Psychosocial risk factors of youth suicide in the Western Pacific: a scoping review

INTRODUCTION

 The Western Pacific region accounts for 25% of global suicide rates globally. In the last decade, however, there is a rising concern over the rate of youth suicides in the region. In line with the regional vision of reducing the rate of non-communicable diseases by 2025, the study contributes to the literature by utilizing a scoping review approach to identify psychosocial risk factors associated with youth suicide in the region.

METHOD

Publications on youth suicide in the Western Pacific region between 2010 and 2021 were reviewed. A total of 43 publications met the inclusion criteria and were read in full.

RESULTS

Psychosocial risk factors associated with suicide in each publication were identified and thematically classified into five themes: interpersonal factors, history of abuse, academic factors, work factors, and minority status.

DISCUSSION

Findings showed discrepancies in youth suicide research across member nations in the Western Pacific. Implications for regional policies on suicide prevention and future research were discussed.

Suicidal behaviour among adults in Cabo Verde in 2020

BACKGROUND

The aim of the investigation was to evaluate past 12-month suicidal behaviour (PSB) among adults in Cabo Verde.

METHODS

Data from 4,563 adults (mean age 41.4 years) that participated in the 2020 Cabo Verde STEPS survey were analysed.

RESULTS

Results indicate that the proportion of PSB (attempt 0.6%, plan 1.5% and ideation 3.3%) was 3.7% (2.4% men/5.0% women). In adjusted logistic regression analysis, younger age, female sex, unemployed, widowed or divorced, alcohol family problem, heart attack, angina or stroke, current smokeless tobacco use and low fruit/vegetable intake were associated with PSB.

CONCLUSION

Almost 4% of participants had PSB and several associated factors were identified that can guide public health interventions.

Suicide risk and mental health in the general population of French Polynesia

OBJECTIVE

There are no reports on the burden of suicidal ideation and suicide attempts in the general population of French Polynesia (FP). We aimed to improve suicide prevention and mental health care by assessing the prevalence of suicide risk and major mental health disorders and care among adults in FP.

METHODS

We conducted the Mental Health in General Population Survey in FP during 2015 to 2017. Participants were selected using the quota method to obtain a representative sample of the general population. Suicide risk and psychiatric diagnoses were assessed using the Mini International Neuropsychiatric Interview.

RESULTS

We included 968 people aged 18 years or older. The prevalence of current suicidal ideation (13.1%) and current (2.6%) and lifetime suicide attempts (18.6%), as well as mental health disorders (42.8%), was high in FP. A notable proportion of participants with these conditions did not seek medical assistance.

CONCLUSION

A high prevalence of suicide risk and mental health disorders was found in the general population of FP. Suicide prevention and mental health plans are needed in FP that include better access to primary care for the diagnosis and treatment of mental health disorders. Further research is needed to clarify cultural risk and protective factors.

Suicide and suicide attempts in the Pacific Islands: A Systematic Literature Review

Background

The Pacific Islands have some of the highest rates of suicide in the Western Pacific region. The purpose of this study was to systematically review the literature on suicidal behaviour in the Pacific Islands.

Methods

A comprehensive search of Web of Science, PubMed, PsycINFO, Cochrane, CINAHL and Embase databases was conducted for all articles published until 1^st February 2021. Inclusion criteria included papers that referred to a pre-specified list of Pacific Islands. Papers referring exclusively to other countries were excluded. Other exclusion criteria included not being about suicide or suicide attempts or not presenting original research. Narrative synthesis was applied without meta-analysis. The review followed PRISMA guidelines.

Findings

A total of 36 papers were included for review. Of the Pacific Islands, Kiribati has the highest age-standardised rate of suicide mortality. Key risk groups across the Islands included youth, people of Indian ethnicity in Fiji (a prominent ethnic group in Fiji), and Indigenous peoples across other Islands. Prominent methods were self-poisoning and hanging. A distinct lack of intervention studies was found.

Interpretation

Overall, the Pacific Islands appear to have relatively high rates of suicide and suicide attempts compared to other countries in the region. This was particularly striking among youth. This review provides important directions for future suicide prevention activities, including means restriction, sensitive media/community coverage, enhanced surveillance, and the development and evaluation of interventions tailored to the needs of young people and other cultural groups.

Funding

None.

Suicide in French Polynesia: a retrospective analysis based on medicolegal documents and interview with family

Objective

To analyse the epidemiological data on suicide in French Polynesia (FP).

Methods

Data on suicides were collected from the Public Health Direction, Judicial Police Investigations Court of Justice records, the Centre d’Opérations et de Renseignements de la Gendarmerie, patient records for those hospitalized in psychiatry and from psychological autopsies.

Results

The dataset consisted of 316 suicide cases in FP over 25 years (1992–2016). In FP, suicide was more frequent in men (sex ratio 3.2:1), young people (mean age, 34.4 years) and individuals with previously diagnosed psychiatric disorders (100 of 316; 31.6%) The most common method of suicide was hanging (276 of 316; 87.3%). A history of previous suicide attempts was found in 25 of 56 (44.6%) of suicide cases, when documented. The most common potential triggering factors for suicide were emotional problems. The suicide rates have remained stable during 1992–2016 (mean 10.6/100 000 inhabitants per year), with periods of economic crises increasing suicide rates.

Conclusions

These results provide valuable information to enable the effective targeting of suicide prevention strategies toward those at high risk. Economic crises had larger impacts in the French overseas territories than mainland France. Given the unprecedented economic impact of the Covid-19 pandemic in FP, there is an urgent need to implement suicide epidemiological surveillance and prevention programmes.

Prevalence and correlates of suicidal behavior among a national population-based sample of adults in Kiribati

INTRODUCTION

Suicidal behavior is an underresearched cause of death in the Western Pacific region. The study aimed to investigate the prevalence and associated factors of suicidal behavior in a population-based survey among 18-69 year-old persons in Kiribati.

METHOD

Cross-sectional nationally representative data of 2156 18-69 year old persons (37 years were the median age) from the "2015-16 Kiribati STEPS survey" were analyzed.

RESULTS

The results indicate that 5.1% of participants had ever attempted suicide and 9.5% engaged in past 12-month suicidal behavior (ideation, planning, and/or attempts). In adjusted logistic regression analysis, cohabiting, psychological distress, and having had a heart attack, angina, or stroke were associated with lifetime suicide attempts. Female sex, younger age, lower education, psychological distress, heart attack, angina or stroke, and high physical activity were positively associated with past 12-month suicidal behavior. In addition, in unadjusted analysis, alcohol family problems, alcohol dependence, family members attempted suicide, and sedentary behavior (3 to <6 hours/day) were associated with lifetime suicide attempts and/or past 12-month suicidal behavior.

CONCLUSION

Almost one in 10 participants were engaged in suicidal behavior in the past 12 months and several factors were detected which could be targeted in intervention activities.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

OBJECTIVES

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

AUTHORS' CONCLUSIONS

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Suicide Prevention in the Western Pacific Region

This chapter draws on internationally available data to describe the epidemiology of suicide and self-harm in the World Health Organization (WHO) Western Pacific Region. It then describes the suicide prevention activities in the region, using in-depth case studies to highlight some key suicide prevention activities in certain countries/areas and the Global Survey on Suicide Prevention conducted in 2013 by the International Association for Suicide Prevention (IASP) and WHO. It demonstrates that there is considerable variability both between and within low and middle income countries and high income countries, both in terms of rates of suicide and self-harm and in terms of the preventive efforts that have been mobilised to address them. Adequate funding for suicide prevention efforts in the region should be a priority, as should the delivery of a range of suicide prevention approaches. Evaluation and monitoring efforts are also crucial.

The WHO/START study in New Caledonia: A psychological autopsy case series

BACKGROUND

Limited information is available about suicidal behavior in the Pacific Islands. Forty percent of the New Caledonian population is indigenous Kanak; insights into the characteristics of suicide deaths in this population compared to other ethnic groups would be valuable. The aim of this paper is to deepen our understanding of the cultural underpinnings of suicide in New Caledonia by presenting the results of the WHO/START psychological autopsy study.

METHOD

A case-series psychological autopsy study was conducted based on medical, police files, and interviews with relatives of 52 individuals who died by suicide in 2014 and 2015 in New Caledonia.

RESULTS

Kanak indigenous individuals represented more than half of suicides. Prevalence of mental disorders was identified in 62% of suicide decedents; a previous suicide attempt was frequent (37% of cases). A serious argument with a partner was the most prevalent life event (60%). Few warning signs were present among young people and Kanak in general.

CONCLUSION

Comparison with information on the general population suggests indigenous Kanak are more vulnerable and that having a mental health disorder plays an important role in suicide. Violent arguments with a partner could also be a major risk factor. Traditional protective factors (being employed, living with their family or partner, religion) appeared to have limited effect on suicide. Mental health promotion, prevention, and care should be prioritized. Prevention strategies, including domestic violence prevention are recommended in New Caledonia. Further research is needed to better identify young and Kanak subjects at risk of suicide.

Suicide risk around the world: a meta-analysis of longitudinal studies

PURPOSE

Suicidal thoughts and behaviors (STBs) have been a persistent problem worldwide. Identifying risk factors for STBs across distinct areas of the world may help predict who or where requires the greatest attention. However, risk factors for STBs are infrequently explored cross-nationally. The present study examined whether psychopathology prospectively predicts STBs across different areas of the world, and whether certain country-level factors moderate the degree of risk conferred.

METHODS

We conducted a meta-analysis of 71 longitudinal studies from 30 different countries that featured psychopathology-related variables predicting STB outcomes. Meta-regression was used to evaluate whether the following country-level factors modified risk: geographic region, income level, and degree of mental health structural stigma.

RESULTS

Over 90% of studies had been conducted in North America and Europe. When assessed by country income level, it was found that only one longitudinal study on psychopathology and STB was conducted outside of a high-income country. Moreover, less than 10% of studies were conducted in high structural stigma contexts. Meta-regression findings revealed that the variation in risk effect sizes across studies was not explained by models including country-level factors.

CONCLUSIONS

Our findings show critical underrepresentation of low- and middle-income countries, which account for a large proportion of global suicide deaths. This reveals a need to broaden the scope of longitudinal research on STB risk, such that countries across more regions, income levels, and degrees of structural stigma are fully accounted for. Such lines of research will improve generalizability of findings, and more precisely inform prevention efforts worldwide.

Global incidence of suicide among Indigenous peoples: a systematic review

BACKGROUND

Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available. Our objective was to examine the global incidence of suicide among Indigenous peoples and assess disparities through comparisons with non-Indigenous populations.

METHODS

We conducted a systematic review of suicide rates among Indigenous peoples worldwide and assessed disparities between Indigenous and non-Indigenous populations. We performed text word and Medical Subject Headings searches in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SciELO) for observational studies in any language, indexed from database inception until June 1, 2017. Eligible studies examined crude or standardized suicide rates in Indigenous populations at national, regional, or local levels, and examined rate ratios for comparisons to non-Indigenous populations.

RESULTS

The search identified 13,736 papers and we included 99. Eligible studies examined suicide rates among Indigenous peoples in 30 countries and territories, though the majority focused on populations in high-income nations. Results showed that suicide rates are elevated in many Indigenous populations worldwide, though rate variation is common, and suicide incidence ranges from 0 to 187.5 suicide deaths per 100,000 population. We found evidence of suicide rate parity between Indigenous and non-Indigenous populations in some contexts, while elsewhere rates were more than 20 times higher among Indigenous peoples.

CONCLUSIONS

This review showed that suicide rates in Indigenous populations vary globally, and that suicide rate disparities between Indigenous and non-Indigenous populations are substantial in some settings but not universal. Including Indigenous identifiers and disaggregating national suicide mortality data by geography and ethnicity will improve the quality and relevance of evidence that informs community, clinical, and public health practice in Indigenous suicide prevention.

A Multidimensional Theory of Suicide

BACKGROUND

Theory is the foundation of science; this is true in suicidology. Over decades of studies of suicide notes, Leenaars developed a multidimensional model of suicide, with international (crosscultural) studies and independent verification.

AIM

To corroborate Leenaars's theory with a psychological autopsy (PA) study, examining age and sex of the decedent, and survivor's relationship to deceased.

METHOD

A PA study in Norway, with 120 survivors/informants was undertaken. Leenaars' theoretical-conceptual (protocol) analysis was undertaken of the survivors' narratives and in-depth interviews combined.

RESULTS

Substantial interjudge reliability was noted (κ = .632). Overall, there was considerable confirmatory evidence of Leenaars's intrapsychic and interpersonal factors in suicide survivors' narratives. Differences were found in the age of the decedent, but not in sex, nor in the survivor's closeness of the relationship. Older deceased people were perceived to exhibit more heightened unbearable intrapsychic pain, associated with the suicide.

CONCLUSION

Leenaars's theory has corroborative verification, through the decedents' suicide notes and the survivors' narratives. However, the multidimensional model needs further testing to develop a better evidence-based way of understanding suicide.

Together to make a difference in mental health in the Western Pacific Region

Mental disorders are among the leading causes of disease burden in the Western Pacific Region of the World Health Organization (WHO). Networking and partnership have been identified as the major components of key strategies to address challenges in meeting mental health needs in the region. This article provides a brief review of relevant initiatives collaboratively developed by the WHO, member states in the region and other partners.

Sleep Disturbances and Suicidality-A Longitudinal Analysis From a Representative Community Study Over 30 Years

Study objectives: Associations between sleep problems and suicidality are increasingly acknowledged, but prospective data from well-controlled long-term community studies are lacking. Methods: We analyzed data from a longitudinal cohort study with n = 591 young adults from Zurich, Switzerland, prospectively followed from 1979 (age 20/21 years) to 2008 (age 49/50 years). Twelve-month prevalence of various mental disorders, socio-environmental confounders and sleep problems were carefully assessed with semi-structured interviews at 7 assessment waves spanning overall a 30-year observation period. Interviews were conducted with the "Structured Psychopathological Interview and Rating of the Social Consequences of Psychological Disturbances for Epidemiology" (SPIKE). The 12-month prevalence of sleep problems was graded according to frequency and associated distress of reported symptoms. 12-month prevalence of suicidality was classified as either mild (transient suicidal ideation) or severe (self-harm, suicide attempts). Results: Concurrently, and fully adjusted for several covariates, including mental disorders, relative to no sleep problems there was an odds ratio (OR) of OR = 1.9 (95% confidence interval 1.4-2.5), OR = 3.3 (2.5-4.4), and OR = 1.9 (1.3-2.8) for mild, moderate and severe sleep problems in association with suicidality. There was no evidence for a prospective effect of broad sleep problems on subsequent suicidality. Mild suicidality, but not severe suicidality, prospectively predicted subsequent broad sleep problems in the fully adjusted multivariate model (adjusted OR = 1.5; 1.1-1.9). Disturbed sleep initiation, a proxy for insomnia, significantly predicted subsequent suicidality (OR = 1.5; 1.1-1.9), whereas mild suicidality, but not severe suicidality, significantly predicted subsequent insomnia (OR = 1.5; 1.1-2.0). Conclusions: Sleep problems and suicidality are longitudinally inter-related, which has important implications for clinical practice. Most importantly, the causal pathways appear to be bi-directional and independent of socio-demographics and concomitant mental disorders. More research is needed to examine the possible biopsychosocial etiological mechanisms linking suicidality to sleep problems.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Non-psychiatric inpatient care preceding admission for self-harm in young people

OBJECTIVE

Many young people contact health services before they harm themselves intentionally. However, they often seek care for non-suicidal or non-psychiatric causes despite having suicidal thoughts. We investigated the non-psychiatric hospital diagnoses received by young people during the year before their first admission to hospital for self-harm.

METHODS

From a national register, we selected people who were hospitalised for an episode of self-harm during the period 1999-2009, at which time they were aged 16 to 24. We compared them with matched controls regarding the probability for having been admitted with different diagnoses during the year preceding the self-harm admission.

RESULTS

The study included 48,705 young people (16,235 cases and 32,470 controls). Those admitted for self-harm were more likely than controls to have been hospitalised for non-psychiatric reasons, which included symptomatic diagnoses such as abdominal pain, syncope/collapse, unspecified convulsions, and chest pain. Certain chronic somatic illnesses were also overrepresented, such as epilepsy, diabetes mellitus type 1, and asthma.

CONCLUSION

Symptomatic diagnoses were more common in those who had been admitted for self-harm. It is possible that psychiatric problems could have been the cause of the symptoms in some of these admissions where no underlying illness could be found, and if this was not uncovered it might lead to a delay in suicide risk assessment. For several chronic illnesses, when admitted to hospital, a psychiatric evaluation might be indicated.

Incidence Rates of Deliberate Self-Harm in Denmark 1994-2011

BACKGROUND

The validity and reliability of suicide statistics have been questioned and few nationwide studies of deliberate self-harm have been presented.

AIM

To calculate rates of deliberate self-harm in Denmark in order to investigate trends and assess the reliability of hospital records.

METHOD

A register study based on all individuals recorded with an episode of deliberate self-harm or probable deliberate self-harm in nationwide registers during 1994-2011.

RESULTS

A substantial difference in the rates of deliberate self-harm and probable deliberate self-harm was noted for both genders. The average incidence rate of deliberate self-harm for women and men was 130.7 (95% CI = 129.6-131.8) per 100,000 and 86.9 (95% CI = 86.0-87.8) per 100,000, respectively. The rates of deliberate self-harm for women increased from 137.6 (95% CI = 132.9-142.3) per 100,000 in 1994 to 152.7 (95% CI = 147.8-157.5) in 2011. For a subgroup of younger women aged 15-24 years, an almost threefold increase was observed, IRR = 2.5 (95% CI = 2.4-2.7). The most frequently used method was self-poisoning.

CONCLUSION

The rates of deliberate self-harm and probable deliberate self-harm differed significantly. An increased incidence of deliberate self-harm among young Danish women was observed, despite detection bias. An improved registration procedure of suicidal behavior is needed.

Benefits of a Secondary Prevention Program in Suicide

Abstract. Background: The effectiveness of suicide intervention programs has not been assessed with experimental designs. Aim: To determine the risk of suicide reattempts in patients engaged in a secondary prevention program. Method: We included 154 patients with suicidal behavior in a quasi-experimental study with a nontreatment concurrent control group. In all, 77 patients with suicidal behavior underwent the Suicide Behavior Prevention Program (SBPP), which includes specialized early assistance during a period of 3–6 months. A matched sample of patients with suicidal behavior (n = 77) was selected without undergoing any specific suicide prevention program. Data on sociodemographics, clinical characteristics, and suicidal behavior were collected at baseline (before SBPP) and at 12 months. Results: After 12 months, SBPP patients showed a 67% lower relative risk of reattempt (χ2 = 11.75, p = .001, RR = 0.33 95% CI = 0.17–0.66). Cox proportional hazards models revealed that patients under SBPP made a new suicidal attempt significantly much later than control patients did (Cox regression = 0.293, 95% CI = 0.138–0.624, p = .001). The effect was even stronger among first attempters. Limitations: Sampling was naturalistic and patients were not randomized. Conclusion: The SBPP was effective in delaying and preventing suicide reattempts at least within the first year after the suicide behavior. In light of our results, implementation of suicide prevention programs is strongly advisable.

Intentional poisoning among elderly people-residents of a large urban agglomeration in Poland

Poisoning is considered a significant health problem among elderly people in Poland. This report refers to patients treated for poisonings at the Toxicology Unit, Lodz, Poland, during the period 2008-2012. The data to be analyzed were obtained from medical records of elderly people. A group of 1167 patients aged 60+ was selected. The number of intentional poisonings in the group of patients was 417, which accounted for 35.7% of all poisonings among the elderly people. Patients attempting intentional poisonings included 301 (72.2%) women and 116 (27.8%) men. The most common cause of intentional poisonings were drugs-96.6% (n = 403). Benzodiazepines (46.9%) dominated among the intentional poisoning by drugs. During the analyzed 5 years, 80.3% (n = 335) were suicidal poisonings and 19.7% (n = 82) were demonstrative poisonings. Cardiovascular disease, which was diagnosed among 53.5% of the patients, was the most common physical illness. In conclusion, drugs are the most frequent type of the toxic agent responsible for poisoning cases among the elderly people. In this situation, the role of family doctors is very important: they should prescribe medicines in amounts not greater than absolutely necessary and maybe more often recommend psychiatric care for the elderly patients.

The Mexican Cycle of Suicide: A National Analysis of Seasonality, 2000-2013

INTRODUCTION

Suicide is a complex and multifactorial phenomenon with growing importance to public health. An increase in its occurrence has been observed in Mexico over the past 10 years. The present article analyzes the secular trend in suicide at the national level between the years 2000 and 2013.

MATERIALS AND METHODS

All suicides during the study period (n = 64,298, of which 82.11% were men) were characterized using a spectral decomposition of the time series and a wavelet analysis to evaluate the effect of seasonal changes, type of area (urban versus rural) and sex.

RESULTS

A seasonal pattern was observed with statistically significant cycles every 12 months, where peaks were identified in May but only for men in urban zones as of the year 2007. In addition, specific days of the year were found to have a higher frequency of suicides, which coincided with holidays (New Year, Mother's Day, Mexican Independence Day and Christmas).

CONCLUSION

A wavelet analysis can be used to decompose complex time series. To the best of our knowledge, this is the first application of this technique to the study of suicides in developing countries. This analysis enabled identifying a seasonal pattern among urban men in Mexico. The identification of seasonal patterns can help to create primary prevention strategies, increase the dissemination of crisis intervention strategies and promote mental health. These strategies could be emphasized during specific periods of the year and directed towards profiles with a higher risk.

Non-fatal suicidal behaviours in French Polynesia: Results of the WHO/START study and its implications for prevention

OBJECTIVES

This is the first research article examining non-fatal suicidal behaviours (NFSB) in French Polynesia. The study was conducted in the frames of the WHO/START Study in 2008-2010. The main objective of the investigation was to obtain reliable data in order to develop evidence-based suicide prevention strategies.

METHOD

Interviews with people presenting with NFSB at the Emergency Department (ED) of the French Polynesia Hospital (CHPF) were conducted by emergency and psychiatry departments' staff examining socio-demographic and clinical information and motives triggering suicidal behaviour. Odds ratios and rate ratios with 95% confidence intervals were calculated.

RESULTS

There were 556 presentations of NFSB by 515 persons at the ED of CHPF (ratio 1.08) with the average rate of 75 per 100,000 for those treated in the hospital. An estimate of cases occurring in remote islands might bring the rate for the whole French Polynesia around 94 per 100,000. NFSB was more prevalent in females; rates for both genders were highest in the age group 25-35 years and 15-24 years. The main suicide method was drug poisoning by psychotropic drugs. The most frequent psychiatric disorder was mood disorder (45.3%); however, 26% of subjects had no 'major' psychiatric disorders, with 14.5% without a psychiatric diagnosis or only reactive disorders (F43-11.7%). There was a high prevalence of previous NFSB (52.1%).

LIMITATIONS

Study includes only NFSB seeking medical help from the biggest hospital in the country.

CONCLUSION

Suicide prevention activities specific to the findings and the socio-cultural context of French Polynesia should be considered.

Testing Brief Intervention and Phone Contact among Subjects with Suicidal Behavior: A Randomized Controlled Trial in French Polynesia in the Frames of the World Health Organization/Suicide Trends in At-Risk Territories Study

The World Health Organization Suicide trends in at-risk territories study is a multi-site regional research program operating first in French Polynesia and countries of the Western Pacific, then extended to the world. The aims of the study were to establish a monitoring system for suicidal behaviors and to conduct a randomised control trial intervention for non-fatal suicidal behaviors. The latter part is the purpose of the present article. Over the period 2008-2010, 515 patients were admitted at the Emergency Department of the Centre Hospitalier de Polynésie Française for suicidal behavior. Those then hospitalized in the Psychiatry Emergency Unit were asked to be involved in the study and randomly allocated to either Treatment As Usual (TAU) or TAU plus Brief Intervention and Contact (BIC), which provides a psycho-education session and a follow-up of 9 phone contacts over an 18-months period. One hundred persons were assigned to TAU, while 100 participants were allocated to the BIC group. At the end of the follow-up there were no significant differences between the two groups in terms of number of presentations to the hospital for repeated suicidal behaviors. Although the study could not demonstrate the superiority of a treatment over the other, nevertheless – given its importance – the investigation captured public attention and was able to contribute to the awareness of the need of suicide prevention in French Polynesia. The BIC model of intervention seemed to particularly suit the geographical and health care context of the country.

Is Case Management Effective for Long-Lasting Suicide Prevention?

BACKGROUND

Case management services have been implemented in suicide prevention programs.

AIMS

To investigate whether case management is an effective strategy for reducing the risks of repeated suicide attempts and completed suicides in a city with high suicide rates in northern Taiwan.

METHOD

The Suicide Prevention Center of Keelung City (KSPC) was established in April 2005. Subjects included a consecutive sample of individuals (N = 2,496) registered in KSPC databases between January 1, 2006, and December 31, 2011, with at least one episode of nonfatal self-harm. Subjects were tracked for the duration of the study.

RESULTS

Of all the subjects, 1,013 (40.6%) received case management services; 416 (16.7%) had at least one other deliberate self-harm episode and 52 (2.1%) eventually died by suicide. No significant differences were found in the risks of repeated self-harm and completed suicides between suicide survivors who received case management and those who refused the services. However, a significant reduction in suicide rates was found after KSPC was established.

CONCLUSION

Findings suggest that case management services might not reduce the risks of suicide repetition among suicide survivors during long-term follow-up. Future investigation is warranted to determine factors impacting the downward trend of suicide rates.

Gender differences in socio-demographic, clinical characteristics and psychiatric diagnosis in/of suicide attempters in a Mexican population

OBJECTIVE

The aim of the present study was to analyse demographic and clinical characteristics, as well as psychiatric diagnoses to identify gender differences in patients with attempted suicide in a Mexican population.

METHODS

Between September 2010 and September 2012, 140 suicide attempts were documented in the Department of Psychiatry at the General Hospital of Comalcalco (Hospital General de Comalcalco in Spanish) in Tabasco, Mexico. Diagnoses were established using the DSM-IV questionnaire in which Axis I and II were considered. The Suicide Intent Scale was also applied.

RESULTS

In our sample, 63.6% were females and 36.4% males. With regard to socio-demographic characteristics, the predominant marital status in males was single, and in females married (χ2=5.93, df=2, p=0.05). In occupation the male group was mainly unemployed and housewife in females (χ2=55.51, df=4, p<0.001). Male subjects were more likely to consume alcohol (χ2=20.40, df=1, p≤0.001), cannabis (χ2=16.62, df=1, p≤0.001) or tobacco. The prevalence of psychiatric diagnosis was significantly different because, the male group was mainly diagnosed with substance-related disorders, whereas female participants showed a prevalence of stress-related disorders (χ2=34.17, gl=4, p=0.0001).

CONCLUSION

Our results provide evidence that the characteristics of suicide attempt are different by gender in the Mexican population. Interventions are necessary for the development of prevention strategies that may lead to a reduction in suicidal behaviour. These preventive activities should consider the occupation for the female group and consumption of alcohol, cannabis or tobacco in the male group.

SIAM (Suicide intervention assisted by messages): the development of a post-acute crisis text messaging outreach for suicide prevention

BACKGROUND

Suicidal behaviour and deliberate self-harm are common among adults. Research indicates that maintaining contact either via letter or postcard with at-risk adults following discharge from care services can reduce reattempt risk. Feasibility trials demonstrated that intervention through text message was also effective in preventing suicide repetition amongst suicide attempters. The aim of the current study is to investigate the effect of text message intervention versus traditional treatment on reducing the risk of suicide attempt repetition among adults after self-harm.

METHODS/DESIGN

The study will be a 2-year multicentric randomized controlled trial conducted by the Brest University Hospital, France. Participants will be adults discharged after self-harm, from emergency services or after a short hospitalization. Participants will be recruited over a 12-month period. The intervention is comprised of an SMS that will be sent at h48, D7, D15 and monthly. The text message enquires about the patients' well-being and includes information regarding individual sources of help and evidence-based self help strategies. Participants will be assessed at the baseline, month 6 and 13. As primary endpoint, we will assess the number of patients who reattempt suicide in each group at 6 months. As secondary endpoints, we will assess the number of patients who reattempt suicide at 13 month, the number of suicide attempts in the intervention and control groups at 6 and 13 month, the number of death by suicide in the intervention and control groups at month 6 and 13. In both groups, suicidal ideations, will be assessed at the baseline, month 6 and 13. Medical costs and satisfaction will be assessed at month 13.

DISCUSSION

This paper describes the design and deployment of a trial SIAM; an easily reproducible intervention that aims to reduce suicide risk in adults after self-harm. It utilizes several characteristics of interventions that have shown a significant reduction in the number of suicide reattempts. We propose to assess its efficacy in reducing suicide reattempt in the suicide attempter (SA) population.

TRIAL REGISTRATION

The study was registered on Clinical Trials Registry (clinicaltrials.gov): NCT02106949, registered on 06 June 2014.

The Rate of Fatality and Demographic Characteristics Associated With Various Suicide Methods

Background: Understanding lethality and risk factors of suicide methods is an initial step in suicide prevention. Aims: To investigate the fatality rate and demographic characteristics of various suicide methods. Method: This study enrolled consecutive individuals with episodes of suicide attempts registered in a surveillance database in a city with a high rate of suicide mortality in Taiwan, from January 1, 2006, to December 31, 2010. In total, 3,089 suicide attempt events (including 2,583 nonfatal suicides and 506 completed suicides) occurred during the study period. Results: Overall, the fatality rate of suicides was 16.4%. Charcoal burning accounted for the most suicide deaths (37.6%), with a fatality rate of 50.1%. Suicide by hanging carried the highest fatality rate (81.2%). Males tended to choose more lethal methods and had higher fatality rates compared with females. Elders and married persons were less likely to attempt suicide by charcoal burning. The case fatality ratio increased along with age among suicide attempts, but not in those using charcoal burning. Conclusion: The choice of suicide methods and lethality might be influenced by one’s demographic characteristics. Results from this study may provide clues for establishing suicide prevention strategies such as restricting access to common lethal suicide methods in the high-risk group.

Methods of suicide predict the risks and method-switching of subsequent suicide attempts: a community cohort study in Taiwan

OBJECTIVE

Suicide is a major public health concern. This study aimed to determine the predictors of repeated suicide attempts, focusing on whether lethality level of the suicidal method predicts the risk of subsequent suicide attempts.

METHODS

All consecutive individuals (N=2,070) with an episode of nonfatal self-harm registered in a surveillance database provided by the Department of Health of Keelung City Government in Taiwan from January 1, 2006 to December 31, 2010 were enrolled and followed up until the end of 2011. The earliest attempt recorded in the database was defined as the index attempt. Subjects were classified according to suicide method into low-lethal and high-lethal groups. Data on time of and methods chosen for subsequent suicide attempts during the follow-up period were analyzed.

RESULTS

Of the total people screened for the study, 18.1% made a repeated suicide attempt. Subjects in the high-lethal group were more likely to be male; aged 35-64 years; and single, divorced, or widowed. Compared to other time intervals, most subsequent suicide attempts occurred within 6 months from the index attempt. The independent predictors for repeated suicide attempts were the use of low-lethal methods in the index attempt and being 35-49 years old. Using high-lethal methods and being older than 50 years were associated with changing suicide method for the second attempt.

CONCLUSION

Lethality level of former suicidal method could predict repeated suicide attempts and changing of suicide methods. Further clarification is needed on whether a higher risk of repeat attempts is associated with higher rates of suicide mortality.