Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries

Stakeholder views regarding a planned primary care office-based interactive multimedia suicide prevention tool

OBJECTIVES

Nearly half of all men who die by suicide visit a primary care clinician (PCC) in the month before death, yet few disclose suicide thoughts. We solicited stakeholders' views to guide development of a tailored multimedia program to activate middle-aged men experiencing suicide thoughts to engage with PCCs.

METHODS

We conducted semi-structured interviews with 44 adults self-identifying as: suicide attempt survivor; family member/loved one of person(s) who attempted or died by suicide; PCC; non-PCC office staff; health administrator; and/or prevention advocate. We coded recorded interview transcripts and identified relevant themes using grounded theory.

RESULTS

Two thematic groupings emerged, informing program design: structure and delivery (including belief the program could be effective and desire for use of plain language and media over text); and informational and motivational content (including concerns about PCC preparedness; fear that disclosing suicide thoughts would necessitate hospitalization; and influence of male identity and masculinity, respectively, in care-seeking for and interpreting suicide thoughts).

CONCLUSION

Stakeholder input informed the design of a primary care tailored multimedia suicide prevention tool.

PRACTICE IMPLICATIONS

In revealing a previously unreported barrier to disclosing suicide thoughts to PCCs (fear of hospitalization), and underscoring known barriers, the findings may suggest additional suicide prevention approaches.

Depression and impulsiveness among soldiers who died by suicide: A psychological autopsy study

INTRODUCTION

Despite the accumulated knowledge about suicide, suicidal acts remain difficult to predict, and many suicides are acted out impulsively.

METHODS

We performed a psychological autopsy study based on inquiries about the deaths of all male soldiers aged 18-21 years who served in the Israeli army and died by suicide between 2009 and 2013 (n = 69). The study population was first divided into two groups: those who had depressive disorder (n = 31); and those who did not (n = 38). Socio-demographic characteristics of the subjects and the characteristics of the suicidal act were compared. Afterwards, the study population was re-divided by the presence or absence of impulsive personality traits (n = 22, and n = 47, respectively), and investigated for distinct suicidal behavior features.

RESULTS

No significant socio-demographic differences were found between the depressed and non-depressed suicide victims. The depressed group had showed more signs of planning the act (47% vs. 23%), and had expressed suicidal ideation in the days preceding the suicide (51.6% vs. 21%). One third of the subjects were found to have an impulsive personality trait, with significantly more histories of disciplinary issues, violence and cluster B personality disorders. Alcohol use during the act was significantly more prevalent among impulsive than non-impulsive subjects (45.4% vs. 14.9%).

CONCLUSION

Identification of distinct clinical groups of suicide victims among young males might help clinicians evaluate high risk cases, and may provide valuable opportunities to alleviate and prevent these events in the future.

Vital Signs: Trends in State Suicide Rates - United States, 1999-2016 and Circumstances Contributing to Suicide - 27 States, 2015

Introduction

Suicide rates in the United States have risen nearly 30% since 1999, and mental health conditions are one of several factors contributing to suicide. Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning.

Methods

Trends in age-adjusted suicide rates among persons aged ≥10 years, by state and sex, across six consecutive 3-year periods (1999–2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health conditions.

Results

During 1999–2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases >30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups.

Conclusions

Suicide rates increased significantly across most states during 1999–2016. Various circumstances contributed to suicides among persons with and without known mental health conditions.

Implications for Public Health Practice

States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

Risk Factors Associated With Near-Lethal Suicide Attempts During Incarceration Among Men in the Spanish Prison System

Studies conducted worldwide indicate that near-lethal suicide attempts are common among incarcerated populations. However, little research attention has been focused on the Spanish prison population. To address this gap in the literature, data were drawn from a sample of men ( N = 2,270) incarcerated in seven prisons in Spain. We compared sociodemographic, criminal/offense, health and mental health, and life events in prison variables between inmates who reported making near-lethal suicide attempts ( n = 616) and those who did not ( n = 1,654) during their current incarceration term. A series of binary and multiple logistic regression analyses indicated that a variety of variables were associated ( p values < .001) with near-lethal suicide attempts, including prior-to-prison employment status, family members in prison, recidivist in prison, childhood trauma, work status in prison, and disciplinary infractions. Our study findings are discussed in light of developing more effective strategies and prevention interventions to reduce attempted suicide in the Spanish Prison System.

The Influence of Perceived Stress and Depression on Suicide-Related Beliefs in Caucasian and Indian Adults

Abstract. Background and Aims: Suicidality research in developing countries, including India, faces logistical and cultural challenges. Technology may help address these challenges and offer data to providers treating a diverse clientele. Method: The relationship between perceived stress and suicide-related beliefs was examined in two populations: Indians in India (n = 374) and Caucasians in English-speaking countries (n = 326); the influence of depression on that relationship was also explored. The study was conducted via an Internet-based survey. Results: Three-way interactions (Ethnicity × Perceived stress × Depression status) were observed, predicting strength of the belief that suicide is a solution to problems, F(1,679) = 4.18, p < .05, and that suicide is a good option if quality of life worsens, F(1,675) = 9.53, p < .01. For both beliefs, Caucasians screening positive for depression exhibited the strongest relationship between stress and suicide-related beliefs; for Indians, that relationship was not moderated by depression status. Caucasians also exhibited a stronger association between higher stress and greater belief strength that suicide is a good option assuming a steady quality of life than did Indians, F(1,680) = 6.05, p < .05. Limitations: Participants were recruited through a depression screening website; results may not generalize to those who are uninterested in depression screening or to those who are unwilling or unable to use the internet for that purpose. Conclusion: Our findings may help to better target interventions to reduce suicidality, for example, employ stress reduction techniques for Caucasians who are depressed, and monitor suicidality for Indians reporting high stress regardless of depression.

Brain derived neurotrophic factor (BDNF) and suicidal behavior: A review of studies from Asian countries

The biological basis of suicide and suicidal behavior is actively researched. Recently, the role of Brain Derived Neurotropic Factor (BDNF) in suicidal behavior has gained attention and significant results are observed. In this review, we aimed to focus on the studies from Asian countries that have explored the role of BDNF and suicidal behavior. The review highlights the findings from these studies and discusses the possible avenues that should be explored in future studies from Asian countries to understand more on suicidal behavior and possible prevention.

Prevalence and correlates of probable depression and post-traumatic stress disorder among female sex workers in Lilongwe, Malawi

Globally, female sex workers (FSW) experience a high prevalence of mental health disorders, but in sub-Saharan Africa these are rarely identified. If left untreated, mental health disorders may place FSW and their partners at risk for HIV/sexually transmitted infections (STIs). We assessed the prevalence and correlates of probable depression, post-traumatic stress disorder (PTSD), and suicidal ideation (SI) in a cohort of 200 FSW in Lilongwe, Malawi. FSW completed the Patient Health Questionnaire-9 and the PTSD Check List-Civilian Version. The prevalence of depression was 8%, as was the prevalence of PTSD. Nearly half (49%) of FSW were experiencing mild depression. FSW were more likely to have probable depression if they completed primary school or initiated sex work before 18 years. They were more likely to have probable PTSD if they had ≥ 20 clients per week or initiated sex work before 18 years. Interventions are needed to diagnose mental health disorders among FSW at great risk for HIV/STIs.

Do Undiagnosed Suicide Decedents Have Symptoms of a Mental Disorder?

BACKGROUND

Psychological autopsy studies consistently report that the rate of detected mental disorders among suicide decedents is below 100%. This implies three possibilities: (a) a subset of suicide decedents did not have a mental disorder at the time of death; (b) all suicide decedents suffered from a mental disorder, but some were undetected due to methodological limitations; and/or (c) suicide decedents with an undetected mental disorder displayed significant and perhaps subclinical features of a mental disorder.

OBJECTIVE

In this article, we examined these possibilities by evaluating the differences in symptoms and stressors between suicide decedents who were undiagnosed and those diagnosed with a mental disorder at the time of death.

METHOD

We reviewed 130 case studies of community-based suicide decedents originally described in Robins' (1981) psychological autopsy study.

RESULTS

Without exception, suicide decedents in Robins' sample suffered either from a clearly diagnosable mental disorder or displayed features indicative of a significant, even if subclinical, presentation of a mental disorder. Undiagnosed and diagnosed suicide decedents did not significantly differ with regards to demographics, violence of suicide method, suicide attempt history, the number and intensity of stressful life events preceding death, and whether their death was a murder-suicide.

CONCLUSION

Although clearly not all who suffer from mental disorders will die by suicide, these findings imply that all who die by suicide appear to exhibit, at minimum, subclinical psychiatric symptoms with the great majority showing prominent clinical symptoms. We conclude with clinical implications and recommendations for future study.

Beyond psychopathology: A case-control psychological autopsy study of young adult males

BACKGROUND

As young Australian males are at a high risk of suicide, the identification of risk factors other than psychopathology is vital for the development of comprehensive suicide prevention measures.

AIMS

The study investigated whether there were differences in risk factors and pathways to suicide in young adult males from Queensland, Australia, with and without a diagnosable psychiatric disorder.

METHODS

A case-control, psychological autopsy method was applied using a control group of young males who had died suddenly from causes other than suicide.

RESULTS

Suicide cases without a psychiatric diagnosis more frequently displayed behaviours indicative of their suicidality (such as previous attempts, disposing of possessions and making statements of hopelessness) than controls without a diagnosis. Suicides without a diagnosis also displayed more 'difficult' personality traits, such as higher levels of neuroticism and aggression. They also experienced poorer quality of life and were significantly more likely than their controls to have experienced a recent separation from a spouse or partner.

CONCLUSION

The results of this study confirmed the existence of several distinct characteristics of young males who die by suicide in the absence of any diagnosable psychiatric disorder.

Why is depression more common among women than among men?

Women are about twice as likely as are men to develop depression during their lifetime. This Series paper summarises evidence regarding the epidemiology on gender differences in prevalence, incidence, and course of depression, and factors possibly explaining the gender gap. Gender-related subtypes of depression are suggested to exist, of which the developmental subtype has the strongest potential to contribute to the gender gap. Limited evidence exists for risk factors to be specifically linked to depression. Future research could profit from a transdiagnostic perspective, permitting the differentiation of specific susceptibilities from those predicting general psychopathologies within and across the internalising and externalising spectra. An integration of the Research Domain Criteria framework will allow examination of gender differences in core psychological functions, within the context of developmental transitions and environmental settings. Monitoring of changing socioeconomic and cultural trends in factors contributing to the gender gap will be important, as well as the influence of these trends on changes in symptom expression across psychopathologies in men and women.

The Reciprocal Relationship between Suicidality and Stigma

INTRODUCTION

Although suicidality is frequently the cause of stigma, it is conversely true that stigma may be the cause of suicidality. The present paper focuses on the complex relationships that exist between suicidal behavior and stigmatizing attitudes.

METHODS

A narrative review of the topic will be presented on the basis of the relevant literature collected from an electronic search of PubMed, ISI Web of Knowledge, and Scopus databases, using stigma, public stigma, structural stigma, perceived stigma, self-stigma, suicide, attempted suicide, and suicidality as key words.

RESULTS

A negative perception is frequently held of suicidal people, labeling them as weak and unable to cope with their problems, or selfish. Individuals who have attempted suicide are subject to similar processes of stigmatization and "social distancing"; insurance policies include an exclusion clause against death by suicide. Subjects with a direct personal experience of depression or suicide strongly endorse a feeling of self-stigma; those who have attempted suicide are often ashamed and embarrassed by their behavior and tend to hide the occurrence as much as possible. Similar processes are observed among family members of subjects who have committed suicide or made a suicide attempt, with a higher perceived stigma present in those bereaved by suicide. Perceived or internalized stigma produced by mental or physical disorders, or through belonging to a minority group, may represent a significant risk factor for suicide, being severely distressing, reducing self-esteem and acting as a barrier in help-seeking behaviors.

CONCLUSION

With the aim of preventing suicide, greater efforts should be made to combat the persisting stigmatizing attitudes displayed toward mental disorders and suicide itself. Indeed, the role of stigma as a risk factor for suicide should further motivate and spur more concerted efforts to combat public stigma and support those suffering from perceived or internalized stigma. Experts and scientific societies should form an alliance with the media in an effort to promote a marked change in the societal perception of mental health issues and suicide. As stigma may result in severe consequences, specialist care and psychological interventions should be provided to populations submitted to stigma.

Family history of suicide and interpersonal functioning in suicide attempters

Difficulties in interpersonal relationships are associated with a wide range of psychiatric diagnoses and have been reported as a trigger for suicidal behavior, too. The aim of this study was to examine the relationship between interpersonal problems and family history of suicide in suicide attempters and to describe relevant patterns of interpersonal problems in this patient group. The study involves 181 patients having their clinical follow-up after a suicide attempt. Family history of suicide was assessed by using the Karolinska Self Harm History Interview or retrieved in patient records. The Inventory of Interpersonal Problems was used to assess personal style in an interpersonal context. Suicide attempters with a family history of suicide had significantly more often an intrusive personal style. The results remained significant after adjustment for personality disorder. The specific interpersonal patterns associated with family history of suicide may interfere with the ability to create stable, long-lasting relationships. In regards to treatment, these personal qualities could cause difficulties in the alliance with health care personnel and make it harder for suicide attempters to accept or benefit from treatment. Attention to suicide attempters' interpersonal problems is of importance to lower their distress.

Psychological autopsy of seventy high school suicides: Combined qualitative/quantitative approach

OBJECTIVE

Suicide is the leading cause of death among Israeli youths but data on causes are scarce. This study used psychological autopsies of 70 Israeli school students who committed suicide during 2004-2011, attempting to determine the causes.

METHODS

Four narratives of the self were identified (qualitative analysis) and compared (quantitative analysis): (1) regressive: functioning and mood deteriorated continuously (45%); (2) tragic: doing well until rapid decline around suicidal crisis (20%); (3) unstable: peaks and crises throughout life (20%); and (4) stable: long lasting state of adverse living circumstances (15%). Functioning, mental disorders, stressful life events and substance abuse were examined.

RESULTS

A representative profile of the suicide-completer emerged. Suicidality in the tragic narrative involved shorter crisis, fewer risk factors and less psychopathology than the other narratives, also better general functioning and better school performance. Though decrease in functioning was evident in all groups, in the tragic group it tended to be disregarded.

CONCLUSION

This study presents an in-depth analysis of a unique suicide population of high school students. A combined methodology of qualitative and quantitative analyses reveals a distinct subpopulation of suicidal adolescents with little or no overt psychopathology that poses a challenge to suicide prevention strategies.

Factors Related to Suicide in LGBT Populations

Abstract. Background: There is evidence of heightened vulnerability to nonfatal suicidal behaviors among LGBT populations yet a paucity of studies into fatal behaviors. Aim: The specific aim of this article was to identify factors related to suicide in LGBT individuals in Australia. Method: The psychological autopsy (PA) method with a matched case-control study design was used. PA interviews were conducted with 27 next-of-kin of an LGBT person that had died by suicide. Three living LGBT controls per suicide case, matched by age and gender, were also interviewed. Results: The key factors relating to suicide in LGBT people were a lack of acceptance by family and self (reflected in higher internalized homophobia and shame), negative feelings about own sexuality/gender, and dissatisfaction with appearance. LGBT people who died by suicide also tended to go through coming out milestones 2 years earlier than controls. There was a higher prevalence of aggressive behaviors and a more predominant history of physical and sexual abuse. Additionally, there was greater incidence of depression and anxiety and alcohol and substance use disorders. Conclusion: Specific predictive factors for suicide in LGBT populations in Australia were identified, including significantly poorer mental health outcomes and more violence across an array of measures.

Structuring Roles and Gender Identities Within Families Explaining Suicidal Behavior in South India

BACKGROUND

This paper examines the social structures, culture, gendered roles, and their implications for suicidal behavior in South India. Exploring the cultural process within the structures of family and society to understand suicide and attempted suicide from the perspectives of survivors, mental health professionals, and traditional healers has not been achieved in the existing suicide-related research studies conducted in India to date.

AIMS

This study aimed to explore the cultural implications of attempted suicide by examining the survivors' life stories, their perceptions, and service providers' interpretations of problem situation.

METHOD

A qualitative design was used drawing on constant comparison method and thematic analysis. The analysis was underpinned by the theoretical concepts of Bourdieu's work. In-depth interviews were conducted with 15 survivors of attempted suicide, eight mental health professionals, and eight traditional healers from Southern India.

RESULTS

The study found interactions among visible and invisible fields such as faith, power, control, culture, family, religion, and social systems to have strengthened the disparities in gender and role structures within families and societies and to have impacted survivors' dispositions to situations.

CONCLUSION

The role of culture in causing suicide and attempted suicide is explained by unraveling the negative impact of interacting cultural and structural mechanisms.

The postmortem proxy-based interview--future directions

The present study aims to provide an overview of the procedural and methodological challenges that need to be addressed when determining the content and application of postmortem proxy-based interviews and recommendations for meeting these challenges in future death investigations are outlined. Preliminary interview considerations are discussed and a step-by-step procedural algorithm for applying proxy-based interview protocol is supplied. A vulnerability-stress model is used for organizing the conceptualization of risk and protective factors into domains of theoretically similar factors. Techniques to improve data collected about mental disorders and stressful life events-variables addressed in nearly all psychological autopsy studies-are suggested, and the importance of examining certain understudied constructs (e.g., psychological factors, family history, select situational factors, childhood adversity, and protective factors) is emphasized. Given the convergence of findings across postmortem proxy-based interviews, whereby extracting postmortem psychiatric diagnoses is the rule, the next generation of studies must offer a point of departure from univariate models, by studying how and why well known exposures interact to produce suicide. In practical terms, targeting specific sub-populations and high-risk individuals can serve as the basis for constructing and testing different clinical hypothesis, which in turn may yield insights into the underlying etiological heterogeneity of suicide.

Suicide Mortality Across Broad Occupational Groups in Greece: A Descriptive Study

Background

Several studies have investigated the relationship between specific occupations and suicide mortality, as suicide rates differ by profession. The aim of this study was to investigate suicide mortality ratios across broad occupational groups in Greece for both sexes in the period 2000–2009.

Methods

Data of suicide deaths were retrieved from the Hellenic Statistical Authority and comparative mortality ratios were calculated. Occupational classification was based on the International Classification of Occupations (ISCO-88) and the coding for Intentional self-harm (X60–X84) was based on the international classification of diseases (ICD-10).

Results

Male dominant occupations, mainly armed forces, skilled farmers and elementary workers, and female high-skilled occupations were seen as high risk groups for suicide in a period of 10 years. The age-productive group of 30–39 years in Greek male elementary workers and the 50–59 age-productive group of Greek professional women proved to have the most elevated number of suicide deaths.

Conclusion

Further research is needed into the work-related stressors of occupations with high suicide mortality risk and focused suicide prevention strategies should be applied within vulnerable working age populations.

Acute and Chronic Risk Preceding Suicidal Crises Among Middle-Aged Men Without Known Mental Health and/or Substance Abuse Problems: An Exploratory Mixed-Methods Analysis

BACKGROUND

Suicides among men aged 35-64 years increased by 27% between 1999 and 2013, yet little research exists to examine the nature of the suicide risk within this population. Many men do not seek help if they have mental health problems and suicides may occur in reaction to stressful circumstances.

AIMS

We examined the precipitating circumstances of 600 suicides without known mental health or substance abuse (MH/SA) problems and with a recent crisis. Whether these suicides occurred within the context of an acute crisis only or in the context of chronic circumstances was observed.

METHOD

Using data from the National Violent Death Reporting System and employing mixed-methods analysis, we examined the circumstances and context of a census of middle-aged male suicides (n = 600) in seven states between 2005 and 2010.

RESULTS

Precipitating circumstances among this group involved intimate partner problems (IPP; 58.3%), criminal/legal problems (50.7%), job/financial problems (22.5%), and health problems (13.5%). Men with IPP and criminal/legal issues were more likely than men with health and/or job/financial issues to experience suicide in the context of an acute crisis only.

CONCLUSION

Suicides occurring in reaction to an acute crisis only or in the context of acute and chronic circumstances lend themselves to opportunities for intervention. Further implications are discussed.

Suicide Among Inuit: Results From a Large, Epidemiologically Representative Follow-Back Study in Nunavut

OBJECTIVE

The Inuit population in Canada's North has suffered from high rates of death by suicide. We report on the first large-scale, controlled, epidemiologically representative study of deaths by suicide in an Indigenous population, which investigates risk factors for suicide among all Inuit across Nunavut who died by suicide during a 4-year period.

METHODS

We identified all suicides by Inuit (n = 120) that occurred between January 1, 2003, and December 31, 2006, in Nunavut. For each subject, we selected a community-matched control subject. We used proxy-based procedures and conducted structured interviews with informants to obtain life histories, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I and II diagnoses, and measures of impulsive and (or) aggressive traits.

RESULTS

Compared with control subjects, subjects who died by suicide were more likely to have experienced childhood abuse (OR 2.38; 95% CI 1.39 to 4.08), have family histories of major depressive disorder (P = 0.002) and suicide completion (P = 0.02), and have been affected by major depressive disorder (OR 13.00; 95% CI 6.20 to 27.25), alcohol dependence (OR 2.90; 95% CI 1.59 to 5.24), or cannabis dependence (OR 3.96; 95% CI 2.29 to 6.8) in the last 6 months. In addition, subjects who died by suicide were more likely to have been affected with cluster B personality disorders (OR 10.18; 95% CI 3.34 to 30.80) and had higher scores of impulsive and aggressive traits (P < 0.001).

CONCLUSIONS

At the individual level, clinical risk factors for suicide among Inuit are similar to those observed in studies with the general population, and indicate a need for improved access to mental health services. The high rate of mental health problems among control subjects suggests the need for population-level mental health promotion.

Insomnia Symptom, Mental Disorder and Suicide: A Case-Control Study in Chinese Rural Youths

Insomnia has been reported as a risk factor of suicidal behaviors, but few studies have examined the association among insomnia, mental disorder and suicide, especially among Chinese populations. In this study, we examined the effect of insomnia symptoms on completed suicide in a large sample of suicides and their controls in Chinese rural youths. Subjects were 388 consecutively recruited suicides and 416 community living controls aged 15-34 years in the rural areas of three provinces in China. Established psychological autopsy method was used for the data collection. Insomnia symptoms were assessed with sleep questions in the Hamilton Depression Rating Scale (HAMD) about insomnia, including difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS) and early morning awakening (EMA). The results showed that DIS (OR=12.01, p<0.001), DMS (OR=12.82, p<0.001) or EMA (OR=12.08, p<0.001) was significantly associated with increased risk of suicide even after mental disorder was controlled for. Our study showed that insomnia can be an independent risk factor for suicide. Mental disorders mediated the association between insomnia and suicide. Insomnia should be assessed and treated for individuals at risk of suicide.

Health and psychosocial service use among suicides without psychiatric illness

Although mental illness is a major suicide risk factor, some cases of suicide list no symptoms of mental disorder at the time of death. Studying suicides without psychiatric illness has important implications for social work because this group's service needs seem to have been overlooked. The authors of this article conducted a psychological autopsy study of 150 people who committed suicide and 150 age- and gender-matched living controls. Suicides without psychiatric illness showed similar detectable psychopathology as the suicide and living control groups with nonpsychotic psychiatric disorders. Though suicides without psychiatric disorders showed fewer warning signs that could be noticed by their informants, they experienced more negative life events than living controls. The suicide cases without psychiatric illness also seemed to be less protected by enabling factors (such as social support and employment) than living controls with and without psychiatric disorders. Furthermore, they had lower use of services than the control and deceased-with-diagnosis groups. With fewer at-risk signs and poorer enabling resources, they were undetected or unengaged by the existing physical, psychiatric, and psychosocial services. This group should be of concern to social workers, who may develop community-based health education programs and preventive services to meet this vulnerable population's psychosocial needs.

Existing and novel biological therapeutics in suicide prevention

We summarize outcomes for several pharmacologic and neurostimulatory approaches that have been considered potential treatments to reduce suicide risk, namely, by reducing suicide deaths, attempts, and ideation in various clinical populations. Available treatments include clozapine, lithium, antidepressants, antipsychotics, electroconvulsive therapy, and transcranial magnetic stimulation. The novel repurposing of ketamine as a potential suicide risk-mitigating agent in the acute setting is also discussed. Research pathways to better understand and treat suicidal ideation and behavior from a neurobiological perspective are proposed in light of this foundation of information and the limitations and challenges inherent in suicide research. Such pathways include trials of fast-acting medications, registry approaches to identify appropriate patients for trials, identification of biomarkers, neuropsychological vulnerabilities, and endophenotypes through the study of known suicide risk-mitigating agents in hope of determining mechanisms of pathophysiology and the action of protective biological interventions.

The effect of targeted and tailored patient depression engagement interventions on patient-physician discussion of suicidal thoughts: a randomized control trial

BACKGROUND

Despite improvements in the diagnosis and treatment of depression, primary care provider (PCP) discussion regarding suicidal thoughts among patients with depressive symptoms remains low.

OBJECTIVE

To determine whether a targeted depression public service announcement (PSA) video or an individually tailored interactive multimedia computer program (IMCP) leads to increased primary care provider (PCP) discussion of suicidal thoughts in patients with elevated risk for clinical depression when compared to an attention control.

DESIGN

Randomized control trial at five different healthcare systems in Northern California; two academic, two Veterans Affairs (VA), and one group-model health maintenance organization (HMO).

PARTICIPANTS

Eight-hundred sixty-seven participants, with mean age 51.7; 43.9% women, 43.4% from a racial/ethnic minority group.

INTERVENTION

The PSA was targeted to gender and socio-economic status, and designed to encourage patients to seek depression care or request information regarding depression. The IMCP was an individually tailored interactive health message designed to activate patients to discuss possible depressive symptoms. The attention control was a sleep hygiene video.

MAIN MEASURES

Clinician reported discussion of suicidal thoughts. Analyses were stratified by depressive symptom level (Patient Health Questionnaire [PHQ-9] score < 9 [mild or lower] versus ≥ 10 [at least moderate]).

KEY RESULTS

Among patients with a PHQ-9 score ≥ 10, PCP discussion of suicidal thoughts was significantly higher in the IMCP group than in the control group (adjusted odds ratio = 2.33, 95% confidence interval = 1.5, 5.10, p = 0.03). There were no significant effects of either intervention on PCP discussion of suicidal thoughts among patients with a PHQ-9 score < 9.

CONCLUSIONS

Exposure of patients with at least moderate depressive symptoms to an individually tailored intervention designed to increase patient engagement in depression care led to increased PCP discussion of suicidal thoughts.

Analysis of newspaper coverage of active aging through the lens of the 2002 World Health Organization Active Ageing Report: A Policy Framework and the 2010 Toronto Charter for Physical Activity: A Global Call for Action

As populations continue to grow older, efforts to support the process of aging well are important goals. Various synonyms are used to cover aging well, such as active aging. The World Health Organization published in 2002 the report Active Ageing: A Policy Framework that according to the call for papers, has brought active ageing to the forefront of international public health awareness. The 2010 Toronto Charter for Physical Activity: A Global Call for Action was singled out in the call for papers as a key document promoting physical activity one goal of the 2002 WHO active aging policy framework. Media are to report to the public topics of importance to them. We investigated the newspaper coverage of aging well and synonymous terms such as active aging through the lens of the 2002 WHO active aging policy framework and the 2010 Toronto Charter for Physical Activity. As sources we used the following newspapers: China Daily, The Star (Malaysia), two UK newspapers (The Guardian, The Times), a database of 300 Canadian newspapers (Canadian Newsstand) and a US newspaper (The New York Times). The study generated data answering the following four research questions: (1) how often are the 2002 WHO active aging policy framework and the 2010 Toronto Charter for Physical Activity mentioned; (2) how often is the topic of active aging and terms conveying similar content (aging well, healthy aging, natural aging and successful aging) discussed; (3) which of the issues flagged as important in the 2002 WHO active aging policy framework and the 2010 Toronto Charter for Physical Activity are covered in the newspaper coverage of active aging and synonymous terms; (4) which social groups were mentioned in the newspapers covered. The study found a total absence of mentioning of the two key documents and a low level of coverage of “active aging” and terms conveying similar content. It found further a lack of engagement with the issues raised in the two key documents and a low level of mentioning of socially disadvantages groups. We posit that reading the newspapers we covered will not expose the reader to the two key documents and the issues linked to aging well including the need to increase physical activity.

Attitudes towards suicidal behaviour in outpatient clinics among mental health professionals in Oslo

BACKGROUND

To investigate attitudes of professionals working in mental health care outpatient clinics in Child and Adolescent Psychiatry (CAP) (for children and adolescents aged 0-18 years) and District Psychiatric Centres (DPC) (for adults aged 18-67 years).

METHODS

Professionals in four outpatient units in Oslo were enrolled (n = 229: 77%). The Understanding of Suicidal Patient scale (USP) (11 = positive to 55 = negative) and Attitudes Towards Suicide questionnaire (ATTS) (1 = totally disagree to 5 = totally agree) were used to assess professionals' attitudes. Questions explored competence, religion, experiences of and views on suicidal behaviour and its treatment.

RESULTS

All the professionals indicated positive attitudes (USP 18.7) and endorsed the view that suicide was preventable (ATTS 4.3). Professionals who had received supervision or were specialists had attitudes that were more positive. Professionals in CAP were less satisfied with available treatment. Psychiatric disorders were considered the most common cause of suicidal behaviour, and psychotherapy the most appropriate form of treatment. The professionals confirmed that patients with other disorders of comparable severity are followed up more systematically.

CONCLUSIONS

The professionals showed positive attitudes with minor differences between CAP and DPC.