Suicide and attempted suicide reported by general practitioners in Belgium, 1990-1991

Definitions and incidence rates of self-harm and suicide attempts in Europe: A scoping review

INTRODUCTION

European countries use various terminologies for self-harm and attempted suicide, which are sometimes used interchangeably. This complicates cross-country comparisons of incidence rates. This scoping review aimed to examine the definitions used and the possibilities to identify and compare incidence rates of self-harm and attempted suicide in Europe.

METHODS

A literature search was conducted in Embase, Medline and PsycINFO for studies published from 1990 to 2021, followed by grey literature searches. Data were collected for total populations originating from health care institutions or registries. Results were presented in tabular form supplemented by a qualitative summary by area.

RESULTS

A total of 3160 articles were screened, resulting in 43 studies included from databases and further 29 studies from other sources. Most studies used the term 'suicide attempt' rather than 'self-harm' and reported person-based rates with annual incidence rates from age 15+. None of the rates were considered comparable due to different reporting traditions related to classification codes and statistical approaches.

CONCLUSION

The present extensive literature on self-harm and attempted suicide cannot be used to compare findings between countries because of the high degree of heterogeneity among studies. International agreement on definitions and registration practices is needed to improve knowledge and understanding of suicidal behaviour.

The lethality of suicide methods: A systematic review and meta-analysis

BACKGROUND

The use of suicide methods largely determines the outcome of suicide acts. However, no existing meta-analysis has assessed the case fatality rates (CFRs) by different suicide methods. The current study aimed to fill this gap.

METHODS

We searched Scopus, Web of Science, PubMed, ProQuest and Embase for studies reporting method-specific CFRs in suicide, published from inception to 31 December 2020. A random-effect model meta-analysis was applied to compute pooled estimates.

RESULTS

Of 10,708 studies screened, 34 studies were included in the meta-analysis. Based on the suicide acts that resulted in death or hospitalization, firearms were found to be the most lethal method (CFR:89.7%), followed by hanging/suffocation (84.5%), drowning (80.4%), gas poisoning (56.6%), jumping (46.7%), drug/liquid poisoning (8.0%) and cutting (4.0%). The rank of the lethality for different methods remained relatively stable across study setting, sex and age group. Method-specific CFRs for males and females were similar for most suicide methods, while method-CFRs were specifically higher in older adults.

CONCLUSIONS

This study is the first meta-analysis that provides significant evidence for the wide variation of the lethality of suicide methods. Restricting highly lethal methods based on local context is vital in suicide prevention.

Rate of suicide and suicide attempts and their relationship to unemployment in Thessaloniki Greece (2000-2012)

INTRODUCTION

Recently there was a debate concerning the relationship between the economic crisis and an increase in attempted and completed suicides in Europe and especially in Greece. The aim of the current study was to calculate the rates of attempted and completed suicide per year in the county of Thessaloniki, Macedonia, northern Greece, for the years 2000-12, and to investigate their relationship with unemployment.

MATERIAL AND METHODS

The archive of the Emergency Outpatient Units of three hospitals was investigated and the results were projected to the county population. Data from the Hellenic statistics authority concerning regional general population and suicides and unemployment were used.

RESULTS

The rate of attempted suicides was 16.69-40.34 per 10(5) inhabitants for males and 41.43-110.82 for females. Medication was the preferred method for 95.93%. The completed suicide rates varied from 3.62 to 5.47 for males and from 0.19 to 1.95 per 10(5) inhabitants for females. The male attempt rate correlated negatively with regional male unemployment (-0.63). For females the respected value was similar (-0.72). Concerning competed suicide rates, the respected values were 0.34 and 0.65. The attempt was repeated by 15.34%; almost half-repeated within the same year and 75% within two years. The female to male ratio varied significantly across years with 2:1 (more females) being the probable value for attempts and 1:3.6 (more males) for completed suicides.

CONCLUSION

This is the first study from Greece reporting rates on the basis of hospital archives. Attempt and suicide rates are low in Greece. Attempts are negatively and suicides are positively correlated with unemployment.

Trends in suicide case fatality in Italy, 1983-2007

The proportion of suicide attempts ending up in the death of the attempter was used in past studies as an index of suicide lethality, or case fatality. This study aimed at investigating whether case fatality of suicide has decreased in Italy over the latest 25 ears using available data, as an alternative hypothesis to the proposed general decrease in suicidal behavior resulting from better identification and treatment of people with mental disorders. The official data on completed and attempted suicides by males and females in Italy, from 1983 to 2007, were analyzed with joinpoint regression analysis, to identify the points (i.e., "joinpoints") where linear trends changed significantly in direction or magnitude. It should be noted that only the most severe suicide attempts are recorded in Italian official statistics. Suicide rates decreased in both sexes, particularly from 1990 onward. Attempted suicide rates increased progressively in males, while in females they reached their peak in 1996-1998 and then decreased. In both sexes suicide case fatalities significantly decreased from 1990 onward. Improved survival after a suicide act is probably the main reason behind this favorable trend. The spreading of emergency services may prevent suicide.

Signs for early diagnosis of heart failure in primary health care

Objective

The current guidelines for the diagnosis of heart failure (HF) are based on studies of hospital-based patients. The aim of this study is to describe the symptoms, clinical signs, and diagnostic procedures confirming the diagnosis of HF in primary health care.

Materials/subjects and methods

Data were prospectively collected during a 2-year period by a nationwide network of sentinel practices. All adult patients without known HF, for which the diagnosis of HF was clinically suspected for the first time, were registered. When diagnosed, HF was confirmed after 1 month.

Results

754 patients with a suspicion of HF were recorded. The diagnosis of HF was confirmed for 74% of the patients. The average age of the patients with confirmed HF was 77.7 years, and for those without HF 75.6 years (P = 0.018). From a logistic regression, breathlessness on exercise (P < 0.001), limitations of physical activity (P = 0.003), and orthopnea (P = 0.040) were the symptoms most associated with HF. The clinical signs most associated with HF, were pulmonary rales (P < 0.001), peripheral edema (P < 0.001), and raised jugular venous pressure (P = 0.039). An electrocardiogram was performed in 75% of the cases, blood analyses in 68%, echocardiogram in 63%, chest X-ray in 61%, and determination of natriuretic peptides in 11% of the cases.

Conclusion

Many clinical signs may occur in patients with HF. However, the occurrence of peripheral edema, breathlessness on exercise, or pulmonary rales, are highly suggestive for HF when diagnosed in primary health care, as is the case in hospital-admitted patients. The diagnosis of HF was often left unconfirmed by an echocardiogram and/or an electrocardiogram.

Symptoms and clinical signs associated with hospital admission and mortality for heart failure

Little information is available on the predicting factors for hospitalisation and mortality in heart failure. The aim of this study was to determine the symptoms and clinical signs at the time of the diagnosis of heart failure that predict hospitalisation within the first month after diagnosis and mortality within the first six months after diagnosis. Data were prospectively collected during a two-year period by a nationwide network of sentinel family practices. All adult patients for whom the first time the diagnosis of heart failure was clinically suspected were registered. One, six and twelve months after the initial diagnosis, the family physicians completed a follow-up form with questions about the final diagnosis, evolution and outcome. In total 557 patients with confirmed heart failure were recorded (median age = 78 years). Hospitalisation within the first month after the diagnosis was best predicted by peripheral oedema (p = 0.001), nocturnal dyspnoea (p = 0.022) and pleural effusion (p = 0.032) at the time of the diagnosis. Six months after the initial diagnosis the mortality was 19% and after 12 months it was 26%. Mortality within the first six months after the diagnosis was best predicted by age (p < 0.001) and pulmonary rales (p = 0.001). Peripheral oedema appeared more among the survivors (p = 0.035). Peripheral oedema, nocturnal dyspnoea and pleural effusion are highly associated with hospitalisation within the first month after diagnosis.

Declining rates of suicidal behavior among general practice patients in Belgium: results from sentinel surveillance between 1993 and 2008

The aim of this study was (1) to estimate the incidence of suicidal behavior, i.e., suicide and suicide attempts, among Belgian general practice patients in 2007-2008 and to estimate trends since previous surveillance periods, i.e., 1991-1993 and 2000-2001; and (2) to investigate characteristics of actors, acts, and first care delivery. Data were collected by the national network of sentinel general practitioners, recording all suicidal behavior they were confronted with in their daily practice in the three periods. In 2007-2008 incidence rates of both suicide and suicide attempts had declined compared to the previous periods while the use of violent versus non-violent suicidal methods remained unchanged. GP involvement in first care after suicidal behavior declined over time from 71% to 39% in the largest part of the population, i.e., younger and adult persons. The last surveillance of suicidal behavior by the Belgian sentinel network of GPs most likely resulted in an underestimation, probably as a result of a declining role of GPs in delivery of first care to patients following suicidal behavior.

The incidence and first-year mortality of heart failure in Belgium: a 2-year nationwide prospective registration

AIMS

The aim of this study is to determine the incidence and mortality of heart failure (HF) in Belgium.

METHODS

Data were prospectively collected during a 2-year period by a nationwide network of sentinel practices. All adult patients for whom, for the first time the diagnosis of HF was clinically suspected were registered. Patients were finally included if the diagnosis of HF was confirmed after 1 month.

RESULTS

The yearly incidence of confirmed HF in the Belgian adult population was estimated to be 194 patients per 100,000 inhabitants (95% CI: 172-218). At diagnosis, the median age of the patients with confirmed HF was 79 years: 82 years for women and 76 years for men (p < 0.0001). For the population aged 55 years or more, the yearly incidence of HF was 502 (95% CI: 444-565) with no significant difference between men and women. At diagnosis, most of the patients were classified as NYHA III (50%), 27% as NYHA IV and 20% as NYHA II. Six months after the initial diagnosis, the mortality was 19% and after 12 months it was 26%.

CONCLUSION

In Belgium, yearly 15,643 new patients of HF are diagnosed (95% CI: 13,861-17,590). HF is fatal for more than one quarter of the patients in the first year after the diagnosis.

Prospective evaluation of insomnia in prison using the Pittsburgh Sleep Quality Index: Which are the factors predicting insomnia?

Objectives. To measure the subjective sleep quality of prisoners complaining of insomnia and to compare it to the subjective sleep quality of prisoners who report "good sleep", in order to determine factors that predict insomnia and severity of insomnia. Participants and methods. PSQI and GHQ scores and patient history were obtained for 86 randomly chosen remanded prisoners complaining of insomnia and 61 randomly chosen prisoners who did not complain of insomnia. Results. PSQI total and component scores were significantly different between insomniac and not insomniac prisoners, except for C7 (daytime dysfunction). A history of sleeping problems before prison (odds ratio: 13.3), the subjective experience of having had stressful events during the past week (odds ratio: 8.5), being separated or divorced (odds ratio: 8.8), GHQ >10 (odds ratio: 8.8), a history of psychiatric problems (odds ratio: 8.3) and the consumption of opiates (odds ratio: 7.9), and to a lesser degree "no sports in prison" and stress related to judicial, familial and prison problems, were predictors of insomnia. We did not find any evidence in this study that work or consumption of caffeine in prison were factors that distinguished good sleepers from insomnia patients. Conclusions. Our study helps prison physicians to identify prisoners at risk for insomnia and to obtain some orientation for treatment decisions. Psychological support to reduce context related stress should be routinely offered to insomniac prisoners.

A pilot study of the suicide victim's last contact with a health professional

Suicide victims frequently have contact with health care professionals in the months before death. The primary aims of this pilot psychological autopsy study were to determine the feasibility of undertaking a full study and to describe the characteristics of the last health care professional contacts with suicide victims aged > 34 years. We interviewed the informants of 52 suicides. Interviews were obtained from 37 health care professionals who had contact with 28 of the suicides during the 3 months before death. The primary reasons for the last contact with the health care professional were mental health (62%), physical health (22%), and social (14%). 87% of health care professional contacts occurred within 1 month of death. Symptoms of depression were noted in 49% of health care professional contacts. Consensus psychological autopsy diagnoses of depression were made in 64% of suicide victims. Overall suicide risk was assessed by 38% of health care professionals during their last contact. This was more likely to occur when the deceased presented as depressed, was aged < 60 years or seen by a psychiatrist. None was assessed to be suicidal. The family informants regarded nine of the suicide victims to have been suicidal before death but informed a health care professional in only one third of the cases. Critical information that might have altered the management is not often accessed from family members.

Attempted suicide among Iranian population

Predictors of suicide attempts in Iran, to distinguish any similarities and differences of these predictors between suicide attempts in Iran and other developed and developing countries and to investigate the relation between general psychiatric symptoms and repetition of suicidal attempts were assessed. The validated Farsi version of the General Health Questionnaire-28 (GHQ-28) was used to assess multiple dimensions of quality of life of suicide attempters as depression, anxiety, social dysfunction, and somatic symptoms. Pivotal differences emerged in the clinical profiles of suicide attempters living in a developing country versus developed countries. In developing countries, those who attempt suicides are more likely to have no psychiatric disorder and are less likely to have used alcohol as part of the suicide attempt, but are more likely to have been assaulted physically or verbally. The results on the GHQ-28 indicate that the process through which individuals move from suicidal thought to action may decrease multiple dimensions of quality of life.

Nationwide monitoring of end-of-life care via the Sentinel Network of General Practitioners in Belgium: the research protocol of the SENTI-MELC study

Background

End-of-life care has become an issue of great clinical and public health concern. From analyses of official death certificates, we have societal knowledge on how many people die, at what age, where and from what causes. However, we know little about how people are dying. There is a lack of population-based and nationwide data that evaluate and monitor the circumstances of death and the care received in the final months of life. The present study was designed to describe the places of end-of-life care and care transitions, the caregivers involved in patient care and the actual treatments and care provided to dying patients in Belgium. The patient, residence and healthcare characteristics associated with these aspects of end-of-life care provision will also be studied. In this report, the protocol of the study is outlined.

Methods/Design

We designed a nationwide mortality follow-back study with data collection in 2005 and 2006, via the nationwide Belgian Sentinel Network of General Practitioners (GPs) i.e. an existing epidemiological surveillance system representative of all GPs in Belgium, covering 1.75% of the total Belgian population. All GPs were asked to report weekly, on a standardized registration form, every patient (>1 year) in their practice who had died, and to identify patients who had died "non-suddenly." The last three months of these patients' lives were surveyed retrospectively. Several quality control measures were used to ensure data of high scientific quality.

Discussion

In 2005 and 2006, respectively 1385 and 1305 deaths were identified of which 66% and 63% died non-suddenly. The first results are expected in 2007. Via this study, we will build a descriptive epidemiological database on end-of-life care provision in Belgium, which might serve as baseline measurement to monitor end-of-life care over time. The study will inform medical practice as well as healthcare authorities in setting up an end-of-life care policy. We publish the protocol here to inform others, in particular countries with analogue GP surveillance networks, on the possibilities of performing end-of-life care research. A preliminary analysis of the possible strengths, weaknesses and opportunities of our research is outlined.

Violent and nonviolent methods of suicide: different patterns may be found in men and women with severe depression

The objective of this study was to investigate violent and nonviolent suicidal acts in men and women with severe depression. The records of 98 suicide victims, who had been admitted to the Department of Psychiatry, Lund University Hospital, Sweden between 1956 and 1969, were evaluated and the subjects were monitored up to 1998. The female group displayed a significant linear trend for nonviolent completed suicide after one suicide attempt, and even more significantly, after repeated attempts. A switch from only nonviolent suicide attempts to completed violent suicide was significantly more common in men than in women. These different progressions may contribute to the expected finding that men used violent methods for completed suicide more often than women.

The epidemiology of suicide and attempted suicide in Dutch General Practice 1983-2003

BACKGROUND

Many patients attempting or committing suicide consult their general practitioner (GP) in the preceding period, indicating that GPs might play an important role in prevention. The aim of the present study was to analyse the epidemiology of suicidal behaviour in Dutch General Practice in order to find possible clues for prevention.

METHOD

Description of trends in suicide and suicide attempts occurring from 1983-2003 in the Dutch General Practice Sentinel Network, representing 1% of the Dutch population. The data were analysed with regard to: 1) suicidal behaviour trends and their association with household situation; 2) presence of depression, treatment of depression and referral rate by GPs; 3) contact with GP before suicide or suicide attempt and discussion of suicidal ideation.

RESULTS

Between 1983 and 2003 the annual number of suicide and suicide attempts decreased by 50%. Sixty percent of the patients who committed or attempted suicide were diagnosed as depressed, of whom 91% were treated by their GP with an antidepressant. Living alone was a risk factor for suicide (odds ratio 1.99; 95% CI 1.50 to 2.64), whereas living in a household of 3 or more persons was a relative risk for a suicide attempt (odds ratio 1.81; 95% CI 1.34 to 2.46). Referral to a psychiatrist or other mental health professionals occurred in 65% of the cases. GPs recalled having discussed suicidal ideation in only 7% of the cases, and in retrospect estimated that they had foreseen suicide or suicide attempts in 31% and 22% of the cases, respectively, if there had been contact in the preceding month.

CONCLUSION

With regard to the prescription of antidepressants and referral of suicidal patients to a psychiatrist, Dutch GPs fulfil their role as gatekeeper satisfactorily. However, since few patients discuss their suicidal ideation with their GP, there is room for improvement. GPs should take the lead to make this subject debatable. It may improve early recognition of depressed patients at risk and accelerate their referral to mental health professionals.

Correlates of suicide in the older adult population in Quebec

This study was undertaken to describe the characteristics of adults aged 60 years and over who committed suicide in Quebec in 1998-1999. In this study, 42.6% of the suicide cases presented mental disorders at the time of their death, mainly depression. Sixty-five (65.3%) percent of the suicide cases would have been considered as having a mental health disorder if sub-threshold depression cases were included. Only 27.7% of the cases did not express any idea of death during the 6-month period preceding their suicide. One interesting finding was that 53.5% of the suicide cases consulted a general practitioner or specialist during the 2-week period preceding their death. Our results showed that only 8.1% had a severe level of functional limitations at the time of their death. This result leads us to interpret with caution the conclusion of some studies suggesting that physical frailty is a major causal factor associated with suicide among the elderly.

Deliberate self-harm (DSH) among older people: a retrospective study in Barnet, North London

BACKGROUND

Rates of suicide remain high among older people and those who deliberately self harm are believed to be at an increased risk of killing themselves in the future. If older people who deliberately harm themselves are to be helped by developments in services we need to understand what currently happens to them in terms of service provision and outcome.

METHODS

A retrospective paper and electronic case note survey was carried out on all older people living in the London Borough of Barnet who presented to Accident & Emergency Departments with DSH over a two-year period. Ensuing actions and events were then tracked.

RESULTS

Forty-three older people with DSH were identified. 18/43 (42%) had previous contact with local psychiatric services. The main method of DSH was overdose of medication (36/43 or 84%). Compared to the general population there were more women and widows. There were similar levels of physical ill-health. Thirty-seven of 43 (86%) received documented psychiatric input outside of hospital following the DSH. The mean follow-up period was 789.0 days (SD 419.8) and during this time 8/43 (19%) had a further documented episode of DSH, and 18/43 (40%) died from natural causes.

CONCLUSIONS

This study confirms the need for improved documentation of DSH and its coding; this needs to be reviewed at local and national level. The vast majority of older people who attempt suicide do have subsequent contact with psychiatric services. There is a strong likelihood of repeat DSH and a higher risk of death by natural causes, emphasising the need to conceptualise DSH as a risk factor relevant to all medical specialities.

Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority.

METHOD

For these guidelines, the CPG Team for Deliberate Self-harm reviewed the treatment outcome literature (including meta-analyses) and consulted with practitioners and patients.

TREATMENT RECOMMENDATIONS

(i) Organization of general hospital services to provide: emergency department admission; a safe environment; integrated medical and psychiatric management; risk assessment; identification of psychiatric morbidity, and adequate follow-up. (ii) Detection and treatment of any psychiatric disorder. (iii) Dialectical behaviour therapy, psychoanalytically orientated partial hospitalization or home-based interpersonal therapy (for certain patients) to reduce repetition of deliberate self-harm (DSH).

CONCLUSION

Deliberate self-harm is common and is costly in terms of both individual distress and service provision. General hospitals are often the first point of clinical contact, but may not be appropriately organized to care for these patients. Evidence for the effectiveness of psychological treatments is based on single RCTs without replication. The three recommended psychological treatments are not widely available in Australia and New Zealand, and the interventions that are, such as cognitive behaviour therapy, problem solving and 'green cards' (an agreement guaranteeing access to services), do not reduce repetition of DSH. The effect of follow-up in psychiatric hospitals or in the community is poorly understood. We need to develop and evaluate interventions that will reduce repetition of both fatal and non-fatal deliberate self-harm and improve the person's functioning and quality of life.

Firearms and Suicide in the Northeast

BACKGROUND

A central question in suicide research is whether firearm availability increases the overall number of suicides rather than the proportion of suicides from guns.

METHODS

Seven state health departments supplied mortality and hospital discharge data for all suicides and nonfatal hospitalized suicide attempts between 1996 and 2000. Firearm prevalence measures came from the Behavioral Risk Factor Survey Surveillance. Pearson correlation coefficients and associated chi statistics were used to quantify the relation between firearm prevalence and rates of suicide; ordinary least squares regression was used to explore whether the relation could be explained by differences across states in attempt rates or method-specific case fatality rates.

RESULTS

Firearm prevalence was positively related to the suicide rate, even after controlling for rates of attempted suicide, and could not be accounted for by differences in method-specific case fatality rates.

CONCLUSION

When it comes to suicide, the availability of household firearms matters-a lot.

The epidemiology of case fatality rates for suicide in the northeast

STUDY OBJECTIVE

We examine how method-specific case fatality rates for suicide differ by age and sex.

METHODS

Seven northeastern states provided mortality and hospital discharge data (1996 to 2000). Suicide acts were divided into 8 categories according to the method used. For each method, the fraction of acts resulting in death (the method-specific case fatality rate) was calculated. Only suicide acts that resulted in hospitalization or death were included.

RESULTS

Overall, 13% of all suicide acts proved lethal (23% for males compared with 5% for females; 7% for people aged 15 to 24 years compared with 34% for individuals aged > or =65 years). Poisoning with drugs accounted for 74% of acts but only 14% of fatalities; firearms and hanging accounted for only 10% of acts but 67% of fatalities. Firearms were the most lethal means (91% resulted in death), followed by drowning (84%) and hanging (82%). For every means, method-specific case fatality rates were higher for male victims and older individuals. Age and sex were associated with overall case fatality rates primarily because of their association with the distribution of methods chosen.

CONCLUSION

Our findings are based on suicide acts that result in hospitalization or death and therefore underestimate the actual incidence of suicide acts and overestimate case fatality rates. Nevertheless, we find that age and sex influence overall case fatality rates primarily through their association with methods used, rather than because of variation in method-specific case fatality rates.

Some relationships among assessments of depression

The Directions program provides an administratively efficient method to screen for psychological disorders in a primary-care setting (FOCUS), confirm the need for treatment, and monitor progress (COMPASS-PC). The instruments are psychometrically sound and grounded in an established theory of mental-health treatment. The present study reports the relationships between FOCUS, COMPASS-PC, and the Hamilton Depression scale for a sample of patients who have been diagnosed as major depressive disorder, dysthymia, or depressive syndrome by standardized criteria (i.e., SCID-IV and DSM-IV). Moreover, Focus and COMPASS-PC are evaluated for their ability to detect depression as defined by SCID-IV and DSM IV. Furthermore, we examine the relationship between the different instruments in their ability to measure response to treatment over time.

Incidence of Completed and Attempted Suicide in Trabzon, Turkey

Summary: Objective: Studies of completed and attempted suicide in Turkey are based on data of State Institute of Statistics (SIS) and emergency clinics of the large hospitals. This study seeks (1) to find, independent of the SIS and hospital data, the annual incidences of completed and attempted suicide in Trabzon, Turkey; (2) to examine the associated factors between the incidence of completed and attempted suicide. Method: The data are derived by using a method specially designed for this study. Data sources include emergency clinics in all hospitals, village clinics, the Forensic Medical Center of Trabzon, the Governorship of Trabzon, “mukhtars” (local village representatives) of neighborhoods, the Office of the Public Prosecutor of Trabzon, the Police Headquarters and Gendarmerie, and the local press organs. Results: The incidences of completed and attempted suicide per 100,000 inhabitants turned out to be 2.60 and 31.5, respectively, whereas the SIS reported the incidence of completed suicide to be 1.11 per 100,000 inhabitants in Trabzon in 1995. Conclusion: Our results demonstrate that SIS data are inadequate for suicide research in Turkey. Our findings show that the risk of completed and attempted suicide is high in young, unmarried, and unemployed persons, and that these groups must be carefully evaluated for suicide risk. The study highlights the need for culture-specific research on suicidal behavior in Turkey.

Suicide in women

This article reviews research into suicide in women during the last 25 years. National rates vary between the extremes of 19/10(5) per year in Sri Lanka and < 1/10(5) per year in the Philippines and Egypt, but almost everywhere rates for women are much lower than male rates, with a median ratio of 2.8/1. The exceptions are in India and China, which report higher rates in young married women. The reproductive process has some influence. While menstruation, hormonal treatment, pregnancy and the puerperium have no major effect, unwanted pregnancy may still lead to suicide under certain circumstances, and severe labour can occasionally do so. Having children protects, but the relative risk is no more than 2.0 in nulliparous women. Social factors also have a limited effect. There are higher rates of suicide in divorced women, but the evidence on widowhood is equivocal. Prosperity and employment have no effect. Sexual abuse, rape and domestic violence undoubtedly lead to suicide attempts, but the evidence on completed suicide is lacking. There are many unanswered questions, especially why rates of completed suicide for women (with a greater prevalence of overt depression) are lower than for men, and why Chinese and Indian women have higher rates. More research is required, especially from developing nations.

Suicide attempts and serious suicide threats in the city of Riga and resulting contacts with medical services

The acute treatment of persons attempting suicide is recognized as very important in a prevention context. The aim of this study is to describe the medical services available to patients who have made suicide attempts or serious threats to commit suicide (SAST) within the city of Riga, to trace their passage through the various medical facilities, and to estimate SAST rates. Data for 1999 were collected from electronic case reports of the Emergency Medical Service (EMS) in Riga and monitoring forms of suicide attempters in Riga Psychoneurological Hospital (RPH) and Narcological Hospital (NH). In 1999 the first contact with the medical service in Riga for 95% of all cases (1024) was the EMS. Of the cases, 51.8% were treated at the general and 17.0% at the orthopaedic hospital. Of all SAST patients 99% have been assessed by at least one psychiatrist, and 43.8% were admitted to the psychiatric hospital at some time. The overall rate of suicide attempts is 149 per 100 000. The male to female ratio for SAST in Riga for individuals aged 15 years and more was 1:0.9. The highest figures were for females aged 15-24 and men aged 25-34. Females used poisonings in 75% of cases, but males used violent suicide methods in 60% of cases, most often involving cutting and associated with the use of alcohol. Data from existing medical services provide reasonably good information on the SAST population in Riga City.

Suicide acts in 8 states: incidence and case fatality rates by demographics and method

OBJECTIVES

This study examined incidence rates of medically identified suicide acts (self-inflicted injuries, either fatal or nonfatal) and case fatality rates by age, sex, race, and method used.

METHODS

The authors analyzed data on 10,892 suicides and 57,439 attempted suicides among hospital-admitted individuals in 8 states, along with 6219 attempted suicides among individuals released from emergency departments in 2 states.

RESULTS

The 8 states experienced a mean of 11 suicides and 119 attempted suicides per 100,000 residents each year. Groups with high suicide rates were men, the elderly, and Whites; groups with high attempted suicide rates were teenagers, young adults, women, and Blacks and Whites aged 25 to 44 years. Blacks aged 15 to 44 years evidenced high attempted suicide rates undocumented in previous studies. Poisoning and firearm were the most common methods used among those attempting suicide and those completing suicide acts, respectively. The most lethal method was firearm.

CONCLUSIONS

The characteristics of suicides and attempted suicides differ dramatically. Method used is important in the lethality of the act.

Diagnostic and therapeutic management of bilateral carotid artery occlusion caused by near-suicidal hanging

In cases of attempted suicide by hanging, a combination of mechanisms causing local destruction of the pharynx, larynx, vessels, and spine, as well as neurologic complications, has to be considered. We present a case of hanging in which a deeply unconscious patient without any palpaple pulsation of the carotid arteries was referred to our otolaryngology department. Computed tomography and angiography showed parapharyngeal air, complete obstruction of both common carotid arteries, and a compensatory circulation through the vertebral arteries. Three hours after the trauma, surgical exploration with resection of the enrolled intima of both carotid arteries and repair of the pharynx was performed. The patient awoke with an infarct of the right hemisphere with incomplete left hemiparesis the next day, but symptoms slowly declined during the following months, and the patient learned swallowing again perfectly. We conclude from our experience that in near-hanged patients a prompt onset of adequate diagnostic and therapeutic measures is mandatory, as good neurologic and functional results may occur even in cases with coma and severe destruction of the carotid arteries and pharyngeal and laryngeal structures. Surgical repair of blunt carotid lesions is recommended and may be crucial for a good outcome.

Suicide and recency of health care contacts. A systematic review

BACKGROUND

Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play.

METHOD

A systematic review of the literature.

RESULTS

Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up to 9% may commit suicide within one day of discharge. The corresponding figures are 11 and 4% for community-based psychiatric care and 83 and 20% for general practitioners.

CONCLUSIONS

Among those who die by suicide, contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.

Late-life suicide and depression in the primary care setting

Late-life depression and suicidal behavior in the primary care setting is a significant public health concern. The prevalence of depression in this population is substantial, yet rates of detection and treatment are far from adequate. Untreated depression has significant consequences with regard to morbidity and mortality. Although suicide is a relatively low-base-rate behavior, a substantial proportion of late-life suicides have contact with their primary care provider prior to their death; thus this offers an avenue for suicide prevention. There is a growing knowledge base concerning what constitutes barriers to the recognition and treatment of late-life depression as well as what constitutes useful screening tools and treatments for the depressed elderly. Important new findings with regard to the functional effects of subsyndromal depression, possible subtypes of late-life depression, the clinical utility of SSRIs and psychotherapeutic interventions, and innovative and collaborative models of care hold promise for advancing the science and practice of treating late-life depression.

Epidemiology of suicide in elderly people in Madrid, Spain (1990-1994)

The progressive aging of the population as a whole, the frequent appearance of degenerative diseases, and the greater frequency of suicide among persons older than 65 years than in younger age groups, are worrisome issues that deserve investigation. The aim of this study was therefore to analyze different epidemiological and social factors that influence suicide behaviour in elderly subjects in Madrid (Spain) during a 5-year period from January 1990 to December 1994. Post-mortem reports on all deaths that were examined at the Institute of Forensic Medicine in Madrid were studied. All cases of suicide in subjects aged > or = 65 years during these years (N = 461) were studied through the autopsy records and information from the coroner's inquest. Variables corresponding to demographic, clinical and interpersonal factors, method of suicide, scene of death, season, month and time of suicide were registered. In both sexes, jumping from a height was the most frequent method (63.6%). Family members had noted symptoms of depression in almost half of the cases (49.5%). Coexisting physical disorders were present in 68.9% of the subjects. Health care professionals have an important role to play in-suicide prevention.

Ethnicity, social factors, illness and suicide: a follow-up study of a random sample of the Swedish population

The aim of this longitudinal study was to determine the influence of ethnicity, social factors and self-reported long-term somatic and psychiatric illness on suicide in a random sample of the Swedish population. The study is based on face-to-face interviews conducted between 1979 and 1985 with a random sample of the Swedish population consisting of 47,762 Swedish-born subjects and 4407 individuals born elsewhere. The sample has been followed via register data concerning cases of suicide (suicides and undetermined deaths) until 31 December 1993. In total, 102 males and 46 females committed suicide prior to this date. Living alone and self-reported somatic illness with impaired health status were very strong risk factors for suicide, with risk ratios of 2.15 (CI, 1.51-3.05) and 1.80 (1.19-2.72), respectively. Ethnicity, defined as being born outside Sweden, had a risk ratio of 1.87 (1.18-2.97) in a model controlled for sex and age. However, this risk decreased with increasing age in the final model. Furthermore, an increased risk of suicide was found among female subjects living in rented flats and among male subjects irrespective of form of tenure, as well as among residents of large urban areas. Respondents with a self-reported long-term psychiatric illness with impaired health status also had a high risk of suicide, which decreased with increasing age. The main finding of this study is that somatic diseases and psychiatric disorders, which are known risk factors for suicide, may be revealed in surveys conducted by interviewers without medical training. Thus self-reported psychiatric and somatic illness appear to have a good potential for predicting suicide, even if the prevalence of psychiatric disorders is to some extent underestimated.

Suicide screening in a primary care setting at a Veterans Affairs Medical Center

Seven-hundred and three patients from a general medical outpatient clinic at a Veterans Affairs hospital completed the SCREENER, a brief self-report questionnaire that screens for psychiatric disorders. The authors found that 7.3% of the patients had suicidal ideation. The younger and white patients were at increased risk. The risk was increased twelvefold in those patients with subjectively fair or poor mental health, sevenfold in the patients with a history of mental health treatment, and fourfold in the patients with fair or poor perceived physical health. When major depression was controlled for, anxiety and substance abuse disorders continued to show an association with suicidal ideation. The suicidal patients made more visits to their primary care physician. Screening patients for anxiety disorders and drug abuse, as well as depression, is a better approach for identifying suicidal ideation in primary care settings than screening for depression alone and may help prevent suicide and suicide attempts.