Age of first suicide attempt in men and women: an admixture analysis

Risk factors for mortality after hospitalization for suicide attempt: results of 11-year follow-up study in Piedmont Region, Italy

PURPOSE

Suicide attempters are at high risk of premature death, both for suicide and for non-suicidal causes. The aim of this study is to investigate risk factors and temporal span for mortality in a cohort of cases admitted to hospital for suicide attempt.

METHODS

The cohort included 1489 patients resident in Piedmont Region, North West of Italy, who had been admitted to hospital or emergency department for suicide attempt between 2010 and 2020. Cox regression models were used to identify risk factors for death. The final multivariate model included gender, age, area deprivation index, family composition, psychiatric disorders, malignant neoplasms, neurological disorders, diabetes mellitus, cardiovascular diseases, chronic obstructive pulmonary disease, and intracranial injury or skull fracture.

RESULTS

During the observation period, 7.3% of patients died. The highest mortality was observed within the first 12 months after suicide attempt, and remained elevated for many years afterwards. Male gender, older age, high deprivation index of the census area, single-parent family, mood disorders, malignant neoplasms, diabetes mellitus and intracranial injuries or skull fracture were independent predictors of death. Risk factors for natural and unnatural causes of death were also identified.

CONCLUSIONS

The mortality risk of suicide attempters is very high, both in the months immediately following the attempt and afterwards. The identification of high-risk groups can help to plan outpatient care following the hospital discharge. Our findings urge the need to design strategies for the assistance and care of these patients at long term in order to reduce the unfavourable outcomes.

Cause-specific mortality after hospital discharge for suicide attempt or suicidal ideation: A cohort study in Piedmont Region, Italy

BACKGROUND

Suicide attempters are at higher risk of death than the general population. The present study aims to investigate the excess of all-cause mortality and cause-specific mortality in a cohort of patients who have attempted suicide or had suicidal ideation compared with the general population.

METHOD

The cohort included 826 patients residing in the Piedmont Region of Northwest Italy who were admitted to a hospital or emergency department for suicide attempts or suicidal ideation between 2010 and 2016. Mortality excesses of the study population compared to the general population were estimated by applying indirect standardization. Standardized Mortality Ratios and 95% Confidence Intervals were calculated for all-cause, and cause-specific, natural, and unnatural causes of death by gender and age.

RESULTS

During the 7 years of follow-up, 8.2% of the study sample died. The mortality of suicide attempters and ideators was significantly higher than that of the general population. Mortality was about twice than expected from natural causes, and 30 times than expected from unnatural causes. The mortality due to suicide was 85 times higher than that of the general population, with an excess of 126 times for females. The SMRs for all-cause mortality decreased with increasing age.

CONCLUSIONS

Patients who access hospitals or emergency departments for suicide attempts or suicidal ideation are a frail group at high risk of dying from natural or unnatural causes. Clinicians should pay special attention to the care of these patients, and public health and prevention professionals should develop and implement appropriate interventions to timely identify individuals at higher risk for suicide attempts and suicidal ideation and provide standardized care and support services.

Low Level of Agreement Between Self-Report and Clinical Assessment of Passive Suicidal Ideation

OBJECTIVE

Discrepancies between patient reports during clinical evaluations and self-reported suicide ideation are of vital importance. We study the agreement in passive suicidal ideation between reports made by clinicians and patients' self-reports.

METHOD

Wish of death in 648 outpatients was assessed by attending clinicians. Within 24 h after clinical evaluation, patients completed a self-report questionnaire in which they were asked whether they had no desire to live. We used cluster analysis to determine the clinical profile of a population of patients according to the concordance between reports made by clinicians and self-reported information.

RESULTS

A low level of agreement (kappa = 0.072) was found between clinicians and patients, as 56.4% (n = 366) of clinician reports classified as containing no death-related ideas although on self-report the patient did state that they had no desire to live. In this group containing discrepancies between the two reports, two clusters were found to have shared characteristics: female sex, middle age, cohabitation, active employment, no history of suicidal behavior, and diagnosis of neurotic, stress-related, and somatoform disorders. In a third, more severe cluster, patients self-reported sleep disturbances, less appetite, poor treatment adherence, and aggressiveness.

CONCLUSIONS

We found low agreement between self-reports and clinician assessments regarding the death wish. Self-reporting may be useful in assessing suicide risk. HIGHLIGHTSLow agreement was found between self-reports and clinician assessments regarding passive suicidal ideation.Most patients in whom the clinician underestimated the risk of suicide were women.Our results suggest that clinicians require adequate documentation of suicidal risk assessment to identify the high-risk population.

Recovery from past suicide attempts: Correlates of time since the last attempt in a national sample of US adults

BACKGROUND

This study takes a lifetime perspective on suicide attempts and examines correlates of years since the last attempt as a potential proxy for recovery from suicidality.

METHODS

Data from 36,309 adults in the National Epidemiologic Survey on Alcohol and Related Conditions-III were used to identify 1,924 respondents (5.3%) who reported a lifetime suicide attempt. Measures included socio-demographics, behavioral factors, and DSM-5 diagnoses, as well as the age at first attempt. Bivariate and multivariate analyses were used to adjust for potentially confounding effects of age and to identify independent factors associated with not attempting suicide for >1-5 years or >5 years.

RESULTS

Of those who reported a lifetime suicide attempt, 7.9% reported their most recent attempt in the past year, 18.6% within 1 to 5 years, and 73.5% in greater than 5 years. While absence of lifetime substance use disorder and past year psychiatric disorder prominently characterized those with no attempt in the past 1 to 5 years, many more sociodemographic advantages additionally characterized those whose last attempt was >5 years ago, including being older, married, employed, higher incomes, no recent homelessness or criminal justice involvement, more social contacts, as well as having less past year substance use or psychiatric disorders.

LIMITATIONS

The retrospective, self-report design introduces the possibility of recall bias.

CONCLUSIONS

Almost three-fourths of people with lifetime suicide attempts have not attempted for more than 5 years. Recovery involves not only psychiatric and substance use disorders but improvements in key socio-demographics and social connectedness over many years.

Borderline personality disorder and prior suicide attempts define a severity gradient among hospitalized adolescent suicide attempters

BACKGROUND

Borderline personality disorder (BPD) and history of prior suicide attempt (SA) have been shown to be high predictors for subsequent suicide. However, no previous study has examined how both factors interact to modify clinical and suicide severity among adolescents.

METHODS

This study presents a comprehensive assessment of 302 adolescents (265 girls, mean age = 14.7 years) hospitalized after a SA. To test clinical interactions between BPD and history of prior SA, the sample was divided into single attempters without BPD (non-BPD-SA, N = 80), single attempters with BPD (BPD-SA, N = 127) and multiple attempters with BPD (BPD-MA, N = 95).

RESULTS

Univariate analyses revealed a severity gradient among the 3 groups with an additive effect of BPD on the clinical and suicide severity already conferred by a history of SA. This gradient encompassed categorical (anxiety and conduct disorders and non-suicidal-self-injury [NSSI]) and dimensional comorbidities (substance use and depression severity) and suicide characteristics (age at first SA). According to regression analyses, the BPD-MA group that was associated with the most severe clinical presentation also showed specific features: the first SA at a younger age and a higher prevalence of non-suicidal self-injury (NSSI) and anxiety disorders. The BPD-MA group was not associated with higher impulsivity or frequency of negative life events.

CONCLUSIONS

Based on these findings and to improve youth suicide prevention, future studies should systematically consider BPD and the efficacy of reinforcing early interventions for anxiety disorders and NSSI.

Prevalence, Onset, and Course of Suicidal Behavior Among Adolescents and Young Adults in Germany

Importance

Suicidal behavior is a leading cause of death among adolescents and young adults. In light of the ideation-to-action framework, the delineation of frequency and temporal characteristics of such behavior during this developmental period is crucial.

Objectives

To provide lifetime and 12-month prevalence estimates of suicidal behavior, including ideation, plan, and attempt, in adolescents and young adults of the general population, and to provide information about age at onset, temporal characteristics of suicidal behavior, including duration (number of years between onset and last occurrence) and frequency (number of episodes), and transition patterns across suicidal behaviors.

Design, Setting, and Participants

A cross-sectional epidemiological study was conducted in a random community sample of 1180 adolescents and young adults aged 14 to 21 years assessed in 2015 to 2016 in Dresden, Germany. Data analysis was performed from October 2018 to March 2019.

Main Outcomes and Measures

Lifetime and 12-month suicidal behavior (ideation, plan, and attempt) were assessed with a standardized diagnostic interview (Munich-Composite International Diagnostic Interview) by trained clinical interviewers. The onset, frequency, and duration of suicidal behavior were assessed by questionnaire.

Results

Of the 1180 participants (495 male [weighted percentage, 51.7%]; mean [SD] age, 17.9 [2.3] years), 130 participants (10.7%; 95% CI, 9.0%-12.8%), 65 participants (5.0%; 95% CI, 3.9%-6.5%), and 41 participants (3.4%; 95% CI, 2.4%-4.7%) reported lifetime suicidal ideation, plan, and attempt, respectively. Any lifetime suicidal behavior was reported by 138 participants (11.5%; 95% CI, 9.7%-13.7%). Age-specific cumulative incidence estimates indicated an increase in suicidal behavior during adolescence, starting at age 10 years (<1%), increasing slightly until the age of 12 years (2.2%), and then increasing sharply thereafter until age 20 years (13.5%). There were different patterns among female and male participants for ideation, plan, and attempt, with an overall higher incidence among female participants for ideation (hazard ratio, 1.51; 95% CI, 1.02-2.22; P = .04), for plan (hazard ratio, 3.31; 95% CI, 1.72-6.36; P < .001), and, among those older than 14 years, for attempt (hazard ratio, 3.07; 95% CI, 1.11-8.49; P = .03). Of those with suicidal ideation, 66.0% reported persistent or recurrent ideation over more than 1 year with 75.0% reporting more than 1 episode. Of the participants with lifetime suicidal ideation, 47.0% reported a suicide plan and 23.9% reported a suicide attempt. The transition to suicide plan or attempt occurred mainly in the year of onset of suicidal ideation or plan; of those who transitioned, 74.9% transitioned from ideation to plan, 71.2% transitioned from ideation to attempt, and 85.4% transitioned from plan to attempt in the same year.

Conclusions and Relevance

There is an urgent public health need for timely identification of suicidal behavior in adolescents and young adults to terminate persistent or recurrent suicidal tendencies and to interrupt the ideation-to-action transition.

Age-at-onset subsets of bipolar I disorders: A critical insight into admixture analyses

Gaussian mixture analysis is frequently used to model the age-at-onset (AAO) in bipolar I disorder and identify homogeneous subsets of patients. This study aimed to examine whether, using admixture analysis of AAO, cross-sectional designs (which cause right truncation), unreliable diagnosis for individuals younger than 10 years old (which causes left truncation) and the selection criterion used for admixture analysis impact the number of identified subsets. A simulation study was performed. Different criteria - the likelihood ratio test (LRT), the Akaike information criterion (AIC), and the Bayesian information criterion (BIC) - were compared using no, left and/or right truncation simulated data. The error rate of each criterion (percentage of erroneous number of detected subsets) was estimated. An application to two real databases, including 2,876 and 1,393 patients, is provided. Without data truncation and regardless of the distribution of AAO, the LRT and the AIC had much higher error rates (12% and 33%, respectively) than the BIC (1%). For a homogeneous population, the error rate increased with the introduction of left truncation. This study shows that the number of subsets identified using admixture analysis may depend on the sample size, the selection criterion, and the study design.

Multicomponent Intervention for Patients Admitted to an Emergency Unit for Suicide Attempt: An Exploratory Study

Suicide is a major cause of premature deaths worldwide and belongs to the top priority public health issues. While suicide attempt is the most important risk factor for completed suicide, intervention for suicide attempters (SA) have produced mixed results. Since an important proportion of SA request medical care, emergency units (EU) are an opportune setting to implement such interventions. This exploratory study evaluated the feasibility and acceptability of a multicomponent intervention for SA admitted to an EU. The intervention consisted of coordination by a case manager of a joint crisis plan (JCP), an early meeting with relatives and the existing care network, as well as phone contacts during 3 months after suicide attempt. Among 107 SA admitted to the emergency unit during the study period, 51 could not be included for logistical reason, 22 were excluded, and intervention was offered to 34. Of these, 15 refused the intervention, which was thus piloted with 19 SA. First-time attempters most frequently declined the intervention. Feasibility and acceptability of phone contacts and case manager were good, while JCPs and meetings were difficult to implement and perceived as less acceptable. Refusal pattern questions the global acceptability and is discussed: JCPs and meetings will have to be modified in order to improve their feasibility and acceptability, especially among first-time attempters.

Anxiety and physical health problems increase the odds of women having more severe symptoms of depression

Severely depressed women incur substantial disability and suicide risk, necessitating an understanding of factors that may contribute to severe depression. The purpose of this research was to determine the degree to which age, physical morbidity, anxiety, and hormonal status predict the likelihood of severe depression among women with mood disorders (n = 298). Data arose from a standardized battery of measures in a multi-center clinical registry of patients with mood disorders. The women were being treated at 17 participating sites of the National Network of Depression Centers. Results of logistic regression analyses indicate that a woman's level of anxiety was the strongest predictor of her likelihood of having severe depression (Exp(B) = 1.33, p = .000), including thoughts of death or suicide. The number of physical health problems that a woman reported was also a significant predictor (Exp(B) = 1.09, p = .04). Neither age nor hormonal status was significant in the final model, although a trend was observed for women with surgically induced menopause to have more severe depression. Findings support the need to work closely with medical practitioners to address physical health problems as part of the treatment plan for depression and to give comorbid anxiety and depression equal priority in symptom management.