Protective Factors of Suicide and Suicidal Behavior Relevant to Emergency Healthcare Settings: A Systematic Review and Narrative Synthesis of Post-2007 Reviews

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The national suicide prevention strategy in India: context and considerations for urgent action

India reports the highest number of suicide deaths in the world. At this time when the Indian Government is formulating a national suicide prevention strategy, we have reviewed the current status of suicides in India, focusing on epidemiology, risk factors, and existing suicide prevention strategies to identify key challenges and priorities for suicide prevention. The suicide rate among Indian girls and women continues to be twice the global rate. Suicide accounts for most deaths in the 15-39 years age group compared with other causes of death. Hanging is the most common method of suicide, followed by pesticides poisoning, medicine overdose, and self-immolation. In addition to depression and alcohol use disorders as risk factors, several social and cultural factors appear to increase risk of suicide. The absence of a national suicide prevention strategy, inappropriate media reporting, legal conflicts in the interpretation of suicide being punishable, and inadequate multisectoral engagement are major barriers to effective suicide prevention. A scaffolding approach is useful to reduce suicide rates, as interventions provided at the right time, intensity, and duration can help navigate situations in which a person might be susceptible to and at risk of suicide. In addition to outlining research and data priorities, we provide recommendations that emphasise multilevel action priorities for suicide prevention across various sectors. We call for urgent action in India by integrating suicide prevention measures at every level of public health, with special focus on the finalisation and implementation of the national suicide prevention strategy.

Factors associated with increased suicidality risk following referral for isotretinoin commencement

OBJECTIVE

To establish whether there is a significant change in suicidality risk following psychiatric assessment for commencement of isotretinoin and identify factors that underpin any potential risk change.

METHOD

Retrospective cohort study. Suicidality risk was defined as a combination of the following: (i) actual/intended self-harm and/or attempted/completed suicide, and (ii) increased service utilisation associated with suicidal ideation/behaviour. All patients referred to Psychiatry for assessment prior to commencement of isotretinoin between 2014 and 2019 were examined. Inclusion criteria: >16 years of age, assessed for commencement of isotretinoin, complete clinical records. Data were collected by reviewing the Electronic Patient Records. Fifty-seven patients were eligible. We employed descriptive statistics, parametric/non-parametric/normality tests and logistic regression analysis, using socio-demographic and clinical characteristics as independent parameters, and suicidality risk as the dependent parameter.

RESULTS

Actual/intended self-harm/attempted suicide decreased significantly following assessment without significant change in service utilisation. Female gender, absence of protective factors and assessment by Consultation-Liaison Psychiatry were linked to increased suicidality risk, after controlling for age, ethnicity, recommendation for isotretinoin, and substance misuse.

CONCLUSIONS

Psychiatric assessment is helpful before commencing isotretinoin. Female gender, and absence of ongoing psychopharmacological and/or psychological intervention and/or regular psychiatric follow-up predict increased suicidality risk among patients assessed for prescription of isotretinoin.

Medically Serious Suicide Attempts in Personality Disorders

Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviors very close to suicides. Personality disorders (PD) are highly prevalent among them, together with affective and substance use disorders. However, few studies have specifically analyzed the role of PD in MSSA. These suicide attempts (SA) are usually followed by longer hospitalization periods and may result in severe physical and psychological consequences. The aim of this study is to compare the profile of MSSA patients with and without PD. MSSA were defined according to Beautrais 'criteria, but had to remain hospitalized ≥48 h. Overall, 168 patients from two public hospitals in Barcelona were evaluated during a three-year period. Mean hospital stay was 23.68 (standard deviation (SD) = 41.14) days. Patients with PD (n = 69) were more likely to be younger, female, make the first and the most serious SA at a younger age, reported recent stressful life-events and more frequently had previous suicide attempts compared to those without PD. However, no differences were found with regards to comorbid diagnoses, current clinical status, features of the attempt, or their impulsivity and hopelessness scores. Therefore, focusing on the subjective, qualitative experiences related to MSSA among PD patients may increase understanding of the reasons contributing to these attempts in order to improve prevention strategies in the future.

Detecting suicide risk using knowledge-aware natural language processing and counseling service data

RATIONALE

Detecting users at risk of suicide in text-based counseling services is essential to ensure that at-risk individuals are flagged and prioritized.

OBJECTIVE

The objective of this study is to develop a domain knowledge-aware risk assessment (KARA) model to improve our ability of suicide detection in online counseling systems.

METHODS

We obtained the largest known de-identified dataset from an emotional support system established in Hong Kong, comprising 5682 Cantonese conversations between help-seekers and counselors. Of those, 682 conversations disclosed crisis intentions of suicide. We constructed a suicide-knowledge graph, representing suicide-related domain knowledge as a computer-processible graph. Such knowledge graph was embedded into a deep learning model to improve its ability to identify help-seekers in crisis. As the baseline, a standard NLP model was applied to the same task. 80% of the study samples were randomly sampled to train model parameters. The remaining 20% were used for model validation. Evaluation metrics including precision, recall, and c-statistic were reported.

RESULTS

Both KARA and the baseline achieved high precision (0.984 and 0.951, shown in Table 2) and high recall (0.942 and 0.947) towards non-crisis cases. For crisis cases, however, KARA model achieved a much higher recall than the baseline (0.870 vs 0.791). The c-statistics of KARA and the baseline were 0.815 and 0.760, respectively.

CONCLUSION

KARA significantly outperformed standard NLP models, demonstrating good translational value and clinical relevance.

Prevalence, risk and protective factors associated with suicidal ideation during the COVID-19 pandemic in U.S. military veterans with pre-existing psychiatric conditions

The coronavirus disease 2019 (COVID-19) pandemic has negatively affected the mental health of the general population. However, less is known about its impact on vulnerable populations, such as veterans with pre-existing psychiatric conditions. Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative cohort of U.S. veterans. Pre-pandemic and 1-year peri-pandemic risk and protective factors associated with suicidal ideation (SI) were examined in veterans with pre-existing psychiatric conditions. 19.2% of veterans screened positive for SI peri-pandemic. Relative to veterans without SI, they had lower income, were more likely to have been infected with COVID-19, reported greater COVID-19-related financial and social restriction stress, and increases in psychiatric symptoms and loneliness during the pandemic. A multivariable analysis revealed that older age, greater pre-pandemic psychiatric symptom severity, past-year SI, lifetime suicide attempt, psychosocial difficulties, COVID-19 infection, and past-year increase in psychiatric symptom severity were linked to peri-pandemic SI, while pre-pandemic higher income and purpose in life were protective. Among veterans who were infected with COVID-19, those aged 45 or older and who reported lower purpose in life were more likely to endorse SI. Monitoring for suicide risk and worsening psychiatric symptoms in older veterans who have been infected with COVID-19 may be important. Interventions that enhance purpose in life may help protect against SI in this population.

Suicidality After Burn Injuries: A Systematic Review

Burn survivors may be at increased risk for suicide due to the nature of their injury and psychiatric comorbidities. The purpose of this review is to assess the evidence as to the prevalence of suicidal ideations and behaviors (attempts and completed suicides) in burn survivors as well as evaluate risk and protective factors. PubMed, EMBASE, CINAHL, Cochrane, PsycINFO, and Web Science databases were searched using search terms regarding suicide, suicidality, and burn. Fourteen full-text manuscripts and two published abstracts were included in the review. Overall, burn survivors demonstrate elevated suicidal ideations and a higher lifetime prevalence of suicide attempts compared to the general population. There is mixed evidence as to rates of completed suicide postburn injury, though rates appear to be relatively low. Risk factors include pain at discharge, perceived level of disfigurement, premorbid psychiatric comorbidities, and past suicide attempts. Results of this systematic review shed light on the scarcity of data on rates of suicidality among burn survivors, which is surprising given the multiple risk factors burn survivors possess including chronic pain, sleep disturbances, history of substance abuse, posttraumatic stress disorder, social isolation, and depression which are linked to suicidality in the general population. Suicide risk screening should be included as an integral part of burn survivors' care, and more research is needed to better understand the magnitude of this phenomenon and offer targeted interventions to vulnerable individuals.