A profile of medically serious suicide attempts

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Recommandations de pratique clinique sur la prise en charge du patient adulte à présentation psychiatrique dans les structures d’urgences

De nombreux patients consultant aux urgences souffrent de pathologies psychiatriques préexistantes ou ont une symptomatologie évocatrice d’une pathologie psychiatrique. En effet, les troubles psychiatriques touchent un adulte sur quatre, et 75%des affections psychiatriques débutent avant l’âge de 25 ans. Le parcours de soins d’un patient adulte à présentation psychiatrique dans les structures d’urgences concerne de multiples intervenants. La complexité inhérente à ces patients complexes ainsi qu’à l’interdisciplinarité induite dans la prise en charge impose un cadre de prise en charge clair et consensuel. Des experts de la psychiatrie, de la gérontopsychiatrie et de la médecine d’urgence se sont réunis pour émettre ces recommandations de bonnes pratiques. Le choix de présenter des recommandations de bonnes pratiques et non des recommandations formalisées d’experts a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. À travers ces recommandations de bonnes pratiques cliniques, ils se sont attachés à décrire la prise en charge de ses patients aussi bien en préqu’en intrahospitalier. Les objectifs de ces recommandations sont de présenter les éléments indispensables à l’organisation du parcours de soins de ces patients, la gestion de l’agitation ainsi que la prise en charge pharmacologique ou non. Une partie spécifique est consacrée aux aspects réglementaires.

Negative Life Events and Suicide in the National Violent Death Reporting System

Negative life events may be a major precipitating factor for suicide and may differ across sociodemographic groups. We used data from the National Violent Death Reporting System (NVDRS) to explore whether age, gender, current mental illness, and disclosure around suicide predicted adult decedents' precipitants for suicide. Method: An NVDRS data set was used that included 58,247 adults who died by suicide between 2005 and 2010. Multivariate logistic regression was used to explore the relationship between sociodemographic characteristics and precipitating factors while controlling for the impact of other factors. Results: Age group (18-34, 35-64, or ≥ 65), sex, current mental illness, and disclosure around suicide significantly predicted various precipitants. Males were more likely than females to have most precipitating factors, particularly a criminal legal problem (odds ratio [OR]: 2.76), job problem (OR: 1.97), or financial problem (OR: 1.42). While younger decedents had more crises and intimate partner problems, middle-aged decedents had more loss of housing (OR: 1.87) and financial (OR: 1.81) and job-related (OR: 1.35) precipitants than the younger group. The odds of a physical health issue increased successively with each age group. Identified mental illness was associated most strongly with a job (OR: 1.43) or physical health problem (OR: 1.35). Individuals who disclosed suicidal ideation had a higher incidence of all precipitants. Conclusions: The precipitants to suicide appear to vary according to individuals' demographic factors, current mental illness, and disclosure of intent. Our understanding of suicide may be enhanced by exploring the causal pathway behind these relationships.

Risk Assessment of Repeated Suicide Attempts Among Youth in Saudi Arabia

Introduction

Although the incidence of suicide attempts continues to increase among youth in Saudi Arabia, no risk assessment tool has been established for suicide attempt repetition in the country's youth population. The objective of the study was to develop risk assessment of suicide attempt repetition among youth in Saudi Arabia.

Methods

This is a retrospective study of youth (10-24 years) with intentional suicide attempt(s) who presented to the emergency departments (ED) at King Abdullah Specialist Children's Hospital (KASCH) and King Abdulaziz Medical City-Riyadh (KAMC-R), Saudi Arabia between 1 January 2015 and 31 December 2017. We excluded youth having unintentional suicide attempts. Data were retrieved for the 157 eligible as having attempted suicide.

Results

Forty-one of 157 (26.1%) had repeated suicide attempts (95% confidence limits: 19.433.7%). Four independent factors were identified that were associated with an increased risk of repeated suicide attempts: age (adjusted odds ratio [aOR] = 1.147, 95% confidence interval (CI) = 11.015-1.297, P=0.028), family problems (aOR = 4.218, 95% CI = 1.690-10.528, P=0.002), psychiatric disorders (aOR = 3.497, 95% CI = 1.519-8.051, P=0.003), and hospitalization (aOR = 5.143, 95% CI = 1.421-18.610, P=0.013). This risk model showed adequate utility with an area under the receiver operating characteristic (ROC) curve (AUC): 77.9%, 95% CI: 69.486.3% with optimism-corrected AUC = 71.8%. Youden index defined a probability of ≥0.38 to predict a high risk of repeated suicide attempts.

Conclusion

The risk of repeated suicide attempts among Saudi youth was high, compatible with what has been reported among youth in England and in France. Age, family problems, psychiatric disorders, and hospitalization are risk factors for repeated suicide attempts. A prevention program for suicide attempts in youth may take into account family problems, screening for psychiatric disorders, and suicidal behavior.

Risk Factors for Serious Suicide Attempts with High Medical Severity

OBJECTIVES

his study investigated the risk factors leading to serious suicide attempts with high medical severity.

METHODS

Nine hundred and eighty-two patients who visited the emergency room after attempting suicide were divided into two groups: suicide attempters with high medical severity (25.3%) and those with low medical severity (74.7%). Demographic variables, clinical characteristics, and factors related to each suicide attempt were compared between the two groups. Multivariate logistic regression analysis was conducted to investigate risk factors for high medical severity in patients' current suicide attempts.

RESULTS

The results show that suicide attempters with high medical severity had more severe depression and psychological disturbances such as agitation, intense emotions, and self-reproach. Suicide attempters with high medical severity also had more serious risk factors for suicide such as repetitive/intense/continuous thoughts of suicide, suicidal planning, and a stronger wish to die. School/work problems and physical illnesses were related to high medical severity with more lethal methods. Logistic regression demonstrated that school/work problems, total risk rating, severity of suicidal ideation, and agitation were risks for more serious suicide attempts, whereas more frequent lifetime suicide attempts were a protective factor.

CONCLUSION

This study demonstrates that suicide attempters with high medical severity had more severe psychopathologies and risk factors related to suicidal behavior than those with low medical severity.

Impulsivity and Impulsivity-Related Endophenotypes in Suicidal Patients with Substance Use Disorders: an Exploratory Study

Suicidal behavior (SB) is a major problem in patients with substance use disorders (SUDs). However, little is known about specific SB risk factors in this population, and pathogenetic hypotheses are difficult to disentangle. This study investigated some SB and SUD-related endophenotypes, such as impulsivity, aggression, trait anger, and risk-taking behaviors (RTBs), in forty-eight patients with SUDs in relation to lifetime history of suicide attempts (SAs). Disorders related to alcohol, cannabis, cocaine, opiates, and hallucinogenic drugs were included. Lifetime SAs was significantly associated with both higher impulsivity and higher aggression, but not with trait anger. A higher number of RTBs were associated with lifetime SAs and higher impulsivity, but not with aggression and trait anger. Assessing these endophenotypes could refine clinical SB risk evaluation in SUDs patients by detecting higher-risk subgroups. An important limitation of this study is exiguity of its sample size. Its primary contribution is inclusion of all SUD types.

Psychological Inflexibility Predicts of Suicidal Ideation Over Time in Veterans of the Conflicts in Iraq and Afghanistan

Psychological inflexibility, or how individuals respond to distressing internal experiences, may be a modifiable risk factor for suicide in veterans. It was hypothesized that psychological inflexibility would predict suicidal ideation after accounting for established risk factors at baseline and 1 year later. Post-9/11 veterans (N = 309) completed clinical interview and self-report measures at baseline and 1-year follow-up. Results indicated that psychological inflexibility predicted severity of suicidal ideation at both baseline and 1 year later, after accounting for established risk factors. Psychological inflexibility is an important marker of risk for suicidal ideation, and could be a target for interventions aimed at reducing suicide.

Serious Suicide Attempts: Systematic Review of Psychological Risk Factors

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Serious Suicide Attempts

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Prevalence of suicide attempters in emergency departments in Japan: a systematic review and meta-analysis

BACKGROUND

The number of hospital admissions related to suicide attempts is increasing worldwide. The Emergency Department (ED) is recognized in Japan as an opportunity to intervene with suicide attempters however, the prevalence of suicide attempters in the ED is unknown. Therefore, a meta-analysis was conducted to provide this information.

METHODS

We conducted searches of databases (PubMed, PsycINFO, CINAHL, ICHUSHI, CiNii) to identify studies about suicide attempters in the ED in Japan. A meta-analysis was used to calculate the pooled prevalence proportion of suicide attempters in the ED, and their prevalence proportion of psychiatric disorder and method of suicide in suicide attempters.

RESULTS

The search of Japanese studies identified 3338 records, of which 70 were included in the meta-analysis. A total of 25 studies reported the psychiatric diagnosis and 62 studies reported the method of suicide. The pooled prevalence proportion of suicide attempters was 4.7%. Mood disorders were the most frequent psychiatric disorders (ICD: 30%, DSM: 35%), and poisoning was the most frequent method of attempting suicide (52%).

LIMITATIONS

There might be a publication bias because only published studies were included. There also might be an information bias, such as reporting bias or misclassification, because most of studies included in the analysis used retrospective designs.

CONCLUSIONS

The results provide clear evidence of the prevalence of suicide attempters in the ED in Japan. The results indicate that suicide attempters in the ED have a higher proportion of mood disorders, and that the most common method of suicide is poisoning.

Risk stratification using data from electronic medical records better predicts suicide risks than clinician assessments

BACKGROUND

To date, our ability to accurately identify patients at high risk from suicidal behaviour, and thus to target interventions, has been fairly limited. This study examined a large pool of factors that are potentially associated with suicide risk from the comprehensive electronic medical record (EMR) and to derive a predictive model for 1-6 month risk.

METHODS

7,399 patients undergoing suicide risk assessment were followed up for 180 days. The dataset was divided into a derivation and validation cohorts of 4,911 and 2,488 respectively. Clinicians used an 18-point checklist of known risk factors to divide patients into low, medium, or high risk. Their predictive ability was compared with a risk stratification model derived from the EMR data. The model was based on the continuation-ratio ordinal regression method coupled with lasso (which stands for least absolute shrinkage and selection operator).

RESULTS

In the year prior to suicide assessment, 66.8% of patients attended the emergency department (ED) and 41.8% had at least one hospital admission. Administrative and demographic data, along with information on prior self-harm episodes, as well as mental and physical health diagnoses were predictive of high-risk suicidal behaviour. Clinicians using the 18-point checklist were relatively poor in predicting patients at high-risk in 3 months (AUC 0.58, 95% CIs: 0.50 - 0.66). The model derived EMR was superior (AUC 0.79, 95% CIs: 0.72 - 0.84). At specificity of 0.72 (95% CIs: 0.70-0.73) the EMR model had sensitivity of 0.70 (95% CIs: 0.56-0.83).

CONCLUSION

Predictive models applied to data from the EMR could improve risk stratification of patients presenting with potential suicidal behaviour. The predictive factors include known risks for suicide, but also other information relating to general health and health service utilisation.

Psychiatric disorders in patients presenting to hospital following self-harm: a systematic review

BACKGROUND

Psychiatric disorders occur in approximately 90% of individuals dying by suicide. The prevalence of psychiatric disorders in people who engage in non-fatal self-harm has received less attention.

METHOD

Systematic review using electronic databases (Embase, PsychINFO and Medline) for English language publications of studies in which psychiatric disorders have been assessed using research or clinical diagnostic schedules in self-harm patients of all ages presenting to general hospitals, followed by meta-analyses using random effects methods.

RESULTS

A total of 50 studies from 24 countries were identified. Psychiatric (Axis I) disorders were identified in 83.9% (95% CI 74.7-91.3%) of adults and 81.2% (95% CI 60.9-95.5%) of adolescents and young persons. The most frequent disorders were depression, anxiety and alcohol misuse, and additionally attention deficit hyperactivity disorder (ADHD) and conduct disorder in younger patients. Personality (Axis II) disorders were found in 27.5% (95% CI 17.6-38.7%) of adult patients. Psychiatric disorders were somewhat more common in patients in Western (89.6%, 95% CI 83.0-94.7%) than non-Western countries (70.6%, 95% CI 50.1-87.6%).

LIMITATIONS

Heterogeneity between study results was generally high. There were differences between studies in identification of study participants and diagnostic procedures.

CONCLUSIONS

Most self-harm patients have psychiatric disorders, as found in people dying by suicide. Depression and anxiety disorders are particularly common, together with ADHD and conduct disorder in adolescents. Psychosocial assessment and aftercare of self-harm patients should include careful screening for such disorders and appropriate therapeutic interventions. Longitudinal studies of the progress of these disorders are required.

Pathways to high-lethality suicide attempts in individuals with borderline personality disorder

The purpose of this study was to develop and test a model of high-lethality suicide attempts (HLSA) in individuals with Borderline Personality Disorder (BPD). An increased number of prior suicide attempts, substance use immediately prior to the attempt, and objective planning were proposed to lead directly to a HLSA, while aggression and impulsivity were hypothesized to lead indirectly to a HLSA through their associations with prior attempts. Path analysis revealed a revised model in which impulsivity was found to be significantly associated with both the lethality of the most recent attempt and the number of prior attempts. These results are discussed in terms of trait and crescendo models of suicidal behavior and their implications for suicide risk assessment among individuals with BPD.

Suicide risk factors and suicide vulnerability in various major psychiatric disorders

PRIMARY OBJECTIVES

There are many known suicide risk factors (SRF) common to major psychiatric disorders, but their impact on suicide vulnerability remains unclear. We used FALCON (Fuzzy Adaptive Learning Control Network) to evaluate those impacts.

METHODS

Staff psychiatrists completed computerized suicide risk scales (CSRS-III) including 21 SRF for 612 patients. Diagnoses were: schizophrenia, schizoaffective, major depression, anxiety disorder, bipolar affective disorder, personality disorder, organic brain syndromes, delusional disorder and other diagnoses. An optimal trained FALCON was obtained by running the network 10 times with 552 CSRS-III, validating with the balance. Medically serious suicide attempts (the vulnerability factor) served as the target variable. The significance of each variable in the trained network was determined by the magnitude of the change in output as affected by the consecutive change in all points of the variable input, then calculating the mean variance of all cases. The direction of influence was determined by the input on the entire scale of each variable, point by point, across all cases, then calculating the mean of all outputs.

RESULTS

The impact and direction of influence of the various SRF differed for each diagnosis.

CONCLUSION

Evaluation of the individual patient with his/her specific impact profile, determination of direction of influence of the corresponding SRF's may assist in increasing the accuracy of individual suicide risk assessment.

Addiction and suicidal behavior in acute psychiatric inpatients

OBJECTIVE

This study aims to evaluate the relationship of alcohol/drug use and effect severities to the degree of suicidality in acutely admitted psychiatric patients. Both degree of substance dependency and degree of substance-induced syndrome were analyzed. In addition, length of stay, involuntary status, and against medical advice discharge status were determined as they related to these variables.

METHODS

Structured clinical admissions and discharge ratings were gathered from 10,667 consecutive, single-case individual records, from an urban acute care county psychiatric hospital.

RESULTS

Data indicate that of the most severely suicidal group, 56% had substance abuse or dependence, 40% were rated as having half or more of their admission syndrome substance induced, and most had nonpsychotic diagnoses. There was an inverse relationship between degree of substance problem and length of stay. Although these patients more commonly left against medical advice, and were readmitted more frequently, they were less likely to be involuntarily committed.

CONCLUSIONS

A large, potentially lethal, and highly expensive subgroup of patients has been characterized, which might be called the "New Revolving Door acute psychiatric inpatient." This group, which uses the most expensive level of care in the mental health system but is substantially addiction related, poses special challenges for inpatient psychiatric units, addiction treatment providers, and health care planners.

The impact of rural residence on medically serious medicinal self-poisonings

OBJECTIVE

Suicide rates are often high in rural areas. Despite the strong association between deliberate self-harm (DSH) and suicide, few have studied rural residence and DSH. Self-poisonings dominate DSH hospital presentations. We investigate a previously reported association between rural residence and medical severity (defined as a subsequent medical/surgical inpatient stay) among emergency department presentations for medicinal self-poisoning (SP) to determine whether differences in agents taken, mental health service use or hospital-level resources explain the relationship.

METHOD

A cohort of n=16,294 12-64-year olds presenting with SP to hospital emergency departments in Ontario, Canada, in 2001/2002 was linked to their service records over time.

RESULTS

The rural-medical severity association was best explained by differences in hospital resources; presenting to hospitals providing inpatient psychiatric services appeared to reduce medical/surgical inpatient stays in favor of psychiatric ones. Among those with a recent psychiatric admission, more intensive ambulatory psychiatric contact may be protective of a psychiatric inpatient stay subsequent to the SP presentation. Compared to nonrural residents, deliberate intent was identified less often in rural residents, particularly males.

CONCLUSIONS

The rural-medical severity association was best explained by disparities in the delivery systems serving rural and nonrural residents, important to rural suicide prevention efforts.

Headache complaints and the risk of suicidal thoughts or behaviors

The association between severe headaches and suicidal thoughts or behaviors is generally attributed to underlying depression, but it is plausible that severe headaches can lead to suicidal thoughts/behaviors, independent of the effects of psychiatric conditions. This association has been observed in only 1 previous study. Our multivariate analysis examined the longitudinal association between severe headaches and development of suicidal thoughts/behaviors over a period of 1 to 2 years among 6832 community-dwelling adults interviewed during the Epidemiologic Catchment Area Study. Severe headaches were significantly associated with developing suicidal thoughts/behaviors after adjusting for psychiatric diagnoses and demographics [adjusted odds ratio (ORa) = 1.48; 95% confidence interval (CI) = 1.04, 2.11], or additionally adjusting for interaction between anxiety and depression (ORa = 1.52; 95% CI = 1.07, 2.16). These results suggest that individuals with severe headaches should be screened for suicidal thoughts/behaviors, irrespective of the presence of a psychiatric condition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Substance-induced suicidal admissions to an acute psychiatric service: Characteristics and outcomes

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients.

Depressive symptoms in women experiencing intimate partner violence

The study was a cross-sectional examination of African American women positive for intimate partner violence (IPV) who presented to the medical or psychiatric emergency department (ED) for treatment. African American women with a recent history of IPV who presented following an attempted suicide (n = 100) were compared to demographically comparable African American women who were IPV positive who had not attempted suicide and presented for treatment of another condition(n= 100). Women completed face-to-face interviews on several measures, including demographics and the Beck Depression Inventory-II (BDI-II). Overall, there were no demographic differences between cases and controls. Attempters reported statistically significant higher scores on all 21 BDI-II items than did nonattempters. Four BDI-II items had effect size values in the medium range: sadness, self-dislike, suicidal thoughts, and feelings of worthlessness. These four items can be used as a brief screen in the ED to detect female patients positive for IPV at increased risk for suicidal behavior.

Childhood abuse, mental healthcare utilization, self-harm behavior, and multiple psychiatric diagnoses among inpatients with and without a borderline diagnosis

Although borderline personality disorder (BPD) has defined diagnostic criteria, a number of other clinical features are associated with this diagnosis. These features may include childhood histories of abuse (eg, sexual, physical, and emotional abuse; the witnessing of violence), high mental healthcare utilization, self-harm behavior, and polysymptomatic presentations that result in multiple Axis I diagnoses. Although each of these variables has been described in the empirical literature, only 1 other study has explored all 4 of these variables in a single study population--the Collaborative Longitudinal Personality Disorders Study. Using clinical diagnoses and self-report surveys, we explored these variables among psychiatric inpatients in a community hospital. We found that, compared with patients with no BPD, those with BPD reported significantly more types of childhood trauma, higher utilization of particular mental health services (ie, number of times and days of hospitalization for mental health or substance abuse, number of psychiatrists and therapists ever seen, number of courses of psychotherapy treatment), and a higher number of self-harm behaviors. Although not significant, there were positive trends for the remaining variables. The authors discuss the implications of these findings as they relate to patients with BPD.

Fuzzy logic detection of medically serious suicide attempt records in major psychiatric disorders

Clinical prediction of suicide is a complicated task. The focus for improved suicide risk detection is on the subgroup of individuals whose high suicide risk remains unrecognized by clinicians. We sought to evaluate the accuracy of Fuzzy Adaptive Learning Control Network (FALCON) neural networks, a nonlinear algorithm, in identification of this subgroup. The study sample included the Computerized Scale for risk of Suicide, including 21 suicide risk factors (including the target variable) drawn from 987 patient records, completed by staff clinicians during face-to-face interviews of hospitalized patients. FALCON evaluated all records in two steps: a) 612 for training and 375 for validation, and b) 887 for training and 100 for validation. The existence of previous medically serious suicide attempts (MSSAs) was chosen as the target variable because it is generally recognized as the strongest suicide risk factor. Sensitivity, specificity, and unknown answers among MSSA and non-MSSA were as follows: 612/375 FALCON, 91%, 85%, 11%, 15%; 887/100 FALCON, 94%, 82%, 20%, 14.5%, respectively. Trained FALCON, a nonlinear neural network, achieves respectable accuracy in detecting MSSA patients based on 20 suicide risk factors. Trained FALCON may therefore assist in identification of subgroup of individuals who remain unrecognized by clinicians and contribute to prevention of suicide.

Predictors of suicidal behavior in a sample of Turkish suicide attempters

In a Turkish sample, 100 suicide attempters, were compared with 60 healthy controls on measures of hopelessness, depression, and suicidal ideation. Suicide attempters were more depressive, more hopeless, and displayed greater suicidal ideation than healthy controls. Depression severity rather than hopelessness correlated with suicidal intent. Suicide lethality was independent of depression severity, hopelessness, and suicidal ideation and intent, suggesting that lethality is likely due to chance.

Factors associated with the medical severity of suicide attempts in youths and young adults

This study examined factors associated with the medical severity of suicide attempts focusing on demographic characteristics, mental health characteristics, and the circumstances of the suicide attempt. Analyses were based on 153 nearly lethal suicide attempters and 47 less lethal suicide attempters aged 13-34 years who presented to emergency departments in Houston, Texas. The results show that young age was significantly associated with a nearly lethal suicide attempt. Prior suicide attempts, hopelessness, depression, and help-seeking (ever) were significantly and negatively associated with a nearly lethal suicide attempt. None of the suicide attempt factors occurring prior to the attempt were associated with a nearly lethal suicide attempt.

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

The series of articles in this special issue of SLTB from the Centers for Disease Control and Prevention (CDC) study of nearly lethal suicide attempts represents an important contribution to research on suicidal behavior. The investigative approach used is attractive, yet also challenging in terms of research methodology. In this commentary I take the opportunity to highlight certain aspects of this line of research as well as to comment on the specific findings of the CDC study and their relationship to existing knowledge. I also discuss the future potential for this research approach and further questions that might be addressed by it.

Validation of the Computerized Suicide Risk Scale--a backpropagation neural network instrument (CSRS-BP)

BACKGROUND

Medically serious suicide attempts have been recognized as the most important predictor of suicide. The Computerized Suicide Risk Scale based on backpropagation neural networks (CSRS-BP) has been recently found efficient in the detection of records of patients who performed medically serious suicide attempts (MSSA). OBJECTIVES. To validate the CSRS-BP by: 1) using the CSRS-BP with patients instead of records; 2) comparing the ability of expert psychiatrists to detect MSSA, using the CSRS checklist; and 3) comparing the results of the Risk Estimator for Suicide (RES) and the self-rating Suicide Risk Scale (SRS) with the CSRS-BP.

METHODS

Two hundred fifty psychiatric inpatients (35 MSSA and 215 non-MSSA) were diagnosed by clinicians using the SCID DSM-IV. Three expert psychiatrists completed the CSRS checklist, and the RES for each patient, and the patients completed the self-report SRS assessment scale. The CSRS-BP was run for each patient. Five other expert psychiatrists assessed the CSRS checklists and estimated the probability of MSSA for each patient. Comparisons of sensitivity and specificity rates between CSRS-BP, assessment scales and experts were done.

RESULTS

Initially, the CSRS-BP, RES, SRS, and experts performed poorly. Although sensitivity and specificity rates significantly improved (two to four times) after the inclusion of information regarding the number of previous suicide attempts in the input data set, results still remained insignificant.

CONCLUSIONS

The CSRS-BP, which was very successful in the detection of MSSA patient records, failed to detect MSSA patients in face-to-face interviews. Information regarding previous suicide attempts is an important MSSA predictor, but remains insufficient for the detection of MSSA in individual patients. The detection rate of the SRS and RES scales was also poor and could therefore not identify MSSA patients or be used to validate the CSRS-BP.

Clinical Evaluation of Prior Suicide Attempts and Suicide Risk in Psychiatric Inpatients

Summary: Background: In practice psychiatrists rely on their own experience and intuition to evaluate the suicide potential of individual patients, but the algorithms for the decision-making process remain unclear. Objectives: (1) to establish models for the decision making process for evaluating suicide risk; (2) to simulate the impact of information concerning the number of previous suicide attempts on the clinician's ability to detect patients who performed medically serious suicide attempts (MSSAs). Methods: Four decision models (linear, dichotomized, hyperbolic, and undifferentiated) depicting the influence of the number of previous suicide attempts on the clinician's recognition of MSSAs in 250 psychiatric inpatients were elicited and tested by a series of discriminant analyses. Results: The dichotomized model (“all or none”) was found to be the most efficient in detecting medically serious suicide attempts. Conclusion: The “all or none” paradigm seems to be the most appropriate way to evaluate the weight of previous suicide attempts in the decision-making process identifying medically serious suicide attempt patients.

A review of 300 attempted strangulation cases Part II: clinical evaluation of the surviving victim

Medical literature describing victims who survive strangulation is scant. The majority of articles on strangulation are found in the forensic literature, describing the post-mortem findings on autopsy. This article presents a suggested protocol for the evaluation and treatment of the surviving victim of strangulation, based upon a review of the available literature. It also corroborates the findings of Strack et al., in the study by the San Diego City Attorney's Office, described in Part I of this series.

The Rorschach Suicide Constellation: assessing various degrees of lethality

In this article we examine the relation between the Rorschach Comprehensive System's Suicide Constellation (S-CON; Exner, 1993; Exner & Wiley, 1977) and lethality of suicide attempts during the course of patients' hospitalization at the Austen Riggs Center (Stockbridge, MA). Patient records were rated as nonsuicidal (n = 37), parasuicidal (n = 37), or near-lethal (n = 30) based on the presence and lethality of self-destructive acts. Diagnostic efficiency statistics utilizing a cutoff score of 7 or more positive indicators successfully predicted which patients would engage in near-lethal suicidal activity relative to parasuicidal patients (overall correct classification rate [OCC] = .79), nonsuicidal inpatients (OCC = .79), and college students (OCC = .89). Although these predictions were influenced by relatively high base rates in the hospital population (14.5%), base rate estimates were calculated for other hypothetical populations revealing different prediction estimates that should be considered when judging the relative efficacy of the S-CON. Logistic regression analysis revealed that an S-CON score of 7 or more was the sole predictor of near-lethal suicide attempts among 9 psychiatric and demographic variables.

Bipolar disorder with comorbid substance abuse: diagnosis, prognosis, and treatment

Alcohol and drug abuse occur frequently in individuals with bipolar disorder, but clinicians may often feel ill-prepared to identify such multi-diagnosis syndromes, to contextualize drug abuse alongside affective symptoms, and to formulate appropriate treatment strategies. Plausible explanations for high comorbidity rates between bipolar illness and substance use disorders are complex and likely embrace numerous factors that extend beyond simple, older theories about drug use as sheer "self-medication." Evidence from epidemiologic, family-genetic, pharmacologic, psychosocial, and clinical psychopathology studies suggest that a majority of bipolar patients are at risk for developing lifetime drug or alcohol-related problems, which may in turn contribute to more varied and complex clinical presentations, accelerated relapses, worsening of depressive features, poorer lithium response, functional disability, and elevated suicide risk. In this article, the author reviews essential concepts about the phenomenology and treatment outcome of bipolar illness with substance use comorbidities and offers a systematic approach to the diagnosis and management of patients with such dual diagnoses.

The association of suicide attempts and comorbid depression and substance abuse in psychiatric consultation patients

Substance abuse has been associated with attempted suicide and suicide. Few studies have examined the prevalence and associations of combined depression and substance abuse in suicide attempters. A chart review study of 1136 adult general hospital patients referred for psychiatric consultation between 1995 and 1998 was conducted to assess this further. Among 371 cases with self-harm, 311 (84%) attempted suicide. Suicide attempters were younger and diagnosed more often with comorbid substance abuse than patients without self-harm. Depressive disorders were found in 59% and substance abuse disorders in 46%. Comorbid depression and substance abuse was the most frequent category in suicide attempters, i.e., in 37%. Self-reported suicide intent was associated with increasing age, male gender, and comorbid depression and substance abuse. The suicide rate in suicide attempters was 322 per 100,000 patient-years, and 131 per 100,000 in consultation patients without self-harm. It is concluded that comorbid depression and substance abuse is associated with attempted suicide in psychiatric consultation patients. Suicide attempters should be thoroughly assessed for substance abuse. The increased suicide rate in psychiatric consultation patients with and without suicide attempts warrants further research.

Victimization of women and its impact on assessment and treatment in the psychiatric emergency setting

An understanding of victimization is critical to the practice of emergency psychiatry. Victimization histories are disturbingly common among women presenting to the PES, particularly among frequent service users. The sequelae of victimization are both psychological and physical and often impair health and functioning across numerous domains. PTSD, BPD, and substance-use disorders are often seen among women with victimization histories, which can be particularly challenging for PES providers. Screening for trauma on PES presentation or history should not be overlooked in any person, including severely mentally ill, homeless, disabled, or elderly women. PES clinicians should remember to ask about victimization and pose questions privately in a direct and an open-ended format while conveying empathic validation. Clinical assessment of women with victimization histories in the PES should be guided by the principles of standard emergency psychiatry and be informed by an understanding of trauma. This includes a working knowledge of trauma dynamics, adherence to sound professional boundaries, and care not to retraumatize patients or re-enact perpetrator-victim dynamics. Voyeurism and regression should be avoided, particularly when eliciting trauma history. The PES should be a place for screening and acute intervention, not for conducting intensive trauma therapy. In the PES, the focus should remain on triage and treatment priorities, those of safety and stabilization, and carefully evaluating for substance use and psychosis. The PES ideally provides a "holding environment" that affords a balance of nurturing, limits, consistency, and communication. A basic knowledge of cognitive-behavioral interventions affording "crisis survival strategies," such as DBT, can be particularly useful to PES clinicians. Clinicians also need to monitor issues of countertransference and the potential to be dismissive to these women with complex, comorbid, and chronic problems and diseases. The role for the use of psychotropic medication in PES cohorts with victimization histories should target acute symptoms. Involving regular providers of these decisions is advised to coordinate care and minimize splitting and risks of polypharmacy. Although the SSRIs are effective in symptom management of disorders related to victimization, patients must be reminded of the side-effect profile, particularly sexual dysfunction and withdrawal and discontinuation syndromes.

How to spot illicit drug abuse in your patients

Illicit drug abuse continues to become more widespread, especially in teenagers. Therefore, it is important for physicians to recognize the signs and symptoms of abuse in their patients. Drug abuse should be considered in differential diagnosis of many physical and nearly all psychiatric complaints. An understanding of the pharmacologic mechanisms and adverse effects of illicit drugs can enhance overall care of patients who abuse drugs. The primary classes of drugs of abuse--cannabinoids, opiates, stimulants, hallucinogens, and inhalants--produce clinically diverse presentations. By recognizing these unique signs and symptoms, physicians can differentiate between drug-induced conditions any psychiatric illness.

Backpropagation and adaptive resonance theory in predicting suicidal risk

The ability of backpropagation and adaptive resonance theory (ART) neural networks to predict the probability of complete suicide, within a two year span, in major psychiatric patients was investigated. Variables associated with suicide risk were collected from the files of 161 hospitalized psychiatric patients with a 10 year or greater history of illness. 84 patients were hospitalized due to suicide attempts and 77 had no previous suicide attempts or ideations. Suicide attempts were rated as medically serious suicide attempts (MSSA) or non-MSSA and used for training the systems. The ability of the neural networks was evaluated by screening the extremes of the suicidal spectrum (1) 54 records of patients who committed suicide and (2) 150 records of patients who never had suicidal thoughts. The records were taken from 3 hospitals, in various geographic regions in Israel. Neither neural network system is reliable in predicting suicide, however, records from one hospital, Gehah Hospital, were better identified than those from the two other hospitals (p < 0.05 for PPV; p < 0.01 for specificity). At present, neural networks are not reliable instruments for evaluating suicidal risk due to the significant number of false positive results. When low risk was indicated reliability was greater (NPV = 75.28%, specificity = 97.10% with ART; NPV = 91.76%, specificity = 95.12% with backpropagation). However, PPV, NPV and specificity rates of both systems achieved with Gehah Hospital records suggest that using a direct-subjective questionnaire may produce better results in the future. ART and backpropagation performed similarly in all measurements.