronounced relative risk in Southeast Germany. In conclusion, the results reflect the heterogeneous findings of previous studies on the association between suicide mortality and antidepressant sales and point to the complexity of this hypothesized link. Furthermore, the findings support tailored suicide preventive efforts within high risk areas.

Suicide in Slovenia Between 1997 and 2010

Background: With an average suicide rate of approximately 30 per 100,000, Slovenia has been regarded as a country with a high suicide rate. In the last decade, however, the suicide rate has gradually decreased to 20.3 per 100,000. Aim: To undertake an analysis of the suicide rate and its characteristics between 1997 and 2010 and to establish whether preventive activities had a significant effect on the suicide rate in the period studied. Method: Data on all 7,317 completed suicides between 1997 and 2010 were obtained from the National Mortality Database. Trends over this period were assessed separately for gender, age, method of suicide, and regional distribution. Data on implemented suicide preventive activities were assessed via regional Public Health Institutes. Results: The suicide rate declined in both genders and in all age groups, except in males aged 10–19 years. The most frequently used method in both genders was hanging. Regions with the highest suicide rate are concentrated in the eastern part of Slovenia. The suicide rate significantly decreased in six regions, but no firm association with preventive activities could be established. Conclusion: Suicide in Slovenia declined significantly during the study period. Preventive activities appear not to have had any notable effect on this decline.

Relationship of suicide rates to economic variables in Europe: 2000-2011

BACKGROUND

It is unclear whether there is a direct link between economic crises and changes in suicide rates.

AIMS

The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates.

METHOD

Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation.

RESULTS

There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged.

CONCLUSIONS

Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

Understanding the attitudes of paramedics towards suicidal patients

Introduction: Since it is almost impossible to identify every suicidal person, the timely intervention of an emergency medical team is of the most importance for preventing suicide attempts. Yet its success depends not only on timely help, but also on the treatment of the suicidal individual, the quality of which is to a large degree determined by the attitudes of the paramedics to the suicide. Hence, this article addresses the issue of how Slovenian paramedics experience suicidal patients, or in other words, what their attitudes to suicidal patients are when treating them. Methods: This study is based on a descriptive qualitative method of empirical research, in which inductive analysis has been used. To collect the empirical material, semi-structured interviews with ten paramedics were conducted between December 2012 and January 2013. Results: Despite their professional conduct in working with suicidal patients, Slovenian paramedics often experience various unpleasant emotions while treating them. Although they show understanding, the paramedics are often caught in dilemma while treating suicidal patients, especially those that refuse help or are aggressive. During the treatment, the paramedics act according to their subjective risk assessment and previous work experience, yet they lack the expertise to work with suicidal patients, particularly communication skills. Discussion and conclusion: The attitude of the participants to suicidal patients is based primarily on the emotional aspect of their work. The research showed that a negative attitude may appear, but is not permanent. It appears only in certain conditions when caring for patients who are aggressive or threaten others and when the participants have not received help from other services.