Risk of suicide in relation to income level in people admitted to hospital with mental illness: nested case-control study

Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017

Importance

Although incidence of suicide in depression varies remarkably temporally, risk factors have been modeled as constant and remain uncharted in the short term. How effectively factors measured at one point in time predict risk at different time points is unknown.

Objective

To examine the absolute risk and risk factors for suicide in hospitalized patients with depression starting from the first days after discharge up to 2 years and to evaluate whether the size of relative risk by factor displays temporal patterns over consecutive phases of follow-up.

Design, Setting, and Participants

This population-based study using Finnish registers (hospital discharge, population, and cause of death registers) included all hospitalizations for depression as the principal diagnosis in Finland from 1996 to 2017, with a maximum follow-up of 2 years. Data were analyzed from January 2022 to November 2023.

Main Outcomes and Measures

Incidence rate (IR), IR ratios, hazard functions, and hazard ratios for suicide by consecutive time periods (0 to 3 days, 4 to 7 days, 7 to 30 days, 31 to 90 days, 91 to 365 days, and 1 to 2 years) since discharge.

Results

This study included 193 197 hospitalizations among 91 161 individuals, of whom 51 197 (56.2%) were female, and the mean (SD) age was 44.0 (17.3) years. Altogether, patients were followed up to 226 615 person-years. A total of 1219 men and 757 women died of suicide. Incidence of suicide was extremely high during the first days after discharge (IR of 6062 [95% CI, 4963-7404] per 100 000 on days 0 to 3; IR of 3884 [95% CI, 3119-4835] per 100 000 on days 4 to 7) and declined thereafter. Several factors were associated with risk of suicide over the first days after discharge. Current suicide attempt by hanging or firearms increased the risk of suicide most on days 0 to 3 (IR ratio, 18.9; 95% CI, 3.1-59.8) and on days 0 to 7 (IR ratio, 10.1; 95% CI, 1.7-31.5). Temporal patterns of the size of the relative risk diverged over time, being constant, declining, or increasing. Clinical factors had the strongest association immediately. Relative risk remained constant among men and even increased among those with alcohol or substance use disorder.

Conclusions and Relevance

In this study, patients hospitalized for depression had extremely high risk of suicide during the first days after discharge. Thereafter, incidence declined steeply but remained high. Within the periods of the highest risk of suicide, several factors increased overall risk manyfold. Risk factors' observed potencies varied over time and had characteristic temporal patterns.

The mediation effects of nightmares and depression between insomnia and suicidal ideation in young adults

Suicide is prevalent among young adults, and epidemiological studies indicate that insomnia, nightmares, and depression are significantly associated with a high incidence of suicidal ideation (SI). However, the causal relationship between these factors and SI remains unclear. Therefore, the purpose of this study was to examine the association between nightmares and depression and insomnia and SI in young adults, as well as to develop a mediation model to investigate the causal relationship between insomnia, nightmare, depression, and SI. We assessed insomnia, nightmares, depression, and SI in 546 young adults using the Insomnia Severity Scale (ISI), Disturbing Dream and Nightmare Severity Scale (DDNSI), Depression Study Scale (CESD-20), and Columbia-Suicide Severity Rating Scale (C-SSRS). Using the Bootstrap method, the mediation effects of nightmares and depression between insomnia and SI were calculated. The results demonstrated that nightmares and depression fully mediated the relationship between insomnia and SI, including the chain-mediation of insomnia and SI between nightmare and depression with an effect value of 0.02, 95% CI 0.01-0.04, and depression as a mediator between insomnia and SI with an effect value of 0.22, 95% CI 0.15-0.29. This study found that depression and nightmares may be risk and predictive factors between insomnia and SI, which implies that the assessment and treatment of depression and the simple or linked effect of nightmares play crucial roles in preventing SI in young adults.

The Role of Socioeconomic Position in the Association Between Mental Disorders and Mortality: A Systematic Review and Meta-Analysis

Importance

Studies are lacking summarizing how the association between mental disorders and mortality varies by socioeconomic position (SEP), particularly considering different aspects of SEP, specific types of mental disorders, and causes of death.

Objective

To investigate the role of SEP in the association between mental disorders and mortality and the association between SEP and mortality among people with mental disorders.

Data Sources

MEDLINE, Embase, PsycINFO, and Web of Science were searched from January 1, 1980, through April 3, 2023, and a snowball search of reference and citation lists was conducted.

Study Selection

Inclusion criteria were observational studies estimating the associations between different types of mental disorders and mortality, stratified by SEP and between SEP and mortality in people with mental disorders.

Data Extraction and Synthesis

Pairs of reviewers independently extracted data using a predefined data extraction form and assessed the risk of bias using the adapted Newcastle-Ottawa scale. Graphical analyses of the dose-response associations and random-effects meta-analyses were performed. Heterogeneity was explored through meta-regressions and sensitivity analyses.

Main Outcomes and Measures

All-cause and cause-specific mortality.

Results

Of 28 274 articles screened, 71 including more than 4 million people with mental disorders met the inclusion criteria (most of which were conducted in high-income countries). The relative associations between mental disorders and mortality were similar across SEP levels. Among people with mental disorders, belonging to the highest rather than the lowest SEP group was associated with lower all-cause mortality (pooled relative risk [RR], 0.79; 95% CI, 0.73-0.86) and mortality from natural causes (RR, 0.73; 95% CI, 0.62-0.85) and higher mortality from external causes (RR, 1.18; 95% CI, 0.99-1.41). Heterogeneity was high (I2 = 83% to 99%). Results from subgroup, sensitivity, and meta-regression analyses were consistent with those from the main analyses. Evidence on absolute scales, specific diagnoses, and specific causes of death was scarce.

Conclusion and Relevance

This study did not find a sufficient body of evidence that SEP moderated the relative association between mental disorders and mortality, but the underlying mortality rates may differ by SEP group, despite having scarcely been reported. This information gap, together with our findings related to SEP and a possible differential risk between natural and external causes of death in individuals with specific types of mental disorders, warrants further research.

Suicide and other causes of death among working-age and older adults in the year after discharge from in-patient mental healthcare in England: matched cohort study

BACKGROUND

Evidence for risk of dying by suicide and other causes following discharge from in-patient psychiatric care throughout adulthood is sparse.

AIMS

To estimate risks of all-cause mortality, natural and external-cause deaths, suicide and accidental, alcohol-specific and drug-related deaths in working-age and older adults within a year post-discharge.

METHOD

Using interlinked general practice, hospital, and mortality records in the Clinical Practice Research Datalink we delineated a cohort of discharged adults in England, 2001-2018. Each patient was matched to up to 20 general population comparator patients. Cumulative incidence (absolute risks) and hazard ratios (relative risks) were estimated separately for ages 18-64 and ≥65 years with additional stratification by gender and practice-level deprivation.

RESULTS

The 1-year cumulative incidence of dying post-discharge was 2.1% among working-age adults (95% CI 2.0-2.3) and 14.1% (95% CI 13.6-14.5) among older adults. Suicide risk was particularly elevated in the first 3 months, with hazard ratios of 191.1 (95% CI 125.0-292.0) among working-age adults and 125.4 (95% CI 52.6-298.9) in older adults. Older patients were vulnerable to dying by natural causes within 3 months post-discharge. Risk of dying by external causes was greater among discharged working-age adults in the least deprived areas. Relative risk of suicide in discharged working-age women relative to their general population peers was double the equivalent male risk elevation.

CONCLUSIONS

Recently discharged adults at any age are at increased risk of dying from external and natural causes, indicating the importance of close monitoring and provision of optimal support to all such patients, particularly during the first 3 months post-discharge.

Suicide and death by other causes among patients with a severe mental illness: cohort study comparing risks among patients discharged from inpatient care v. those treated in the community

AIMS

People diagnosed with a severe mental illness (SMI) are at elevated risk of dying prematurely compared to the general population. We aimed to understand the additional risk among people with SMI after discharge from inpatient psychiatric care, when many patients experience an acute phase of their illness.

METHODS

In the Clinical Practice Research Datalink (CPRD) GOLD and Aurum datasets, adults aged 18 years and older who were discharged from psychiatric inpatient care in England between 2001 and 2018 with primary diagnoses of SMI (schizophrenia, bipolar disorder, other psychoses) were matched by age and gender with up to five individuals with SMI and without recent hospital stays. Using survival analysis approaches, cumulative incidence and adjusted hazard ratios were estimated for all-cause mortality, external and natural causes of death, and suicide. All analyses were stratified by younger, middle and older ages and also by gender.

RESULTS

In the year after their discharge, the risk of dying by all causes examined was higher than among individuals with SMI who had not received inpatient psychiatric care recently. Suicide risk was 11.6 times (95% CI 6.4-20.9) higher in the first 3 months and remained greater at 2-5 years after discharge (HR 2.3, 1.7-3.2). This risk elevation remained after adjustment for self-harm in the 6 months prior to the discharge date. The relative risk of dying by natural causes was raised in the first 3 months (HR 1.6, 1.3-1.9), with no evidence of elevation during the second year following discharge.

CONCLUSIONS

There is an additional risk of death by suicide and natural causes for people with SMI who have been recently discharged from inpatient care over and above the general risk among people with the same diagnosis who have not recently been treated as an inpatient. This mortality gap shows the importance of continued focus, following discharge, on individuals who require inpatient care.

Positive Youth Development and Depression: An Examination of Gender Differences in Croatia and Spain

Depression is a major public health issue and the literature has consistently showed that the rates of depression increase dramatically during youth transition to adulthood, and gender differences merge in this period. Positive youth development (PYD) framework is focused on strengths that make young people more resistant to negative outcomes, like depression, and more capable to choose a positive life direction. The aim of the study was to examine the relationship between the 5Cs of PYD and depression in Croatia and Spain, as well as to analyze gender differences. This research was conducted within the PYD Cross-National Project. High school and university students from Eastern Croatia and Southern Spain participated in the study (M age = 19.37, SD = 2.11; 62.3% female). There were 584 students from Croatia and 768 students from Spain, who filled in self-reports of PYD and depression (i.e., PYD-SF and PHQ-9, respectively). Results showed that male participants presented more Competence and Confidence, while female participants reported more Connection, Caring, Character, overall PYD, but also more depressive symptoms. Furthermore, Confidence and Connection were negative correlates of depressive symptoms, with neither Spain nor Croatia showing remarkable gender differences. These results may have some implications concerning the promotion of the 5Cs of PYD as a recommendable approach to promote youth mental health in Croatia and Spain from a gender perspective. Youth mental health services and initiatives that engage the partnership of youth contexts, such as the family, schools and neighborhoods, should not only address risk factors for mental health problems, but also protecting factors as the 5Cs, thus providing a more inclusive and sustainable support for youth well-being.

Determining occupation for National Violent Death Reporting System records: An evaluation of autocoding programs

BACKGROUND

Suicide is a leading cause of death for working-age adults. Suicide risk varies across occupations. The National Violent Death Reporting System (NVDRS) collects information about violent deaths occurring in the United States. Occupation can be determined using autocoding programs with NVDRS data. The objective of this analysis is to determine the accuracy of autocoding programs for assigning occupations in the NVDRS.

METHODS

Deaths from suicide were identified in NVDRS for individuals age 16 and older from 2010 to 2017. Occupations were assigned after processing job description free text with autocoding programs. Job assigned by autocoding program were compared with the occupation code recorded on the death certificate.

RESULTS

Assignment of major occupation group had substantial agreement (Cohen's kappa > 0.7) for the two autocoding programs evaluated. Agreement of assigned code varied across race/ethnicity and occupation type.

CONCLUSIONS

Autocoding programs provide an efficient method for identifying the occupation for decedents in NVDRS data. By identifying occupation, circumstances of suicide and rates of suicide can be studied across occupations.

Social Status and Suicidal Activity Among Psychiatric Patients: Moderating Effects of Gender, Race and Psychiatric Diagnosis

The relationship between suicide and social class has proved to be complex. Durkheim predicted suicide rates would increase with social status, while others thought the opposite. Results have been mixed. In some studies, suicidality has increased with increasing social status, and in other studies, the two variables have had an inverse relationship. These studies have been primarily conducted on general non-psychiatric populations The present study, in contrast, examines this relationship on a 20-year prospective longitudinal sample of 400 psychiatric patients (differentiated by psychiatric diagnosis) after index hospitalization. Of these, 160 patients show some sign of suicide risk (87 cases of suicidal ideation, 41 of suicide attempts, and 32 suicide completions). A complicated pattern emerges across psychiatric diagnosis, gender, and race. The great majority of patients show no statistically significant relationship between social status and suicide risk. At the maximally different extremes, however, a dramatic difference does emerge. White women diagnosed with nonpsychotic depression show a positive relationship between social status and suicide risk (p < .01) while black men diagnosed with schizophrenia show a negative relationship between these 2 variables (p < .02). The relationship between social status and suicidality among psychiatric patients varies across race, gender, and psychiatric diagnosis. More research needs to be done on this complex and important topic, especially with regard to samples of psychiatric patients. The role of anomie should be studied.

Risk factors for suicide in depression in Finland: first-hospitalized patients followed up to 24 years

OBJECTIVE

To examine longitudinally risk factors for suicide in depression, and gender differences in risk factors and suicide methods.

METHOD

We linked data from (i) The Finnish Hospital Discharge Register, (ii) the Census Register of Statistics Finland, and (iii) Statistics Finland's register on causes of deaths. All 56 826 first-hospitalized patients (25 188 men, 31 638 women) in Finland in 1991-2011 with a principal diagnosis of depressive disorder were followed up until death (2587 suicides) or end of the year 2014 (maximum 24 years).

RESULTS

Clinical characteristics (severe depression adjusted hazard ratio [AHR] 1.19 [95% CI 1.08-1.30]; psychotic depression AHR 1.45 [1.30-1.62]; and comorbid alcohol dependence AHR 1.26 [1.13-1.41]), male gender (AHR 2.07 [1.91-2.24]), higher socioeconomic status and living alone at first hospitalization were long-term predictors of suicide deaths. Highest risk was associated with previous suicide attempts (cumulative probability 15.4% [13.7-17.3%] in men, 8.5% [7.3-9.7%] in women). Gender differences in risk factors were modest, but in lethal methods prominent.

CONCLUSION

Sociodemographic and clinical characteristics at first hospitalization predict suicide in the long term. Inpatients with previous suicide attempts constitute a high-risk group. Despite some gender differences in risk factors, those in lethal methods may better explain gender disparity in risk.

Suicide Attempts and Completions among Mothers Whose Children Were Taken into Care by Child Protection Services: A Cohort Study Using Linkable Administrative Data

OBJECTIVE

The objective of this study is to examine suicide attempts and completions among mothers who had a child taken into care by child protection services (CPS). These mothers were compared with their biological sisters who did not have a child taken into care and with mothers who received services from CPS but did not have a child taken into care.

METHODS

A retrospective cohort of mothers whose first child was born in Manitoba, Canada, between April 1, 1992, and March 31, 2015, is used. Rates among discordant biological sisters (1872 families) were compared using fixed-effects Poisson regression models, and mothers involved with CPS (children in care [ n = 1872] and received services [ n = 9590]) were compared using a Poisson regression model.

RESULTS

Compared with their biological sisters and mothers who received services, the adjusted incidence rate ratio (aIRR) of death by suicide was greater among mothers whose child was taken into care by CPS (aIRR = 4.46 [95% confidence interval (CI), 1.39-14.33] and ARR = 3.45 [95% CI, 1.61-7.40], respectively). Incidence rates of suicide attempts were higher among mothers with a child taken into care compared with their sisters (aIRR = 2.15; 95% CI, 1.40-3.30) and mothers receiving services (aIRR = 2.82; 95% CI, 2.03-3.92).

CONCLUSIONS

Mothers who had a child taken into care had significantly higher rates of suicide attempts and completions. When children are taken into care, physician and social workers should inquire about maternal suicidal behaviour and provide appropriate mental health.

Trauma history is associated with prior suicide attempt history in hospitalized patients with major depressive disorder

Although the relationships between PTSD, abuse history, and suicidal behaviors are well-established in military and outpatient samples, little data is available on this relationship in inpatient samples. This study examines the relationships between these variables and related demographic and clinical correlates in a sample of psychiatric inpatients with a diagnosis of major depressive disorder using electronic medical record (EMR) data. Controlling for relevant demographic and clinical variables, PTSD diagnosis and history of abuse were both significantly associated with history of suicide attempt, but in a combined model, only history of abuse remained as a significant predictor. Whereas history of abuse was associated with a history multiple suicide attempts, PTSD diagnosis was not. Both insurance status and gender acted as significant moderators of the relationship between history of abuse and history of suicide attempt, with males and those with public/no insurance having greater associations with history of suicide attempts when an abuse history was present. These data indicate the importance of documentation of PTSD, abuse history, and history of suicide attempts. The results also suggest that in the presence of an abuse history or PTSD diagnosis, additional time spent on safety and aftercare planning following hospital discharge may be indicated.

EPA guidance on mental health and economic crises in Europe

This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.

Occupational class differences in suicide: evidence of changes over time and during the global financial crisis in Australia

BACKGROUND

Previous research showed an increase in Australian suicide rates during the Global Financial Crisis (GFC). There has been no research investigating whether suicide rates by occupational class changed during the GFC. The aim of this study was to investigate whether the GFC-associated increase in suicide rates in employed Australians may have masked changes by occupational class.

METHODS

Negative binomial regression models were used to investigate Rate Ratios (RRs) in suicide by occupational class. Years of the GFC (2007, 2008, 2009) were compared to the baseline years 2001-2006.

RESULTS

There were widening disparities between a number of the lower class occupations and the highest class occupations during the years 2007, 2008, and 2009 for males, but less evidence of differences for females.

CONCLUSIONS

Occupational disparities in suicide rates widened over the GFC period. There is a need for programs to be responsive to economic downturns, and to prioritise the occupational groups most affected.

Suicidal ideation and distress in family members bereaved by suicide in Portugal

The present study assessed the impact of suicide and distress on suicidal ideation in a sample of 93 Portuguese family members bereaved by suicide. A control community sample of 102 adults also participated. After controlling for educational level, those bereaved by the suicide of a family member were found to have higher levels of suicidal ideation. Forty-two percent of family members had Suicide Ideation Questionnaire scores at or above the cutoff point. General distress, depression, anxiety, and hostility related to suicidal ideation, whereas time since suicide also interacted with general distress and depression in predicting suicidal ideation.

Risk factors for suicide among 34,671 patients with psychotic and non-psychotic severe depression

BACKGROUND

Severe unipolar depression is associated with increased risk of suicide, but it remains unknown whether the same risk factors are present in the non-psychotic (non-PD) and psychotic (PD) subtypes respectively. Therefore, this study aimed to identify risk factors for suicide in non-PD and PD separately, and to investigate if the presence of psychotic symptoms is an independent risk factor for suicide in severe depression.

METHODS

This register-based, nationwide, historical prospective cohort study used logistic regression analyses to ascertain risk factors for suicide among all adults diagnosed with severe depression at Danish psychiatric hospitals between January 1, 1994 and December 31, 2010. The risk for suicide was expressed as adjusted odds ratios (AOR).

RESULTS

A total of 34,671 individuals with severe depression (non-PD: n=26,106 and PD: n=12,101) were included in the study. Of these, 755 completed suicide during follow up. PD was not found to be an independent risk factor for suicide in severe depression (AOR=0.97 [0.83-1.15]). Older age (non-PD AOR=1.05 [per year], PD AOR=1.04 [per year]), male sex (non-PD AOR=1.89, PD AOR=1.98), and a previous incident of self-harm (non-PD AOR=5.02, PD AOR=5.17) were significant risk factors for both groups.

LIMITATIONS

As the study population was comprised only of patients with contact to psychiatric hospitals, the results cannot be extrapolated to the primary care setting.

CONCLUSION

The following risk factors for non-PD and PD were identified: older age, male gender and previous incidents of self-harm. In suicide prevention efforts, equal attention should be paid to non-PD and PD patients.

Preventing suicide among inpatients

OBJECTIVE

Inpatient suicide comprises a proportionately small but clinically important fraction of suicide. This study is intended as a qualitative analysis of the comprehensive English literature, highlighting what is known and what can be done to prevent inpatient suicide.

METHOD

A systematic search was conducted on the Cochrane Library, PubMed, Embase, Web of Knowledge, and a personal database for articles on cohort series, preferably controlled, of inpatient suicide (not deliberate self-harm or attempted suicide, unless they also dealt specifically with suicide data).

RESULTS

A qualitative discussion is presented, based on the findings of the literature searched.

CONCLUSIONS

The bulk of inpatient suicides actually occur not on the ward but off premises, when the patient was on leave or had absconded. Peaks occur shortly after admission and discharge. It is possible to reduce suicide risk on the ward by having a safe environment, optimizing patient visibility, supervising patients appropriately, careful assessment, awareness of and respect for suicide risk, good teamwork and communication, and adequate clinical treatment.

Social economic inequalities and mental health II. Methodological aspects and literature review

Summary

Objective - This study provides a framework for mental health inequalities beginners. It describes the methods used to measure socio economic inequalities and the inter-relations with different aspects of mental health: residence, mental health services organisation and main diagnostic categories. Method - Literature electronic-search on Medline, Psyclit, Econlit, Social Science Index and SocioSearch usingand relating the key-words inequalities, deprivation, poverty, socio-economic status, social class, occupational class, mental health for the period 1965-2002 (June). The articles selected were integrated with manual search (publications of the same authors, cross-references, working documents and reports of international andregional organisations). Results - Inequality is not an absolute concept and, mainly, it has been changing during the last years. For example, the integration and re-definition of variables that capture, in simple indices, a complex reality; the accent on social more than on economic aspects; the geo-validity and time-reference of the inequality's indices. Moreover, the inequalities could be the result of individual preferences, in this case, the social selectionand social causation issues will raise the suitability for a public intervention. Conclusions - Up to now, research has been mainly concentrated in describing and measuring health inequalities. For designing effective interventions, policy makers need to ground decisions on health-socioeconomic inequalities explanatory models.

Declaration of Interest

this work was partly funded by the Department of the Public Health Sciences “G. Sanarelli” of the University of Rome “La Sapienza” and the Department of Medicine and Public Health of the University of Verona.

School performance and risk of suicide in early adulthood: follow-up of two national cohorts of Swedish schoolchildren

BACKGROUND

Poor school performance and low IQ are associated with an increased risk of suicide in males; it is uncertain whether cognitive performance is a risk factor for suicide in females and whether severe mental illness influences these associations.

METHOD

Record linkage study of Swedish education, population and census data with mortality and inpatient registers. Data were available for 95,497 males and 91,311 females born in 1972 and 1977 and followed up until 31 December 2005.

RESULTS

230 males and 90 females died from suicide over the follow-up period. There were strong inverse associations between school performance at age 16 and subsequent suicide risk in males (fully adjusted hazard ratio (HR) per SD increase in school performance score: 0.6 (95% CI 0.6 to 0.7; p < 0.001)) but not females: adjusted HR. 1.1 (CI 0.9 to 1.4 p = 0.50). In males there were almost four fold differences in suicide risk between children in the top and bottom fifths of the range of school grade scores. Similar associations were seen with upper secondary school performance (age 18/19 years). There was no strong evidence that deterioration in school performance between ages 16 and 18 was associated with increased suicide risk. Amongst men who developed severe psychiatric illness school performance was not associated with suicide risk.

LIMITATIONS

We had limited information on the prevalence of minor psychiatric disorder in cohort members and no data on IQ for the cohort as a whole.

CONCLUSIONS

Good performance in secondary (age 16) and upper secondary (age 18) school is associated with a reduced risk of suicide in men but not women. This protective effect is not seen amongst those who develop severe psychiatric illness. These differences indicate that the aetiology of suicide differs in males and females and in those with and without severe mental illness.

Veterinary surgeons and suicide: a structured review of possible influences on increased risk

Veterinary surgeons are known to be at a higher risk of suicide compared with the general population. There has been much speculation regarding possible mechanisms underlying the increased suicide risk in the profession, but little empirical research. A computerised search of published literature on the suicide risk and influences on suicide among veterinarians, with comparison to the risk and influences in other occupational groups and in the general population, was used to develop a structured review. Veterinary surgeons have a proportional mortality ratio (PMR) for suicide approximately four times that of the general population and around twice that of other healthcare professions. A complex interaction of possible mechanisms may occur across the course of a veterinary career to increase the risk of suicide. Possible factors include the characteristics of individuals entering the profession, negative effects during undergraduate training, work-related stressors, ready access to and knowledge of means, stigma associated with mental illness, professional and social isolation, and alcohol or drug misuse (mainly prescription drugs to which the profession has ready access). Contextual effects such as attitudes to death and euthanasia, formed through the profession's routine involvement with euthanasia of companion animals and slaughter of farm animals, and suicide 'contagion' due to direct or indirect exposure to suicide of peers within this small profession are other possible influences.

Relationship between service ecology, special observation and self-harm during acute in-patient care: City-128 study

BACKGROUND

Special observation (the allocation of nurses to watch over nominated patients) is one means by which psychiatric services endeavour to keep in-patients safe from harm. The practice is both contentious and of unknown efficacy.

AIMS

To assess the relationship between special observation and self-harm rates, by ward, while controlling for potential confounding variables.

METHOD

A multivariate cross-sectional study collecting data on self-harm, special observation, other conflict and containment, physical environment, patient and staff factors for a 6-month period on 136 acute-admission psychiatric wards.

RESULTS

Constant special observation was not associated with self-harm rates, but intermittent observation was associated with reduced self-harm, as were levels of qualified nursing staff and more intense programmes of patient activities.

CONCLUSIONS

Certain features of nursing deployment and activity may serve to protect patients. The efficacy of constant special observation remains open to question.

Association of IQ scores and school achievement with suicide in a 40-year follow-up of a Swedish cohort

OBJECTIVE

Few studies have investigated the association of childhood IQ and school achievement with suicide. The aim of this study was to investigate the association of childhood IQ with suicide in a cohort of Swedish women and men.

METHOD

21 809 subjects born in 1948 and 1953 who completed IQ and school tests at age 13 years have been followed until 2003. Information on paternal education and in-patient care for psychosis was linked using the Swedish personal identification number.

RESULTS

There were 180 suicides amongst subjects with measured IQ. High IQ was associated with reduced suicide risk among men (OR per unit increase in age-adjusted model 0.90, 95% CI 0.83-0.99), while there was no statistical evidence of an association in women (OR 1.04, 95% CI 0.90-1.20). Among men with a history of psychosis, high IQ was associated with an increased risk of suicide.

CONCLUSION

Low childhood IQ at age 13 years is associated with an increased risk of suicide in men but not in women; however, amongst those with psychosis, low IQ appears to be protective.

High social class and suicide in persons at risk for schizophrenia

OBJECTIVE

The relationship between suicide and social class has been equivocal. While some authors have reported that higher social class is related to higher rates of suicide, most other studies report that lower social class is associated with higher rates of suicide. Our study attempted to resolve these inconsistencies by using a High Risk for schizophrenia method.

METHOD

Children of women with severe schizophrenia were assessed in 1962. In 2005, when subjects were a mean age of 58 years, we identified those who had committed suicide.

RESULTS

A higher rate of suicide was associated with risk for schizophrenia in the High-Risk sample. Higher social class origin was associated with suicide in persons at risk for mental illness.

CONCLUSION

Higher social class origin was associated with suicide in subjects at genetic risk for schizophrenia (but not those without risk).

Acute Stress Promotes Aggressive-Like Behavior in Rats Made Allergic to Tree Pollen

It has been reported that allergies are associated with depression and possibly suicide in women. Aggression is an important behavioral component that predisposes depressed individuals to suicidal acts. In the present study we examined the relationship between allergies and aggression to determine a potential contribution of allergies in factors of risk for suicidal behavior. Because stress plays a critical role in the manifestation of clinical symptoms of allergies and also in suicidal behavior, we also studied the role of acute stress. Female inbred Brown Norway rats known for their susceptibility to respiratory allergies were sensitized and challenged with a mixture of tree pollen and evaluated in the resident-intruder test for detection of aggressive behaviors. They were also subjected to acute stress by sessions of inescapable forced swimming and re-evaluated in the resident intruder test. Animals made allergic to tree pollen and subjected to acute stress displayed increased aggressive-like behavior as compared with control-saline treated animals or to their own aggressive scores previous to the stress session. These results suggest that allergies and stress increases aggressive-like behavior, indicating that these conditions may be important factors promoting altered emotional reactivity with the potential to influence suicidal behavior.

Epilepsy and risk of suicide: a population-based case–control study

BACKGROUND

Studies have linked epilepsy with an increased suicide risk, but the association might be modified by psychiatric, demographic, and socioeconomic factors.

METHODS

Suicide cases were identified in the Cause of Death Register in Denmark from 1981 to 1997. Up to 20 controls, matched by sex, birth year, and calendar date, were assigned to each suicide case.

FINDINGS

We identified 21 169 cases of suicide and 423 128 controls. 492 (2.32%) individuals who committed suicide had epilepsy compared with 3140 (0.74%) controls, corresponding to a three times higher risk (rate ratio [RR] 3.17 [95% CI 2.88-3.50]; p<0.0001). The RR remained high after excluding those with a history of psychiatric disease and adjusting for socioeconomic factors (1.99, 1.71-2.32; p<0.0001). The highest risk of suicide was identified in patients with epilepsy and comorbid psychiatric disease, even after adjusting for socioeconomic factors (13.7, 11.8-16.0; p<0.0001). In individuals with epilepsy, the highest risk of suicide was found during the first half year after diagnosis was made (5.35, 3.43-8.33; p<0.0001), and was especially high in those with a history of comorbid psychiatric disease (29.2, 16.4-51.9; p<0.0001).

INTERPRETATION

Individuals with epilepsy have a higher risk of suicide, even if coexisting psychiatric disease, demographic differences, and socioeconomic factors are taken into account. Our study identifies people with newly diagnosed epilepsy as a vulnerable group that require special attention.

Suicide and occupation: the impact of socio-economic, demographic and psychiatric differences

BACKGROUND

To explore the risk of suicide associated with occupation while evaluating the impact of socio-economic, demographic and psychiatric differences.

METHOD

A nested case-control study with 3195 suicides and 63 900 matched controls. Information on causes of death, occupation, psychiatric admission, marital status and socio-economic factors was obtained from routine registers.

RESULTS

Across the 55 occupations investigated, the risk of suicide ranged from 2.73 [95% confidence interval (CI) 1.77-4.22] among doctors to 0.44 (95% CI 0.27-0.72) among architects and engineers compared with primary school teachers. With the exception of doctors and nurses, most of the excess risk of suicide associated with particular occupations is explained by the social and economic characteristics of people in those occupations. Much, but not all, of the excess risk in doctors and nurses is due to their increased use of self-poisoning, a method for which they have the knowledge to use effectively. Occupation has little association with suicide among people who suffer from a psychiatric illness, except for doctors, where the excess risk is 3.62 (p=0.007).

CONCLUSIONS

Most of the considerable variation in suicide risk across occupations is explained by socio-economic factors, except for doctors and nurses. Apart from in doctors, the risk of suicide has little association with occupation among people who suffer from a psychiatric illness. Restriction of access to lethal means is an important strategy in suicide prevention.

Psychiatric illness, socioeconomic status, and marital status in people committing suicide: a matched case-sibling-control study

STUDY OBJECTIVE

Suicides cluster in both families and persons with psychiatric disorders and socioeconomic disadvantages. This study compares these factors between suicide cases, their siblings, and population based controls in an attempt to evaluate both the familial and the individual element of these factors.

DESIGN

Nested case-control study. Information on causes of death, psychiatric admission, marital status, children, and socioeconomic factors was obtained from routine registers.

SETTING

Denmark.

PARTICIPANTS

985 suicide cases, 1104 sex-age (+/-3 years) matched siblings, and 16 619 controls.

MAIN RESULTS

The suicide rate ratios obtained from the case-sibling and the case-control analysis, respectively, were of similar magnitude. For example, in the case-sibling analysis the adjusted suicide rate ratios associated with discharge from a psychiatric hospital within the previous 365 days, being unemployed the previous year, having a postgraduate degree and being single were 42.13 (95% CI 17.75 to 100.02), 1.78 (1.35 to 2.36), 0.51 (0.21 to 1.26), and 2.69 (1.91 to 3.79), respectively. The corresponding rate ratios obtained from the case-control analysis were 47.91 (35.41 to 64.83), 1.76 (1.49 to 2.08), 0.45 (0.26 to 0.76), and 2.39 (1.87 to 3.07). Moreover, the analogous ratios when comparing siblings and controls were 1.98 (1.08 to 3.63), 1.22 (1.06 to 1.41), 0.65 (0.44 to 0.95), and 0.89 (0.75 to 1.06).

CONCLUSIONS

People who commit suicide deviate similarly from siblings and controls in exposure to hospitalised psychiatric disorders and socioeconomic disadvantages, although these factors contribute to the familial aggregation of suicides.

Divergent trends in suicide by socio-economic status in Australia

OBJECTIVES

This study investigated secular trends in socio-economic status (SES) differentials in Australian suicide (1979-2003), which includes overall declines in male suicide from 1998.

METHOD

Suicide rates were stratified by approximate equal-population quintiles of area-based SES for the period 1979-2003 and examined across five quinquennia, centred on each Australian Census from 1981 to 2001, to determine if (1) SES differentials in suicide have persisted over time, and (2) if SES differentials have widened or narrowed. Suicide rates (per 100,000) were adjusted for confounding by sex, age, country-of-birth, and urban-rural residence using Poisson regression models, and secular changes in SES differentials were assessed using trend tests on suicide rate ratios (low to high SES quintiles).

RESULTS

Socio-economic status (SES) differentials persisted across the study period for both males and females after adjusting for the effects of age, migrant status, and urban-rural residence, with the largest differences between low and high SES groups evident in males, and especially young males (20-34 years). For males, suicide rates increased significantly in all SES groups until 1998, before diverging significantly in the most recent 5-year period, particularly in younger males (P<0.0001). In young males, suicide rates in the most recent period increased in the low SES group from 44.8 in 1994-1998 to 48.6 in 1999-2003 (an 8% increase). In contrast, suicide rates in the middle SES group decreased from a peak of 37.3 to 33.5 (a 10% decrease), and in the high SES group from a peak of 33.0 to 27.9 (a 15% decrease). A similar statistically significant divergence of a lesser magnitude was also evident in all age males and younger females (20-34 years).

CONCLUSION

This study shows that SES differentials in suicide persisted in Australia for most of the period 1979-2004. The decline in suicide in young males in the most recent quinquennium was limited to middle and high SES groups, while the low SES group displayed a continued increase. The continued increase in suicide in low SES males has implications for social and economic intervention and suicide control programs.

Smart and suicidal? The social ecology of intelligence and suicide in Austria

According to de Catanzaro's (1981) evolutionary theory of human suicide, a threshold intelligence is necessary for suicidality. A corollary deducible from this assertion is that intelligence and suicide mortality should be positively related. The present study tested de Catanzaro's corollary within a country. Using district-level IQ data of the entire non-institutionalized Austrian male year-of-birth cohort of 1969 who survived up to compulsory military conscription, including IQ testing in 1987 (n = 55474), the subsequent (1987-2001) district-level cohort loss due to suicide mortality was investigated. Across 99 Austrian districts, the regional IQ was weakly but statistically significantly, positively related to the regional standardized suicide rate as well as to the regional percentage of mortality due to suicide in this very cohort, when these relations were controlled for likely confounders (male divorce and unemployment rates and male net income), but not statistically reliable without these controls. It is argued that the most parsimonious interpretation of these aggregate-level findings remains that intelligence level and suicide mortality are positively related.

Effect of psychiatric illness and labour market status on suicide: a healthy worker effect?

STUDY OBJECTIVE

To describe the association between labour market status and death by suicide with focus on admission with a psychiatric disorder.

DESIGN

Nested case-control study. Data from routine registers.

SETTING

Entire Danish population.

PARTICIPANTS

9011 people aged 25-60 years who committed suicide during 1982-1997 and 180 220 matched controls.

MAIN RESULTS

In the general population, not being fully employed is associated with a twofold to threefold increased relative risk of death by suicide, compared with being fully employed. In contrast, fully employed people who have been first admitted to a psychiatric hospital within the past year are at increased suicide risk. Patients who are unemployed, social benefits recipients, disability pensioners, or otherwise marginalised on the labour market have a suicide risk of 0.60 (95% CI: 0.46 to 0.78), 0.41 (0.23 to 0.74), 0.70 (0.45 to 1.08), and 0.86 (0.53 to 1.41), respectively. Although a similar risk decrease is found in women, men, people younger than 30 years, people older than 45 years, and in people who become unemployed, the reversed effect attenuates with time since admission, and little association is seen when a marginal structural model is applied.

CONCLUSIONS

Although the results show an increased suicide mortality associated with unemployment and labour market marginalisation in the general population, the results suggest little or an inverse association between unemployment and suicide in people with psychiatric illness. The associations seen suggest the need to consider healthy worker selection effects when studying the causal pathway from unemployment and psychiatric illness to suicide.

The ecological association between suicide rates and indices of deprivation in English local authorities

INTRODUCTION

There are several published studies that have been focused on the ecological association between suicide rates in different areas with indices of deprivation or fragmentation. Most of these studies, however, have used census-based indices of deprivation or fragmentation. In the present study the newly developed Indices of Deprivation have been used, taking into account the results of the spatial autocorrelation tests.

METHODS

Data on all deaths for which suicide or an open verdict was returned during 1996-1998 in England were subjects of this study. These data were provided by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The indices of deprivation and the population counts were provided by the Department of the Environment, Transport and the Region (DETR) and Office for National Statistics (ONS), respectively.

RESULTS

The results show that, in England as a whole, the rates of suicide in young and middle-aged males were strongly associated with the indices of deprivation. However, the rates of suicide in females and in older age groups were less influenced by the indices of deprivation. In the present study all the indices of deprivation tended to show a similar pattern in which a better socio-economic status of local authorities was associated with a lower rate of suicide.

CONCLUSION

These findings suggest that at the local authority level, the "hot spots" index of deprivation may represent the same level of magnitude in predicting the rates of suicide as the number of unemployed or income-deprived people. However, more studies using multilevel modelling are needed to shed more light on the ecological associations between suicide rates and socio-economic and social cohesion status.

Change in suicide rates for patients with schizophrenia in Denmark, 1981-97: nested case-control study

OBJECTIVE

To study the change in risk of suicide among patients with schizophrenia and related disorders.

DESIGN

Nested case-control design with linked data.

SETTING

4 longitudinal Danish registers.

PARTICIPANTS

18,744 people aged up to 75 years who committed suicide in 1981-97 individually matched with 20 controls.

RESULTS

Over the time studied the reduction in suicide rate among patients with schizophrenia and schizophrenia spectrum disorder was similar to that seen in the general population (incidence rate ratio 1.00, 95% confidence interval 0.98 to 1.03). The reduction among patients with other psychosis in the schizophrenia spectrum was faster than the reduction seen in the general population. Among people admitted to hospital with schizophrenia the risk of suicide was highest in the first year after first admission, and the excess risk was largest in the younger age groups-that is, the risk decreased per year for every additional year of age.

CONCLUSION

The suicide rate among patients with a diagnosis of schizophrenia and related disorders has fallen. This may be due to better psychiatric treatment, reduced access to means of suicide, or improvements in treatment after suicide attempts.

Familial, psychiatric, and socioeconomic risk factors for suicide in young people: nested case-control study

OBJECTIVE

To estimate the risk of suicide in young people related to family and individual psychiatric and socioeconomic factors.

DESIGN

Population based nested case-control study.

SETTING

Data from longitudinal Danish registers. CASES AND CONTROL: 496 young people aged 10-21 years who had committed suicide during 1981-97 in Denmark and 24, 800 controls matched for sex, age, and time.

MAIN OUTCOME AND MEASURES

All suicides in Denmark compared with controls; parents and siblings identified from population based registers; inpatient information from discharge registers of national hospitals; and socioeconomic data from administrative registers.

RESULTS

Parental factors associated with an increased risk of suicide in young people were suicide or early death, admission to hospital for a mental illness, unemployment, low income, poor schooling, and divorce, as well as mental illness in siblings and mental illness and short duration of schooling in the young people themselves. The strongest risk factor was mental illness in the young people. The effect of the parents' socioeconomic factors decreased after adjustment for a family history of mental illness and a family history of suicide.

CONCLUSIONS

Recognising mental illness in young people and dealing with it appropriately could help prevent suicides. The high relative risk associated with a low socioeconomic status of the parents may be confounded and overestimated if not adjusted for mental illness and suicide in the family.