Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland

Substance use disorders as risk factors for suicide in an Eastern and a Central European city (Tallinn and Frankfurt/Main)

Cultural and regional differences on the well-known elevated suicide risk in substance use disorders have not been clarified yet. Therefore, the suicide risk associated with substance use disorders in a society of transition and in a socially and economically stable society should be identified and compared. Data from two population-based matched case-control studies were used to analyse the association between alcohol and other substance consumption and the risk of suicide. Data in Frankfurt were obtained by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) in 163 suicides that occurred in 1999 and 2000, and data from Tallinn were collected according to DSM-IV criteria on 156 deceased persons who committed suicide in 1999 by using the psychological autopsy method and in each city in matched population-based control persons by personal interview. In both cities, substance use disorders were significantly associated with suicide. Odds ratios for suicide were higher in Tallinn than in Frankfurt. The highest risk was observed in Tallinn among men with alcohol use disorders, aged 35 to 59 years. Although substance use and, in particular, alcohol use disorders were confirmed as risk factors for suicide in Tallinn and in Frankfurt, the much higher suicide risk associated with alcoholism in Tallinn than in Frankfurt indicates the importance of cultural, socio-political, and regional impact of suicide risk in alcoholism.

Smoking differently modifies suicide risk of affective disorders, substance use disorders, and social factors

BACKGROUND

Although an association between smoking and suicide has repeatedly been shown, information about a modifying influence of smoking on other risk factors for suicide is lacking.

METHODS

Axis I and Axis II disorders, sociodemographic factors, and tobacco use were assessed by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) in 163 suicides (mean age 49.6+/-19.3 years; 64.4% men;) by psychological autopsy method and by personal interview in 396 living population-based control persons (mean age 51.6+/-17.0 years; 55.8% men).

RESULTS

Smoking status (current smokers, lifetime non-smokers, and former smokers) differently modifies the effects of psychiatric disorders and sociodemographic variables on suicide risk. Former and current smoking modified suicide risk associated with affective disorders, but only current smoking increased suicide risk for substance use disorders. Ex-smokers with affective disorders, particularly with major depression, had less increased suicide risk than current smokers and non-smokers with affective disorders. Estimated suicide risks for personality disorders and 'no professional training' were strongly increased by smoking.

LIMITATIONS

Due to the small size of some of the subgroups, confidence intervals are wide. Therefore, precise risk estimation is not possible.

CONCLUSIONS

Clinicians should interpret smoking as an indicator of increased risk of suicide for individuals with substance use disorders, personality disorders, and adverse social factors. Further studies are needed to investigate the effects of smoking cessation on suicide risk of patients with psychiatric disorders such as major depression and substance use disorders.

Substance use disorders and risk for completed suicide

Substance use disorders are among the most frequent psychiatric disorders found in suicides. In psychological autopsy studies between 19% and 63% of all suicides suffered from substance use disorders, mostly from alcohol use disorders. Suicide risk is highly increased in substance use disorders, particularly in alcohol use disorders, and in co-morbid alcoholism and depression. So far, some risk factors for suicide have been identified in alcoholism. Nevertheless, various questions about the relationship between substance use disorders and suicide remain open, which indicate directions for future research.

Suicide attempts by poisoning in Hanoi, Vietnam: methods used, mental problems, and history of mental health care

The objective of this paper was to investigate methods of poisoning, presence of mental problems, and the rate of psychiatric care among suicide attempters in Vietnam. Three hundred and nine suicide attempters by poisoning admitted to Bach Mai Hospital's Poison Control Center were investigated by trained nurses and qualified psychiatrists. Standardized questionnaires were used to assess methods of suicide, presence of mental problems, and psychiatric care. The most common methods were poisoning by psychotropic drugs in urban, and pesticides in rural areas. ICD-10 confirmed disorders were present in 68% of the cases and 73% rated positive on SRQ-20. Most patients were not in contact with psychiatric care. Restrictions on availability and handling of drugs and pesticides should be reinforced. Better infrastructures are needed for identification and treatment of persons with mental disorders.

Irish coroners' attitudes towards suicide and its prevention

BACKGROUND

Coroners routinely enquire into suicide deaths and communicate with people bereaved by suicide. However, no research has been conducted into coroners' attitudes towards suicide and its prevention.

AIMS

We assessed attitudes towards suicide among Irish coroners in order to determine their understanding of suicide and its prevention.

METHODS

An internationally validated questionnaire assessing attitudes towards suicide was sent to all coroners in the Republic of Ireland and Northern Ireland.

RESULTS

Sixty completed questionnaires (response 62%) were analysed. Overall, the coroners' responses reflected openness towards communication about suicide and suicide prevention initiatives. Approximately, one in five favoured the attitudes that suicide is a right or that it may be a justifiable resolution. Only 23% agreed that people who die by suicide are usually mentally ill.

CONCLUSIONS

Irish coroners favour communication about suicide and have a positive attitude towards its prevention but they appear to underestimate the prevalence of mental illness.

Suicidality in a sample of Arctic households

We investigated the association of suicidal ideation and behavior with depression, anxiety, and alcohol abuse in a Canadian Arctic Inuit community. Inuit (N = 111) from a random sample of households completed assessments of anxiety and depression, alcohol abuse, and suicidality. High rates of suicidal ideation within the past week (43.6%), and suicide attempts within last 6 months (30%), were reported. Ideation was more frequent among younger persons, whereas those favoring local native language were less likely to report a wish to die. Higher overall suicidality scores were associated with higher anxiety, and alcohol abuse, but not with depression or gender. Implications for future research are discussed.

Admission to intensive care for parasuicide by self-poisoning: variation by time cycles, climate and the lunar cycle

The aim of this study was to characterize patients after self-poisoning with suicidal intent regarding age, sex and type of substances ingested, as well as to identify temporal variations of attempted suicides and associations with climate variables and the lunar cycle. During the years 2002-2004, a total of 691 patients were admitted for self-poisoning parasuicides. The male to female ratio was 1:1.65 with mean ages of 39 and 37 years, respectively. Benzodiazepines and antidepressants were the most frequently taken substances. A significant variation with the time of the day with a peak before midnight was observed for both sexes. Variation with the day of the week was less clear and showed a peak incidence for parasuicides on Mondays. There was no significant variation with the monthly or annual cycle. The frequency of parasuicides was associated with "bad weather" (precipitation). No association of parasuicide incidences to the lunar cycle was observed.

Temperament and character of suicide attempters

Temperamental features are strongly associated with suicidal behaviors both in general population and clinical samples. In the present study we considered the association between personality traits, measured by Temperament and Character Inventory (TCI), and suicidal behavior. We analyzed five samples: a German control sample of 1148 healthy individuals; 144 German suicide attempters affected by Mood (n=101), Schizophrenia spectrum (n=20) and Borderline Personality (n=23) Disorders; 46 Italian suicide attempters affected by Mood Disorders (UP=15; BP=31); 76 German non-suicide Mood Disorder patients; 147 Italian non-suicide Mood Disorder patients. Suicide attempters showed higher scores in Harm Avoidance (HA) and lower scores in Self-Directedness (SD) and Cooperativeness (C), when compared to controls. Nevertheless, comparing the German and the Italian suicide attempter groups with the non-suicide Mood Disorder patient groups, no differences were detected. This could be due to the effect of Mood Disorder on personality. In conclusion, the present study reveals the difficulty to disentangle the personality profile of suicide attempters from their psychopathology. Those findings may be useful for cautions in further dissecting this complex phenotype.

Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies

The purpose of the present review is to evaluate the effects of common risk factors for suicide by meta-analyses using data extracted from studies based on the psychological autopsy method. We focused on five common risk factors of suicide: substance-related disorders, mood disorders, adverse marital status, adverse employment status, and self-harm behaviors. A total of 24 articles were identified from MEDLINE in which the crude odds ratio (OR) could be calculated for the above five risk factors through 30 April 2007, using such search keywords as "suicide," "psychological autopsy," and "case-control study." Overall, both substance-related disorders [OR = 5.24; 95% confidence interval (CI) = 3.30-8.31] and mood disorders [OR = 13.42; 95% CI = 8.05-22.37] were strongly associated with suicidal risk. Suicidal attempt and deliberate self-harm, which can directly lead to completed suicide, have been shown to be very strongly associated with suicidal risk [OR = 16.33; 95% CI = 7.51-35.52]. Effects of social factors such as adverse marital and employment status were relatively small. As substance-related disorders and mood disorders were strongly associated with an increased risk of completed suicide, the comorbidity of these two disorders should be paid a maximum attention. The effective prevention of suicide depends on whether we can successfully incorporate these personal factors as well as social factors into an adequate multi-factorial model.

Familial transmission of suicidal behavior

Adoption and twin studies show that familial transmission of suicidal behavior is partly attributable to genetic factors. Transmission of suicidal behavior is mediated by transmission of impulsive aggression or neuroticism and neurocognitive deficits. The most plausible explanations for nongenetic familial transmission are the intergenerational transmission of abuse and adverse familial environments. Bereavement and relationship disruption contribute to suicidal risk via the development of complicated grief, although long-term effects may be mediated by a complex chain of interrelated events. Imitation may contribute to suicidal risk, at least in attempted suicide. However, so-called family environmental factors often are related to risk factors that are heritable. Conversely, genetic factors exert their impact on depression and suicidal behavior via interaction with a stressful environment.

Inter-regional variations in men's attitudes, suicide rates and sociodemographics in Quebec (Canada)

BACKGROUND

Suicide rates can vary quite considerably and attitudes regarding suicide may explain part of the variation.

METHOD

The present study investigated, across the 17 regions of Quebec (Canada), men's attitudes towards suicide, expressing pain and help seeking, as they are related to suicide rates and sociodemographic variables (unemployment, divorce/separation, income and education).

RESULTS

Most correlations were non-significant. However, in regions with an above-average educational level and with higher divorce/separation rates, men had better attitudes towards expressing pain. Furthermore, in regions where men were more inclined to express pain, suicide rates were lower. Also, significant positive correlations were found between suicide rates and low educational level, but also between an increase in suicide rates and an increase in income level.

CONCLUSIONS

Where the aetiology of suicide is concerned, researchers must examine both sociodemographic factors and the psychological factors associated with them.

Psychological autopsy study of suicide in three rural and semi-rural districts of Sri Lanka

BACKGROUND

Knowledge concerning the epidemiology of suicide in Sri Lanka is limited despite its suicide rates being amongst the highest in the world.

AIM

To examine the characteristics of a large sample of Sri Lankan suicides to inform approaches to prevention.

METHOD

Psychological autopsy study of suicides occurring in three rural districts of Sri Lanka during August-October 1997.

RESULTS

Interviews were conducted with contacts of 372 (74%) of the 499 suicides that occurred over the study period. Males accounted for 79% of the deaths. Twenty-one percent of male and 57% of female suicides were aged <25 years of age. Pesticide self-poisoning accounted for 259 (70%) of the deaths. Almost two-thirds (62%) of the deaths occurred in hospital and 95 (26%) had made previous suicidal gestures. 138 (37%) were moderately or severely depressed and 144 (49%) of male suicides, but only 2 (2.5%) of the females, were alcohol dependent. Illegally brewed alcohol (kasippu) was the main product used by two thirds (62%) of problem drinkers. There was a family history of suicide in 20% of cases.

CONCLUSION

Pesticide self-poisoning accounts for over two thirds of suicides in rural Sri Lanka. Suicide prevention efforts in Sri Lanka should focus on restricting access to pesticides, improving the medical management of pesticide poisoning, reducing alcohol misuse-particularly targeting the supply of illegal alcohol-and improving the identification and aftercare of people who self-harm.

Prospective study on suicidal ideation among Japanese undergraduate students: correlation with stressful life events, depression, and depressogenic cognitive patterns

The present study examines the effects of stressful life events, depression, and depressogenic cognitive patterns on suicidal ideation in 500 Japanese undergraduate students. The above factors were assessed at baseline (T1) and two weeks later (T3). At T1, structural equation modeling confirmed that (1) cognitive patterns and depression, but not stressful life events, influence suicidal ideation, and (2) cognitive patterns also influence suicidal ideation through depression. These findings were confirmed in a longitudinal analysis. The results suggest that the effects of stressful life events on suicidal ideation are indirect and are mediated by depressogenic cognitive styles and depressed mood.

Unemployment and Suicidal Behavior in a New Zealand Birth Cohort

Abstract. This study examined the association between exposure to unemployment and suicidal behaviors (suicidal ideation and attempted suicide) in a birth cohort of New Zealand young adults using fixed-effects logistic and Poisson regression models. Data were gathered on unemployment and suicidal behaviors at annual periods from ages 16-25 years. At all ages increasing exposure to unemployment was associated with increased risks of suicidal ideation (p < .0001) and number of suicide attempts (p < .0001). Following adjustment for fixed effects and time-dynamic covariates, associations between unemployment and suicidal ideation reduced to marginal significance (p < .10), while the association between unemployment and suicide attempts was not statistically significant (p > .10). After adjustment, those experiencing 6 or more months of unemployment in a given year had odds of suicidal ideation that were 1.43 (95% CI: .96 to 2.16) times higher, and rates of suicide attempts that were 1.72 (95% CI: .89 to 3.32) times higher, than those who were not exposed to unemployment. Although unemployment was associated with moderate increases in risks of suicidal behaviors, much of this association was explained by confounding factors.

Cluster C personality disorders in major depressive episodes: the relationship between hostility and suicidal behavior

There is some evidence for an association between Cluster C Personality Disorders (CCPD) and suicidal behavior. We compared depressed inpatients with and without CCPD in terms of suicidal behavior and associated psychopathology. Cluster A or B personality disorder co-morbidity were exclusion criteria for both groups (cases and controls). Depressed inpatients with "pure" CCPD had higher levels of suicidal ideation but not more previous suicide attempts compared with patients without CCPD. Greater suicidal ideation in depressed patients with CCPD in our study was associated with more hostility. Future studies examining the relationship between suicidal ideation and hostility in CCPD may clarify whether treatment focused on hostility might be of use for decreasing suicidal ideation in depressed patients with CCPD (Spitzer, Williams, Gibbon et al., 1990).

Duloxetine: meta-analyses of suicidal behaviors and ideation in clinical trials for major depressive disorder

BACKGROUND

Uncertainty regarding relationships of antidepressant treatment and suicidality encouraged systematic review of data on suicidal behaviors and ideation from Phase II and III clinical trials of duloxetine for major depressive disorder (MDD).

METHODS

We evaluated all completed duloxetine trials in MDD with data lock by February 2, 2004. We compared incidence of suicide-related events with duloxetine versus placebo in controlled trials, using Mantel-Haenszel incidence difference (MHID) and exposure time-adjusted rate difference (MHRD) methods, and analyzed changes in Hamilton Depression Scale (HAMD) Item-3 (suicidality) scores.

RESULTS

There were no significant differences in the incidence of suicide-related events with duloxetine versus placebo in 12 placebo-controlled trials (duloxetine, 1812; placebo, 1184 [corrected] patients). The MHID for suicide-related behaviors was -0.03% (95% confidence interval [CI], -0.48 to 0.42) and MHRD -0.002 (95% CI, -0.02 to 0.02). Changes in HAMD Item-3 suicidality scores showed more improvement with duloxetine (MHID, 9.56%; 95% CI, 4.50 to 14.6; P < 0.001) and less worsening of suicidal ideation with duloxetine (MHID, -4.25%; 95% CI, -6.55 to -1.95; P < 0.001). Other Item-3 findings showed no consistent pattern; a slightly higher proportion of duloxetine-treated patients with a change from 0 (absent) to 3 was balanced against a higher proportion of placebo-treated patients changing from 0 to 2.

CONCLUSIONS

We found no evidence of an increased risk of suicidal behaviors or ideation during treatment with duloxetine compared with placebo in MDD patients. HAMD Item-3 suicidality scores had more improvement and less worsening of suicidal ideation with duloxetine than placebo.

Depression among heroin users: 12-Month outcomes from the Australian Treatment Outcome Study (ATOS)

A cohort comprising 495 heroin users were interviewed for the Australian Treatment Outcome Study and were re-interviewed at 12-month follow-up. The rate of current major depression declined significantly from 26% to 11% for the follow-up period. Those with current major depression on follow-up experienced fewer total days in treatment, but engaged in more treatment episodes. In comparison to those without depression, depressed individuals had less exposure to methadone/buprenorphine maintenance and residential rehabilitation for the follow-up period, but spent more time in detoxification. Those with current major depression on follow-up also reported heavier heroin and other drug use, more risk-taking behaviors, poorer physical health, and greater psychopathology than those without a diagnosis of current major depression. Although caution in interpreting these relationships is advised given the potential for confounding by client characteristics, the findings of this study illustrate the need to consider depression in the treatment of heroin dependence.

Critical issues in psychological autopsy studies

This paper reviews research based on the psychological autopsy (PA) method applied to the study of suicide. It evidences the presence of a number of methodological problems. Shortcomings concern sampling biases in the selection of control subjects, confounding influences of extraneous variables, and reliability of the assessment instruments. The absence of homogeneity among studies in the procedure employed, as well as the lack of defined guidelines for performing this type of inquiry are emphasized. Questions needing empirical investigation in the future are pointed out. It is concluded that the validity and reliability of findings emerging from the use of this method of investigation would benefit from a standardization of its application.

Alcohol dependence and suicidal behavior: from research to clinical challenges

Epidemiological and clinical data suggest high rates of suicidal behavior in alcohol-dependent individuals. Suicide attempters are likely to be young, to be single or separated, and to have made prior attempts. They differ from non-attempters by higher levels of impulsive aggression, drug use, and psychiatric comorbidity, particularly personality and depressive disorders. Treatment-seeking, alcohol-dependent individuals often present with multiple risk factors. Early recognition of suicidal behavior is hindered, however, by insufficient data regarding the acute phenomenology of imminent risk. Similarly, little research is available to guide intervention efforts. Initial trials support the use of fluoxetine for the treatment of suicidal, alcohol-dependent persons with comorbid depressive disorders. Future studies may clarify the relative efficacy of various psychotherapeutic and pharmacological approaches to treating these patients.

THE ASSOCIATION BETWEEN ALCOHOL MISUSE AND SUICIDAL BEHAVIOUR

AIMS

Despite recent small reductions in overall suicide rates, rates among those aged 25-44 have remained high. The aim of this paper was to examine the evidence for a link between alcohol misuse/consumption and suicidal behaviour, explore the reasons for this association, and consider the implications for reducing rates of suicidal behaviour.

METHODS

A medline search was performed to find relevant research evidence.

RESULTS

There is evidence to suggest alcohol misuse predisposes to suicidal behaviour through its depressogenic effects and promotion of adverse life events, and both behaviours may share a common genetic predisposition. Acute alcohol use can also precipitate suicidal behaviours through induction of negative affect and impairment of problem-solving skills, as well as aggravation of impulsive personality traits, possibly through effects on serotonergic neurotransmission.

CONCLUSIONS

Effective interventions for problem drinking may help reduce suicide rates. At a public health level, reducing overall alcohol consumption may be beneficial, and the measures shown to be most effective in this regard are those that aim to restrict availability of alcohol.

Psychiatric comorbidity may not predict suicide during and after hospitalization. A nested case-control study with blinded raters

BACKGROUND

To investigate the differential impact of DSM-IV axis-I and axis-II disorders on completed suicide and to study if psychiatric comorbidity increases the risk of suicide in currently and previously hospitalized psychiatric patients.

METHODS

A nested case-control design based on case notes from 136 suicides and 166 matched controls. All cases and controls were rediagnosed using the SCID-CV for axis-I and the DSM-IV criteria for axis-II disorders and the inter-rater reliability was satisfactory. Raters were blind to the case and control status and the original hospital diagnoses.

RESULTS

Depressive disorders and bipolar disorders were associated with an increased risk of suicide. No such effect was found for comorbidity between axis-I disorders and for comorbidity between axis-I and axis-II disorders.

LIMITATIONS

Psychiatric diagnoses, although made using a structured and criteria-based approach, was based on information recorded in case notes. Axis-II comorbidity could only be investigated at an aggregated level.

CONCLUSIONS

Psychiatric comorbidity did not predict suicide in this sample. Mood disorders did, however, increase the risk significantly independent of history of previous suicide attempts. Both findings can inform identification and treatment of patients at high risk for completed suicide.

Predisposing and Precipitating Factors for Suicide Among Alcoholics: Empirical Review and Conceptual Integration

Alcohol dependence is a potent risk factor for suicide. Accordingly, alcoholics should be targeted in suicide prevention efforts. This article reviews the literature on suicide among alcoholics and provides a model that may inform research, clinical work, and prevention efforts. In this model, we propose that aggression/impulsivity, severe alcoholism, negative affect, and hopelessness are key predisposing factors for suicide among alcoholics. We propose that major depressive episodes and stressful life events, particularly interpersonal difficulties, are key precipitating factors. We also integrate these constructs in a model that proposes that many acts of suicide among alcoholics may be viewed as acts of reactive aggression executed in the midst of distress over a lost or threatened relationship. Empirical evidence for the model is discussed along with its limitations. The next generation of research on alcoholism and suicide should include a focus on the interpersonal anlage of suicide in this population.

The economic burden of depression in the US: societal and patient perspectives

Depression imposes significant costs on sufferers, their families and care-givers, employers and insurance payers. This article summarises medical and health economics literature regarding the societal economic burden of depression and the incremental economic burden of depression sufferers in comparison with non-depressed counterparts. This substantial knowledge base probably underestimates the true economic burden of the disease because the available data and analysis techniques do not capture all of the subtle costs of this condition. Future investigation is likely to focus on the relationship between depression and comorbid conditions, the role of caregiver burdens, and the economic differences in life outcomes.

Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review

OBJECTIVE

Involvement of personality traits in susceptibility to suicidality has been the subject of research since the 1950s. Because of the diversity of conceptual and methodological approaches, the extent of their independent contribution has been difficult to establish. Here, we review conceptual background and empirical evidence investigating roles of traits in suicidal behaviors.

METHOD

We selected original studies published in English in MEDLINE and PsycINFO databases, focusing on suicidal ideation, suicide attempts, or suicide completions, and using standardized personality measures.

RESULTS

Most studies focused on investigating risk for suicide attempts. Hopelessness, neuroticism, and extroversion hold the most promise in relation to risk screening across all three suicidal behaviors. More research is needed regarding aggression, impulsivity, anger, irritability, hostility, and anxiety.

CONCLUSION

Selected personality traits may be useful markers of suicide risk. Future research needs to establish their contributions in relation to environmental and genetic variation in different gender, age, and ethnocultural groups.

Axis I disorders and personality disorders as risk factors for suicide

There is a lack of psychological autopsy studies assessing the influence of axis I disorders on axis II disorders as risk factors for suicide. Therefore, we investigated the association between personality disorders, axis I disorders, and suicide. Psychiatric disorders were evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) in 163 completed suicides (mean age 49.6 +/- 19.3 years; 64.4% men) and by personal interview in 396 population-based control persons (mean age 51.6 +/- 17.0 years; 55.8% men). In both genders, suicides significantly more often had personality disorders of all clusters than controls, also after adjustment for axis I disorders (p < 0.001, each). In addition, alcohol-related disorders, major depression, and co-occurrence of personality disorders of more than one cluster (men: OR = 16.13; women: OR = 20.43) remained independent predictors for suicide in both genders, "pure" cluster B personality disorders only in women and "pure" cluster C personality disorders only in men. In both genders, co-occurrence of personality disorders of more than one cluster contributed to risk of completed suicide after control for axis I psychiatric disorders and has to be considered as an independent risk factor for suicide.

Recent life events and suicide: a case-control study in Tallinn and Frankfurt

The purpose of this study was to analyze the differences in the disposition and frequency of recent life events preceding suicide in two cities with different socio-political backgrounds: Tallinn in Estonia and Frankfurt/Main in Germany. The information about 156 suicidents in Tallinn and 163 suicidents in Frankfurt was compiled using the psychological autopsy technique [Shneidman, E. S. (1981). The psychological autopsy. Suicide and Life-Threatening Behavior, 11, 325-340; Jacobs, D., & Klein-Benheim, M. (1995). The psychological autopsy: A useful tool for determining proximate causation in suicide cases. Bulletin of American Academy of Psychiatry Law, 23(2), 165-182]. General population controls were matched by age and sex. The occurrence of recent life events was similar among suicidents in Tallinn (81%) and Frankfurt (77%). However, in both sites only male suicides had higher risk of occurrence of any life event than controls (Tallinn: OR'=1.9; 95% CI=1.1-3.7; Frankfurt: OR'=2.0; 95% CI=1.0-4.1) and the mean number of life events was significantly higher among male suicidents in Tallinn in comparison with controls. This may indicate that males are more sensitive to the rapid changes in a society undergoing transition. It seems that it is not the number of life events, but rather their meaning and disposition that creates the risk of suicide. Family discord (weighted OR=4.5; 95% CI=2.5-8.1), loss of job (weighted OR=2.6; 95% CI=1.0-6.4) and financial deterioration (weighted OR=2.2; 95% CI=1.3-3.8) were more prevalent among suicides in Tallinn in comparison with those in Frankfurt. The most significant differences between suicides and controls were family discord, separation and loss of job in Tallinn and somatic illness in Frankfurt. These differences between the two societies, post-Soviet Estonia and Germany, could be explained by the different positions of Estonia and Germany on the survival/self-expression dimensions recorded by the World Value Survey. People in Estonia tend to emphasize economic and physical security above all other goals, and feel threatened by the changes taking place in society. In Germany, good health is considered a necessity for a consumer and self-expressive style of life, and poor health is perceived as a serious threat to the quality of life in a post-materialistic value system.

Suicide in developing countries (2): risk factors

The majority of studies on risk factors for suicide have been conducted in developed countries, and less work has been done to systematically profile risk factors in developing countries. The current paper presents a selective review of sociodemographic, clinical, and environmental/situational risk factors in developing countries. Taken together, the evidence suggests that the profiles of risk factors in developing countries demonstrate some differences from those in developed countries. In some developing countries, at least, being female, living in a rural area, and holding religious beliefs that sanction suicide may be of more relevance to suicide risk than these factors are in developed countries. Conversely, being single or having a history of mental illness may be of less relevance. Risk factors that appear to be universal include youth or old age, low socioeconomic standing, substance use, and previous suicide attempts. Recent stressful life events play a role in both developing and developed countries, although their nature may differ (e.g., social change may have more of an influence in the former). Likewise, access to means heightens risk in both, but the specific means may vary (e.g., access to pesticides is of more relevance in developing countries). These findings have clear implications for suicide prevention, suggesting that preventive efforts that have shown promise in developed countries may need to be tailored differently to address the risk factor profile of developing countries.

Alcohol consumption and suicide

About 90% of people in Western countries use alcohol at some time in their lives, and 40% experience temporary or permanent alcohol-related impairment in some area of life as a result of drinking. Multiple sociocultural and environmental factors influence suicide rates, and thus studies conducted in one nation are not always applicable to other nations. Impulsivity and aggression are strongly implicated in suicidal behaviour. Constructs related to aggression and impulsivity confer additional risk for suicidal behaviour in people with alcohol dependence. Lower serotonin activity is tied to increased aggression/impulsivity, which in turn may enhance the probability of suicidal behaviour. Acute alcohol use is associated with suicide. Suicide completers have high rates of positive blood alcohol. Intoxicated people are more likely to attempt suicide using more lethal methods. Alcohol may be important in suicides among individuals with no previous psychiatric history. Alcohol dependence is an important risk factor for suicidal behaviour. Mood disorder is a more powerful risk factor for suicide among problem drinkers as age increases. All individuals with alcohol use disorders should be assessed for suicide, especially at the end of a binge or in the very early phase of withdrawal. Middle-age and older men with alcohol dependence and mood disorders are at particularly high risk.

Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the National Comorbidity Survey

Definitions and classification schemes for suicide attempts vary widely among studies, introducing conceptual, methodological, and clinical problems. We tested the importance of the intent to die criterion by comparing self-injurers with intent to die, suicide attempters, and those who self-injured not to die but to communicate with others, suicide gesturers, using data from the National Comorbidity Survey (n = 5,877). Suicide attempters (prevalence = 2.7%) differed from suicide gesturers (prevalence = 1.9%) and were characterized by male gender, fewer years of education, residence in the southern and western United States; psychiatric diagnoses including depressive, impulsive, and aggressive symptoms; comorbidity; and history of multiple physical and sexual assaults. It is possible and useful to distinguish between self-injurers on the basis of intent to die.

Suicide in Batman, southeastern Turkey

The southeastern part of Turkey has comparatively high female suicide rates. We aimed to research social, economic, cultural, and psychiatric reasons of suicides in Batman in a case-controlled psychological autopsy study comparing suicides with matched community controls. The female suicide rate was 9.3 per 100.000 and the female/male ratio was 1.72/1. The suicides most frequently occurred in young females, mean age 20.7. The most frequent method (45%) was hanging. The most frequent stressful life events were health problems and family disruption. High suicide rates among females may be related to negative social status of females living in the region.

Family genetic studies, suicide, and suicidal behavior

The extant adoption, twin, and family studies of suicide and suicidal behavior are reviewed. Suicidal behavior is highly familial, and on the basis of twin and adoption studies, heritable as well. Both completed and attempted suicide form part of the clinical phenotype that is familially transmitted, as rates of suicide attempt are elevated in the family members of suicide completers, and completion rates are elevated in the family members of attempters. A family history of suicidal behavior is associated with suicidal behavior in the proband, even after adjusting for presence of psychiatric disorders in the proband and family, indicating transmission of attempt that is distinct from family transmission of psychiatric disorder. Impulsive aggression in probands and family members is associated with family loading for suicidal behavior, and may contribute to familial transmission of suicidal behavior. Shared environment effects such as abuse, imitation, or transmission of psychopathology are other possible explanations.

Suicidal behavior prevention: WHO perspectives on research

Suicide has been identified as a serious public health problem which is receiving increasing attention. Whereas a large number of Member States of the World Health Organization (WHO) reports on suicide mortality, no systematic national data on attempted suicide exist. Having recognized the need for comparable information about attempted suicide across different countries and cultures, WHO's Multisite Intervention Study on Suicidal Behaviors is presented.

Attempted suicide among heroin users: 12-month outcomes from the Australian Treatment Outcome Study (ATOS)

A cohort of 495 heroin users, recruited for the Australian Treatment Outcome Study (ATOS), were re-interviewed at 12 months regarding suicide attempts over the follow-up period. The proportion who had attempted suicide in the 12 months since baseline was not significantly different from that reported in the 12 months preceding ATOS enrolment (12.2% versus 9.1%), and attempted suicide did not decline significantly in any of the index treatment groups. Among males, there was no significant reduction in attempted suicide (8.7% versus 8.1%). Among females, however, the proportion reporting an attempt declined significantly from 19.7 to 9.8%. Of those who reported suicidal ideation at baseline, 22.8% made an attempt over the follow-up period, as did 19.0% of those who had major depression. Large, and significant, declines in suicidal ideation (23.1% versus 6.9%) and major depression (25.5% versus 10.9%) occurred over the study period. Independent predictors of a suicide attempt over the follow-up period were: social isolation, having made an attempt in the preceding 12 months, suicidal ideation at baseline, a greater number of treatment episodes and higher levels of baseline polydrug use.

Personality as a mediator of demographic risk factors for suicide attempts in a community sample

The aim of this study was to determine whether personality might partially explain associations between sociodemographic factors and self-reported suicide attempts. This analysis was motivated by reports that certain personality traits are logical targets for intervention, whereas sociodemographic characteristics are not generally modifiable. Data were from a postal survey sent to community residents who were previously selected at random (N = 912). Age, gender, health-insurance status, education, self-reported health, and marital history were identified as relevant sociodemographic predictors of having made one or more lifetime suicide attempts. Risk associated with each of these variables was mediated by the personality traits of self-directedness (SD) and harm avoidance (HA). In a multiple logistic-regression analysis constrained to sociodemographic predictors, only young age, female sex, poor self-reported health, and Medicaid status remained as predictors of suicide attempts. When personality factors were added to the model, all of the sociodemographic predictors except Medicaid status were rendered nonsignificant or marginally significant. Risk associated with gender was primarily related to HA, risk associated with poor self-reported health was mediated by both HA and SD, and the risk associated with young age was primarily mediated by SD; the last was the largest mediation effect observed. In contrast, risk associated with receipt of Medicaid, presumed to indicate low socioeconomic status, was not mediated by personality. We conclude that risk associated with certain nonmodifiable demographic factors is often mediated by potentially modifiable intrapersonal factors, such as SD.

Psychiatric and characterological factors relevant to excess mortality in a long-term cohort of prostitute women

We previously reported on the causes of death in a 30-year open cohort of 1,969 prostitute women. Excess mortality was mostly accounted for by homicide, suicide, drug and alcohol toxicity, and AIDS, with AIDS deaths occurring in prostitutes identified as injecting drug users. Presently, we examine observed mortality trends in light of the literature on personality and psychopathological characteristics reported for prostitute women, and with reports linking such personality characteristics to excess mortality. We observed consistency between the observed pattern of mortality in prostitute women and mortality that would be expected in a sample of persons at high risk for antisocial and borderline personality disorder.

Detection of alcohol consumption in suicides

Screening instruments for detection of alcohol consumption, abuse, and dependence for use in psychological autopsy studies with case control design are not validated. Therefore, interrater and test-retest reliability of the Luebeck Alcohol Dependence and Abuse Screening Test (LAST) and the usability of this test for the psychological autopsy method were investigated. Alcohol consumption was evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and the LAST in 163 completed suicides (mean age 49.6 +/- 19.3 years; 64.4% men) and by personal interview in 396 population-based controls (mean age 51.6 +/- 17.0 years; 55.8% men). Of the controls, 35 were additionally assessed by interviewing informants; these results were compared with those generated by personal interview. Comparison of LAST scores by personal and informant's interview of controls generated a Spearman correlation coefficient of 0.74 (P < 0.0001). The LAST (7 item-version, cut-off of 2) revealed high sensitivity and specificity for alcohol abuse and dependence, in both controls and suicides. LAST scores were significantly associated with high, frequent, and hazardous alcohol consumption (P < 0.001) in suicides. Our findings provide support for reliability and validity of identifying individuals with alcohol dependence and abuse obtained through the best-estimate method using the LAST. This 7-item questionnaire can be recommended as a useful tool for the psychological autopsy procedure in postmortem research.

Recent life events preceding suicide attempts in a personality disorder sample: findings from the collaborative longitudinal personality disorders study

Few studies have examined the relationship between life events, suicide attempts, and personality disorders (PDs), in spite of the strong associations between PDs and suicidal behavior, and the poor coping strategies often exhibited by these individuals. The authors examined whether participants with PDs who attempted suicide during the first 3 years of a prospective, longitudinal study were more likely to experience specific life events in the month during and preceding the suicide attempt. Of 489 participants with PDs, 61 attempted suicide during the 3-year, follow-up interval. Results indicated that negative life events, particularly those pertaining to love-marriage or crime-legal matters, were significant predictors of suicide attempts, even after controlling for baseline diagnoses of borderline PD, major depressive disorders, substance use disorders, and a history of childhood sexual abuse. Therefore, certain types of negative life events are unique risk factors for imminent suicide attempts among individuals with PDs.

Psychiatric diagnoses in 3275 suicides: a meta-analysis

BACKGROUND

It is well known that most suicide cases meet criteria for a psychiatric disorder. However, rates of specific disorders vary considerably between studies and little information is known about gender and geographic differences. This study provides overall rates of total and specific psychiatric disorders in suicide completers and presents evidence supporting gender and geographic differences in their relative proportion.

METHODS

We carried out a review of studies in which psychological autopsy studies of suicide completers were performed. Studies were identified by means of MEDLINE database searches and by scanning the reference list of relevant publications. Twenty-three variables were defined, 16 of which evaluating psychiatric disorders. Mantel-Haenszel Weighted Odds Ratios were estimated for these 16 outcome variables.

RESULTS

Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death. There were major gender differences. Diagnoses of substance-related problems (OR = 3.58; 95% CI: 2.78-4.61), personality disorders (OR = 2.01; 95% CI: 1.38-2.95) and childhood disorders (OR = 4.95; 95% CI: 2.69-9.31) were more common among male suicides, whereas affective disorders (OR = 0.66; 95% CI: 0.53-0.83), including depressive disorders (OR = 0.53; 95% CI: 0.42-0.68) were less common among males. Geographical differences are also likely to be present in the relative proportion of psychiatric diagnoses among suicides.

CONCLUSIONS

Although psychopathology clearly mediates suicide risk, gender and geographical differences seem to exist in the relative proportion of the specific psychiatric disorders found among suicide completers.

The suicidal process; prospective comparison between early and later stages

BACKGROUND

Mechanisms contributing to suicidal behaviour may differ according to how far individuals have progressed through the suicidal process.

METHODS

Lifetime and subsequent 12-month cumulative incidences were obtained of death ideation, death wishes, suicide contemplation and deliberate self-harm in a survey (n=5618) of Dutch adults. Mokken's scale analysis was used to examine whether these were compatible with underlying lifetime and 12-month severity dimensions of suicidality. Sociodemographic details and personality traits, 12-month occurrence of negative life events, hopelessness and CIDI-generated DSM-III-R diagnoses were obtained. Ordered logistic regression was used to examine whether the effects of these on the 12-month incidence of suicidality differed by individuals' prior lifetime history of suicidality.

RESULTS

Mental illness was more strongly associated with 12-months' suicidality in the presence (ordered logistic regression coefficient 0.80, 95% confidence interval 0.48-1.12) than the absence of previous suicidality (0.49 [0.25-0.74]). The reverse obtained for negative life events (0.18 [0.08-0.29] vs. 0.40 [0.33-0.48], respectively) and a number of sociodemographic risk factors. Female gender was a risk factor for 12-months' suicidality (0.47 [0.28-0.66]) only when it was first-onset.

LIMITATIONS

Completed suicides were not recorded. Self-report of lifetime suicidal behaviour may be biased.

CONCLUSION

Environmental influences on suicidal behaviour are most pronounced early in the suicidal process which, after it has progressed, becomes more autonomous and intricately linked with mental illness and depression in particular. Men progress through the suicidal process faster than women. Management of suicidal behaviour depends on the stage of the process the person is at.

A call for research on planned vs. unplanned suicidal behavior

Unplanned acts of suicidal behavior involve little preparation or forethought whereas planned acts may be carefully conceived and implemented. Planned acts are associated with greater depression, hopelessness, and lethality, but there are meager data on other factors associated with planning. The prevention of planned and unplanned acts may require different strategies, but in either case improved knowledge is required to tailor prevention efforts. Improved knowledge can be facilitated by the acceleration of validation studies on assessments of planning, taking steps to avoid the conflation of assessments of planning with measurements of psychopathology such as impulsivity, and the use of controlled research designs.

Suicide note themes and suicide prevention

OBJECTIVE

The aim was to determine if suicide note themes might inform suicide prevention strategies.

METHOD

The themes of 42 suicide notes from the Northern Ireland Suicide Study (major psychological autopsy study) were examined.

RESULTS

The commonest themes were "apology/shame" (74%), "love for those left behind" (60%), "life too much to bear" (48%), "instructions regarding practical affairs post-mortem" (36%), "hopelessness/nothing to live for" (21%) and "advice for those left behind" (21%). Notes of suicides with major unipolar depression were more likely than notes of suicides without major unipolar depression to contain the themes "instructions regarding practical affairs post-mortem" (67% versus 19%, p = 0.005) and "hopelessness/nothing to live for" (40% versus 11%, p = 0.049). Notes of suicides with a previous history of deliberate self-harm were less likely than notes of suicides without a history of deliberate self-harm to contain the theme "apology/shame" (58% versus 87%, p = 0.04). Notes of elderly suicides were more likely than non-elderly notes to contain the theme "burden to others" (40% versus 3%, p = 0.03).

CONCLUSIONS

The fact that three quarters of suicide notes contained the theme "apology/shame" suggests that the deceased may have welcomed alternative solutions for their predicaments. Scrutiny of suicide note themes in the light of previous research findings suggests that cognitive therapy techniques, especially problem solving, may have an important role to play in suicide prevention and that potential major unipolar depressive (possibly less impulsive) suicides, in particular, may provide fertile ground for therapeutic intervention (physical and psychological). Ideally all primary care doctors and mental health professionals working with (potentially) suicidal people should be familiar with basic cognitive therapy techniques, especially problem solving skills training.

Defense styles in depressed suicide attempters

Defense styles may discriminate between depressed patients with or without recent suicide attempts. The aim of the present study was to identify which defense mechanisms are associated with recent suicide attempts in depression. The Defense Style Questionnaire (DSQ) was rated at admission by 156 depressed inpatients with (n = 60) or without (n = 96) recent suicide attempt. Depression intensity was correlated negatively with mature style, humor and sublimation and positively with projection. Although it was not significantly different in terms of sociodemographic and depression variables, recent suicide attempters had higher scores on immature style, especially acting out, passive agression, autistic fantasy and projection. Prospective assessment of defense styles and suicide attempts should be carried out to determine whether these differences are a cause of imminent suicide attempts in depression. If so, the DSQ may be used in clinical practice to help discriminate depressed patients with high risk of imminent suicide attempt.

Antidepressant prescribing and suicide rate in Northern Ireland

PURPOSE

Although antidepressants are the most commonly used treatment for depressive illness, there is uncertainty if their use is associated with a reduction in suicide rate. Antidepressant prescribing in Northern Ireland has increased over fivefold in the decade 1989-1999. The authors sought to explore whether this increase was associated with a reduction in suicide rate taking into account social and political factors thought also to have an influence on suicide.

MATERIALS AND METHODS

Factors that have been suggested to influence suicide were entered into a linear regression with frequency of suicide and undetermined deaths (referred to as suicide rate) as the dependent variable. The above factors were antidepressant prescribing, unemployment rate, household alcohol expenditure and persons charged with terrorist offences. The rise in younger suicides, in recent decades, suggests this analysis should be carried out separately for younger (less than 30 years) and older (30 years and above) suicides separately. The predictors in the two models are based on aggregate data for the total group.

RESULT

In the younger group there was no association between antidepressant prescribing and suicide. For the older group increased antidepressant prescribing was associated with a reduction in suicide rate over the 10 years of the study.

CONCLUSION

Increasing antidepressant prescribing appears to be an effective strategy for reducing suicide. This has been demonstrated in older individuals.

Bipolar disorder. III: Harm avoidance a risk factor for suicide attempts

OBJECTIVES

The aim of the study was to examine whether personality, i.e. temperament and character influence suicide attempts in bipolar patients.

METHODS

Bipolar patients were recruited from lithium dispensaries. Temperament and character inventory (TCI) was administered to 100 euthymic bipolar patients and 100 controls.

RESULTS

Age of onset was significantly lower in patients with suicide attempts in the total bipolar group (I and II) and bipolar I patients compared with patients without suicide attempts. Bipolar (I and II) and bipolar I patients with suicide attempts were significantly higher in harm avoidance (HA) and reward dependence compared with patients without suicide attempts. Patients (I and II) with suicide attempts had significantly more anticipatory worry, fatigability and asthenia than patients without suicide attempts. Bipolar I patients with suicide attempts had significantly more fatigability and asthenia and were more dependent than patients without suicide attempts. HA was lowest in patients with no suicide attempts and no family history of suicide, higher in patients with family history of suicide or patients with suicide attempts, and significantly highest in patients with suicide attempts and family history of suicide. Patients with suicide attempts and family history of suicide had more anticipatory worry, fatigability and asthenia. Bipolar disorder was significantly correlated to HA and suicide attempts to HA and PS. Family history of suicide and gender were significantly correlated to suicide attempts.

CONCLUSIONS

Age of onset, HA, PS, gender and family history of suicide had a moderate to very strong effect on suicide attempts in bipolar patients.

Attempted suicide among entrants to three treatment modalities for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence and risk factors

AIMS

To determine the lifetime and recent histories of attempted suicide among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with a recent history of attempted suicide.

DESIGN

Cross-sectional structured interview.

SETTING

Sydney, Australia.

PARTICIPANTS

Six hundred and fifteen current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT).

FINDINGS

A lifetime history of attempted suicide was reported by 34% of subjects, 13% had attempted suicide in the preceding year and 5% had done so in the preceding month. Females were more likely to have lifetime (44% versus 28%) and 12 month (21% versus 9%) suicide attempt histories. The 12 month prevalence of attempted suicide among treatment groups ranged between 11% (MT, NT) and 17% (RR). Factors associated with recent suicide attempts were: being an RR entrant, female gender, younger age, less education, more extensive polydrug use, benzodiazepine use, recent heroin overdose, Major Depression, current suicidal ideation, Borderline Personality Disorder (BPD)and Post-Traumatic Stress Disorder.

CONCLUSIONS

Recent suicidal behaviour is a major clinical problem for heroin users, and for females and RR entrants in particular. An essential adjunct to treatment for heroin dependence is routine screening for depression and suicidal ideation, with the provision of appropriate treatment where needed.

Genetics of suicide: an overview

Risk for suicide may have heritable contributions. Evidence supporting this hypothesis includes strong and consistent findings from more than 20 controlled family studies indicating nearly 5-fold greater relative risk of suicidal acts among relatives of index cases with suicidal behavior compared to relatives of nonsuicidal controls. Relative risk was greater for completed suicide than for attempts. Contributions of genetic instead of environmental factors are indicated by a higher average concordance for suicidal behavior among co-twins of suicidal identical twins compared to fraternal twins or to relatives of other suicidal subjects, in at least seven studies. Three studies indicate significantly greater suicidal risk, particularly for completed suicide, among biological versus adoptive relatives of suicidal or mentally ill persons adopted early in life. Molecular genetics studies have searched inconclusively for associations of suicidal behavior with genes mainly for proteins required for central serotonergic neurotransmission. Complex interactions of environmental with heritable risk and protective factors for suicide and psychiatric illnesses or vulnerability traits are suspected, but specific intervening mechanisms remain elusive. Familial or genetic risks for psychiatric factors strongly associated with suicide, such as major affective illnesses and alcohol abuse, as well as impulsive or aggressive traits, have not consistently been separated from suicidal risk itself.

If suicide is a public health problem, what are we doing to prevent it?

Although not a disease, suicide is a tragic endpoint of complex etiology and a leading cause of death worldwide. Just as preventing heart disease once meant that specialists treated myocardial infarctions in emergency care settings, in the past decade, suicide prevention has been viewed as the responsibility of mental health professionals within clinical settings. By contrast, over the past 50 years, population-based risk reduction approaches have been used with varying levels of effectiveness to prevent morbidity and mortality associated with heart disease. We examined whether the current urgency to develop effective interventions for suicide prevention can benefit from an understanding of the evolution of population-based strategies to prevent heart disease.

Weather and suicide: the present state of knowledge on the association of meteorological factors with suicidal behaviour

OBJECTIVE

To review the available literature on the association between daily and longer-term weather data and the incidence of attempted and completed suicide.

METHOD

A computerized search supplemented by a cross-check of the references sections of the thereby identified papers was performed.

RESULTS

A total of 27 studies looking for a relationship between attempted or completed suicide and weather or climate data were found. Most of the papers reported a statistical association of suicidal acts with at least one weather factor. However, the results are not conclusive and in part contradictory.

CONCLUSION

Possibly due to the high variance in methodological approaches of the studies it is not possible to identify a specific weather condition associated with a generally higher risk for suicide. Weather and seasonal effects may interact with each other. Environmental effects on brain function and weather-related interactions of people may be involved in the occurrence of suicidal behaviour.